Stroke Acute Management and Outcomes During the COVID-19 Outbreak

Abstract

Background and Purpose: The coronavirus disease 2019 (COVID-19) outbreak has added challenges to providing quality acute stroke care due to the reallocation of stroke resources to COVID-19. Case series suggest that patients with COVID-19 have more severe strokes; however, no large series have compared stroke outcomes with contemporary non–COVID-19 patients. Purpose was to analyze the impact of COVID-19 pandemic in stroke care and to evaluate stroke outcomes according to the diagnosis of COVID-19. Methods: Retrospective multicenter cohort study including consecutive acute stroke patients admitted to 7 stroke centers from February 25 to April 25, 2020 (first 2 months of the COVID-19 outbreak in Madrid). The quality of stroke care was measured by the number of admissions, recanalization treatments, and time metrics. The primary outcome was death or dependence at discharge. Results: A total of 550 acute stroke patients were admitted. A significant reduction in the number of admissions and secondary interhospital transfers was found. COVID-19 was confirmed in 105 (19.1%) patients, and a further 19 patients were managed as suspected COVID-19 (3.5%). No differences were found in the rates of reperfusion therapies in ischemic strokes (45.5% non–COVID-19, 35.7% confirmed COVID-19, and 40% suspected COVID-19; P =0.265). However, the COVID-19 group had longer median door-to-puncture time (110 versus 80 minutes), which was associated with the performance of chest computed tomography. Multivariate analysis confirmed poorer outcomes for confirmed or suspected COVID-19 (adjusted odds ratios, 2.05 [95% CI, 1.12–3.76] and 3.56 [95% CI, 1.15–11.05], respectively). Conclusions: This study confirms that patients with COVID-19 have more severe strokes and poorer outcomes despite similar acute management. A well-established stroke care network helps to diminish the impact of such an outbreak in stroke care, reducing secondary transfers and allowing maintenance of reperfusion therapies, with a minor impact on door-to-puncture times, which were longer in patients who underwent chest computed tomography.

Change in stroke presentations during COVID-19 pandemic in South-Western Sydney

“…The initial decrease in stroke presentations was followed by a rebound of 77% in the period May-June. The initial decrease in cases was like that reported in the literature (15,17–22,24–28,34–39). We saw a reduction in stroke presentations despite a relatively low incidence of SARS-CoV-2 infections compared to other centres internationally.…”

Fewer COVID‐19‐associated strokes and reduced severity during the second COVID‐19 wave: The Madrid Stroke Network

“…To note, the incidence of COVID‐19 during the first wave might be underestimated since PCR tests were restricted to symptomatic patients, whilst the second wave also included asymptomatic PCR‐confirmed COVID‐19 patients. Interestingly, in contrast to the first wave [10], the rate of stroke admissions remained stable throughout the second wave.…”

“…One important concern related to the COVID-19 outbreak was its negative impact on acute stroke care, with reported reductions in ischaemic and hemorrhagic stroke hospitalizations, as well as in IVT and MT rates compared with historical controls [1,2]. A prior report from the Madrid Stroke Network analyzing the first COVID-19 pandemic wave showed a reduction in stroke admissions but a high rate of reperfusion therapies in patients with ischaemic stroke (43.3%), with no differences depending on COVID-19 diagnoses [10]. This finding, together with the maintenance of door-to-imaging, doorto-needle and door-to-puncture times within the recommended range, suggest that the solid organized framework helped address the COVID-19 pandemic without a major impact on acute stroke care [10].…”

“…A retrospective, multicenter cohort study was conducted that included all consecutive acute stroke patients admitted to any of the seven hospitals equipped with stroke units (SUs) and endovascular treatment facilities in the Madrid Health Region [14]. The number and characteristics of stroke patients with or without a diagnosis of SARS-CoV-2 infection were compared and the organizational changes implemented for stroke care between the first (25 February to 25 April 2020) [10] and second (21 July to 21 November 2020) pandemic waves were recorded. The dates defining the two waves were selected considering the beginning of the rise in the incidence and the flattening of the downward slope of the curve according to the official data on the daily incidence of COVID-19 in the Madrid Health Region [15].…”

Grace Under Pressure: Resiliency of Quality Monitoring of Stroke Care During the Covid-19 Pandemic in Mexico City

“…John and Kesav also reported that 15 out of 20 patients (75%) with COVID-19 and acute ischemic stroke had LVO ( 13 ). Also, SARS-CoV-2 positive stroke patients have been found to be younger, with a higher baseline NIHSS ( 14 ) and worse clinical outcomes ( 15 – 17 ), including increased mortality ( 18 ). These findings suggest that, besides the strain that the pandemic itself causes on health systems, stroke may be particularly aggravated.…”