Global COVID-19 registry finds strokes associated with COVID-19 are more severe, have worse outcomes and higher mortality
July 10, 2020
Science Daily/American Heart Association
Patients with COVID-19 who have an acute ischemic stroke (AIS) experience more severe strokes, have worse functional outcomes and are more likely to die of stroke than AIS patients who do not have COVID-19. The wide range of complications associated with COVID-19 likely explain the worse outcomes.
Acute ischemic strokes (AIS) associated with COVID-19 are more severe, lead to worse functional outcomes and are associated with higher mortality , according to new research published yesterday in Stroke, a journal of the American Stroke Association, a division of the American Heart Association.
In "Characteristics and Outcomes in Patients with COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry," researchers analyzed data on patients with COVID-19 and AIS treated at 28 health care centers in 16 countries this year and compared them to patients without COVID-19 from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) Registry, from 2003 to 2019. Researchers sought to determine the clinical characteristics and outcomes of patients with COVID-19 and AIS.
Between January 27, 2020 to May 19, 2020, there were 174 patients hospitalized with COVID-19 and AIS. Each COVID-19 patient with AIS was matched and compared to a non-COVID-19 AIS patient based on a set of pre-specified factors including age, gender and stroke risk factors (hypertension, diabetes, atrial fibrillation, coronary artery disease, heart failure, cancer, previous stroke, smoking, obesity and dyslipidemia). The final analysis included 330 patients total.
In both patient groups, stroke severity was estimated with the National Institute of Health Stroke Scale (NIHSS), and stroke outcome was assessed by the modified Rankin score (mRS). When AIS patients with COVID-19 were compared to non-COVID-19 patients:
COVID-19 patients had more severe strokes (median NIHSS score of 10 vs. 6, respectively);
COVID-19 patients had higher risk for severe disability following stroke (median mRS score 4 vs. 2, respectively); and
COVID-19 patients were more likely to die of AIS.
The researchers noted there are several potential explanations for the relationship between COVID-19-associated strokes and increased stroke severity: "The increased stroke severity at admission in COVID-19-associated stroke patients compared to the non-COVID-19 cohort may explain the worse outcomes. The broad, multi-system complications of COVID-19, including acute respiratory distress syndrome, cardiac arrhythmias, acute cardiac injury, shock, pulmonary embolism, cytokine release syndrome and secondary infection, probably contribute further to the worse outcomes including higher mortality in these patients. ... The association highlights the urgent need for studies aiming to uncover the underlying mechanisms and is relevant for prehospital stroke awareness and in-hospital acute stroke pathways during the current and future pandemics."
https://www.sciencedaily.com/releases/2020/07/200710131516.htm
Ischemic stroke rates decrease during COVID-19 pandemic
June 9, 2020
Science Daily/Michigan Medicine - University of Michigan
A new research letter reveals fewer people have been admitted to stroke centers in Michigan and northwest Ohio since the onslaught of the COVID-19 pandemic, and significantly fewer patients received a mechanical thrombectomy for their ischemic stroke.
The authors call COVID-19's influence on other critical illnesses like stroke a bystander effect. That's because time is of the essence for patients with stroke, but not everyone is getting to a comprehensive stroke center for needed care right now.
In the letter, researchers from Michigan Medicine with colleagues across the Michigan Stroke Treatment Improvement Collaborative reported a significant reduction in ischemic stroke admissions in March when compared both to February of this year (17.8%) and to March of 2019 . Similarly, rates of a procedure for ischemic stroke, mechanical thrombectomy, significantly declined this March compared to February and compared to March of 2019.
"A combination of patient fears, stringent patient transfer criteria, and health system strains may have contributed to lower ischemic stroke admissions as well as the near disappearance of thrombectomy procedures," the authors write.
The differences were most pointed in ischemic stroke and quantity of thrombectomy procedures, authors say, while there was less of a change compared to past months for hemorrhagic stroke.
https://www.sciencedaily.com/releases/2020/06/200609095025.htm
Stroke rates among COVID-19 patients are low, but cases are more severe
Overall stroke hospital admissions are down globally
May 21, 2020
Science Daily/American Heart Association
The rate of strokes in COVID-19 patients appears relatively low, but a higher proportion of those strokes are presenting in younger people and are often more severe compared to strokes in people who do not have the novel coronavirus, while globally rates for stroke hospitalizations and treatments are significantly lower than for the first part of 2019, according to four separate research papers published this week in Stroke, a journal of the American Stroke Association, a division of the American Heart Association.
In "SARS2-CoV-2 and Stroke in a New York Healthcare System," researchers reported key demographic and clinical characteristics of patients who developed ischemic stroke associated with the COVID-19 infection and received care within one hospital system serving all 5 boroughs of New York City.
During the study period of March 15 through April 19, 2020, out of 3,556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging-proven ischemic stroke. They compared those 32 patients admitted with stroke and COVID-19 to those admitted only with stroke (46 patients) and found that the patients with COVID-19:
tended to be younger, average age of 63 years vs. 70 years for non-COVID stroke patients;
had more severe strokes, average score of 19 vs. 8 on the National Institutes of Health Stroke Scale;
had higher D-dimer levels, 10,000 vs. 525, which can indicate significant blood clotting;
were more likely to be treated with blood thinners, 75% vs. 23.9%;
were more likely to have a cryptogenic stroke in which the cause is unknown, 65.6% vs. 30.4%; and
were more likely to be dead at hospital discharge, 63.6% vs. 9.3%.
Conversely, COVID-19 stroke patients were less likely than those stroke patients without the novel coronavirus to have high blood pressure (56.3% vs. 76.1%) or to have a prior history of stroke (3.1% vs. 13%).
The researchers observed that the rate of imaging-confirmed acute ischemic stroke in hospitalized patients with COVID-19 in their New York City hospital system was lower compared to prior reports in COVID-19 studies from China. One reason for the difference might be related to variations in race/ethnicity between the two study populations. In addition, the low rate of ischemic stroke with COVID-19 infection may be an underestimate because "the diagnosis of ischemic stroke can be challenging in those critically ill with COVID-19 infection who are intubated and sedated," said lead study author Shadi Yaghi, M.D., FAHA, of the department of neurology at NYU Grossman School of Medicine in Manhattan.
Yaghi said, "It was difficult to determine the exact cause of the strokes of the COVID-19 patients, however, most patients appeared to experience abnormal blood clotting. Additional research is needed to determine if therapeutic anticoagulation for stroke is useful in patients with COVID-19." The researchers noted that at least one clinical trial is already underway to investigate the safety and efficacy of treatment for active clotting vs. preventive treatment in certain patients with COVID-19 infection presenting with possible clotting indicators.
Yaghi and his coauthors also noted the number of stroke cases with COVID-19 seems to have peaked and is now decreasing. This finding may be related to the overall reduction in COVID-19 hospital admissions, which may be due to social distancing and guidance for people to stay at home. In addition, the number of stroke patients hospitalized during the study period was significantly lower than the same time frame in 2019.
Similar trends are reported in several other studies also published this week in Stroke, reflecting a global disruption of emergency health care services including delayed care and a lower-than-usual volume of stroke emergencies during the COVID-19 pandemic crisis.
In a Hong Kong study, "Delays in Stroke Onset to Hospital Arrival Time during COVID-19," by lead author Kay Cheong Teo, M.B.B.S., researchers compared the stroke onset time to hospital arrival time for stroke and transient ischemic attack (TIA) patients from Jan. 23 to March 24, 2020 (the first 60 days from the first diagnosed COVID-19 case in Hong Kong) to the same time period in 2019. In 2020, 73 stroke patients presented to Queen Mary Hospital compared to 83 in 2019. However, the time from stroke onset-to-arrival time was about an hour longer in 2020 compared with last year (154 minutes vs. 95 minutes). In addition, the number of patients arriving within the critical 4.5-hour treatment window dropped from 72% in 2019 to 55% in 2020.
Also from China, "The impact of the COVID-19 epidemic on stroke care and potential solutions," by lead author Jing Zhao, M.D., Ph.D., detailed survey results from more than 200 stroke centers through the Big Data Observatory Platform for Stroke of China, which consists of 280 hospitals across China. They found that in February 2020, hospital admissions related to stroke dropped nearly 40%, while clot-busting treatment and mechanical clot-removal cases also decreased by 25%, compared to the same time period in 2019. The researchers cited several factors likely contributed to the reduced admissions and prehospital delays during the COVID-19 pandemic, such as lack of stroke knowledge and proper transportation. They also noted that another key factor was patients not coming to the hospital for fear of virus infection.
In a fourth study, "Mechanical Thrombectomy for Acute Ischemic Stroke Amid the COVID-19 Outbreak," by lead author Basile Kerleroux, M.D., researchers in France compared patient data from stroke centers across the country from February 15 through March 30, 2020 to data of patients treated during the same time period in 2019. They found a 21% decrease (844 in 2019 vs. 668 in 2020) in overall volume of ischemic patients receiving mechanical thrombectomy during the pandemic compared to the previous year.
Additionally, there was a significant increase in the amount of time from imaging to treatment overall -- 145 minutes in 2020 compared to 126 minutes in 2019, and that delay increased by nearly 30 minutes in patients transferred to other facilities for treatment after imaging. The researchers said delays may have been due to unprecedented stress on emergency medical system services, as well as primary care stroke centers lacking transfer resources needed to send eligible patients to thrombectomy capable stroke centers within the therapeutic window. They noted stricter applications of guidelines during the pandemic period could also have meant some patients may have not been referred or accepted for mechanical thrombectomy treatment during that time.
https://www.sciencedaily.com/releases/2020/05/200521124648.htm
Call for broad changes in stroke care during COVID-19
New guidelines needed to preserve health care resources, limit disease spread and ensure optimal care
May 14, 2020
Science Daily/Loyola University Health System
Broad modifications to current standards for treating acute stroke patients during the COVID-19 pandemic may be needed to preserve health care resources, limit disease spread and ensure optimal care, according to a Loyola Medicine neurologist.
"Doctors are seeing a rise in COVID-19 patients of all ages suffering from stroke and other vascular complications, as the COVID-19 virus overwhelms the health care system," said Jose Biller, MD, chairperson of neurology at Loyola University Medical Center, and professor, Loyola University Chicago Stritch School of Medicine, and co-author of a new editorial, "Acute Stroke Care in the Coronavirus 2019 Pandemic."
"COVID-19 may increase the risk of stroke as a result of several mechanisms, including enhanced inflammatory response, increased blood clotting tendencies, and damage of the inner layers of the blood vessels (endothelial damage)," said Dr. Biller. In general, the majority of stroke patients are older and have underlying medical conditions associated not only with risk for acute ischemic stroke (AIS), but also poor outcomes associated with COVID-19.
Dr. Biller says new guidelines are needed to safely manage stroke patients, both with and without COVID-19, within the limitations of strained health systems during this "ferocious novel pandemic."
"We believe that it is crucial for the stroke community to relax guidelines and stroke pathways while continuously providing high quality of care, including treatment algorithms, post intravenous thrombolysis monitoring, diagnostic work up, disposition planning, prevention measures, in order to optimally care for stroke patients while minimizing the chances of contributing to the rapid spread of COVID-19," according to the editorial, co-authored by Rima M. Dafer, MD, MPH, and Nicholas D. Osteraas, MD, MS, both of Rush University Medical Center, and appearing in the Journal of Stroke and Cerebrovascular Diseases.
The recommendations pertain to all aspects and stages of care, and include the following highlights:
Prehospitalization. Patients or loved ones should continue to call 911 to report a stroke. In addition to standard triage, emergency medical system (EMS) personnel should screen patients over the phone for COVID-19 symptoms. Telemedicine should be considered for patients with low suspicion of stroke, or mild symptoms with no potential indication for intervention. All patients with acute stroke symptoms should be treated as suspected or possible COVID-19 patients.
Emergency Room Evaluation. In the emergency room, patients should be screened for COVID-19 prior to evaluation by the stroke team. All patients should wear a mask.
Hospitalization. Hospitals should designate isolated units for stroke care. Patients receiving intravenous chemical thrombolysis (a common stroke treatment involving an intravenous injection of drugs directly to the blood clot) may be monitored virtually with two-way video conferencing to minimize staff infection.
Rehabilitation Planning. Rehabilitation for stroke patients can include physical, occupational, and speech therapy, along with other rehabilitation. All therapists and health care workers caring for COVID-19 patients should wear appropriate protective gear. Whenever appropriate, therapy services should emphasize patient exercises that can used at home.
Family Members. As many hospitals have restricted visitors during COVID-19, extra effort will need to be made to reach families by phone to discuss a patient's condition, treatment options and discharge planning. Exceptions to the visitor policy, such as discussions regarding end-of-life care, should be made when appropriate.
Transfers. Stroke care often involves networks of hospitals; commonly a comprehensive "hub" with multiple smaller hospitals or "spoke" sites which transfer stroke patients to the "hub" for emergency treatment or Intensive Care Unit (ICU) care. Tele-stroke should be encouraged to evaluate patients and to prevent unnecessary transfers. For AIS patients, neuroimaging and COVID-19 screening should be obtained at the smaller, spoke site hospital before a patient is transferred to a larger medical center.
Discharge Planning. Discharges to acute rehabilitation institutions and long-term facilities have been delayed due to concerns about the spread of COVID-19 infections in long-term care facilities and nursing homes. Hospitals may need to designate rehabilitation beds for patients who do not qualify for transfer to acute inpatient facilities, as well as discussing possible discharge to home when medically stable and appropriate until the pandemic is under control.
Finally, the article recommends establishing stroke networks within cities, as well as collaboration between institutions "as the surge of COVID-19 worsens." This should include "collaborations among stroke networks to establish a rotating weekly coverage for acute stroke care in a specified geographic area; thus, both freeing hospital resources and releasing stroke call responsibilities, and allowing these physicians to help in caring for patients on the COVID-19 units."
https://www.sciencedaily.com/releases/2020/05/200507150514.htm