Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration

Abstract

BackgroundUnprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown.MethodsWe performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment.ResultsOf the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7–21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (βadj=-73.2, 95% CI −153.8–7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (βadj=-3.85, 95% CI −36.9–29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (βadj=-46.44, 95% CI −62.8 to – -30.0, P<0.01) and higher NIHSS (βadj=-2.15, 95% CI −4.2to – -0.1, P=0.05).ConclusionsIn this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.

Decline in Rehab Transfers Among Rehab-Eligible Stroke Patients During the COVID-19 Pandemic

“… 2 This observation has since been validated in a larger multicenter study which showed a 28% decline in discharges to IRFs, 3 and a 40% decline in IRF discharges among patients with severe strokes who underwent thrombectomy. 4 The decline in discharge rates to IRFs remains unexplained, and may be the consequence of many patient-level and system-wide factors which warrant further exploration. The implications of a 30-50% loss in rehab-eligible patients receiving aggressive physical, speech, and occupational therapy are tremendous.…”

“…This difference in disability among patients admitted during the COVID-19 period persisted at 3 months (p=0.009).LOS was no different between the study periods (p=0.72; Table2). Between the study periods, there was also no difference in median LOS among patients discharged to IRF (6d [IQR[3][4][5][6][7][8][9][10][11][12] vs. 5d[3][4][5][6][7][8], p=0.54) or to home (2d [IQR 1-4] vs. 2d [IQR 1-4], p=0.92), although LOS was generally longer among patients discharged to IRF versus home (6d [IQR 3-9] vs. 2d [IQR 1-4], p<0.001). Of the 11 patients with COVID-19 and stroke, 4 were discharged to IRF, 3 to a subacute inpatient rehabilitation facility, and 3 went home.…”

Effects of the COVID-19 pandemic on stroke response times: a systematic review and meta-analysis

“…Across studies, these were widely attributed to precautions associated with COVID-19 such as symptom screening, additional PPE requirements, and isolation policies within hospitals (figure 3A). Minimal delays to stroke treatment during COVID-19 have also been identified in large multicenter studies,14 further showing the ability of hospital systems to adapt workflow to maximize patient outcomes. Interestingly, our analysis showed only a 2.8% increase in mean DTG times, but a 19.7% increase in mean DTR times.…”

Did COVID-19 impact stroke services? A multicenter study

“…In addition, there was a controversy among different reports regarding the change of pattern of acute stroke management [ 10 ] that resulted in either an increased, decreased, or no change of onset to door or door to needle times [ 11 ]. Consequently, the outcome of stroke has changed to variable degrees in different health facilities [ 4 ].…”