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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

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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

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