Despite the evidence suggesting a high rate of cerebrovascular complications in patients with SARS-CoV-2, reports have indicated decreasing rates of new ischemic stroke diagnoses during the COVID-19 pandemic. The observed decrease in emergency department (ED) visits is unsurprising during this major crisis, as patients are likely to prioritize avoiding exposure to SARS-CoV-2 over addressing what they may perceive as mild symptoms of headache, lethargy, difficulty speaking, and numbness. In the central and south Texas regions where we practice, we suspect that patient admission, treatment, and discharge volumes for acute stroke treatment have decreased significantly since COVID-19–related shelter-at-home orders were issued. Symptoms of stroke are frequently noticed by a family member, friend, or community member before they are recognized by the patients themselves, and these symptoms may be going unnoticed due to limited face-to-face encounters. This possibility emphasizes the importance of patient education regarding stroke warning signs and symptoms during the current period of isolation and social-distancing. The south Texas population, already saddled with above-average rates of cardiovascular and cerebrovascular disease, has a higher stroke mortality rate compared to Texas and U.S. averages; however, the number of patients presenting to EDs with acute ischemic stroke diagnoses is lower than average. In our viewpoint, we aim to present the relative literature to date and outline our ongoing analyses of the highly affected and diverse stroke populations in San Antonio and Austin, Texas, to answer a simple question: where did all our stroke patients go?
UNSTRUCTURED Despite the evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2, reports indicate a falling rate of new ischemic stroke diagnoses. An observed decrease in emergency department visits should come as no shock during times of major crises, as patients prioritize avoiding exposure to SARS-CoV-2 against the acute situation that they may perceive as mild symptoms of a headache, lethargy, difficulty speaking, and numbness. In the central and south Texas regions where we practice, we suspect that patient admission, treatment and discharge volumes for acute stroke treatment have decreased significantly since COVID-19 related shelter-at-home orders were issued. Symptoms of stroke are frequently noticed by another family member, friend, or community member before they are recognized in the patients themselves, and perhaps these symptoms are going unnoticed due to limited face-to-face encounters. This emphasizes the importance of patient education on stroke warning signs and symptoms during the current times of isolation and social-distancing. The central Texas population, already saddled with above-average rates of cardiovascular and cerebrovascular disease, has a higher stroke mortality rate compared to Texas and U.S. averages. But the number of patients presenting to emergency departments with acute ischemic stroke diagnoses are lower than average. To put it simply: where did all our stroke patients go?
Hypothesis: Hospital presentation for acute stroke may have been delayed during COVID-19. We hypothesize that stroke patients with mild symptoms (NIHSS <= 5) were more likely to present in a delayed fashion during the early days of the pandemic. Methods: Get with The Guidelines Stroke registry was used to identify stroke patients that presented between January 1 and August 31, 2020 to the University Hospital in San Antonio, Texas. The cohort was stratified by date of presentation (before COVID: Jan 1 - Mar 15; during COVID: Mar 16 - Aug 31) and presenting NIHSS (<=5 versus >5). We then analyzed by the thrombolytic exclusion criteria delay to arrival and the time interval of stroke symptoms discovery to hospital presentation. Subgroup analysis included age, sex, and ethnicity; race was excluded due to 90% Caucasian cohort. Results: A total of 294 subjects were included of which 115 were before and 179 were during COVID. There were no significant differences in the demographics for these two time periods, although a trend for greater male presentation was seen during COVID (Table 1). After both groups were dichotomized by NIHSS <=5, stroke symptoms discovery to hospital arrival and delay to arrival (Table 2) were not significantly different across subgroups. Conclusions: Regardless of NIHSS, a significant time delay in acute stroke presentation to our hospital was not seen when comparing before and during COVID. Although our study included a large Hispanic population, the cohort was primarily Caucasian; and therefore, the results have limited application. Whether men were more likely than women to present with stroke during COVID is unclear but warrants further study with a larger sample size.
BACKGROUND Neuroimaging has become a standard modality for accurate assessment of stroke because it can reflect cerebrovascular tissue pathophysiology and predict stroke outcome. Computed tomography (CT) and magnetic resonance imaging (MRI) scans provide diagnostic information to objectively identify salvageable brain tissue, allowing care teams to successfully select patient who will benefit from therapy. Accurate imaging assessment is important for individualized management of patients with stroke, whose symptom reports are often the initial trigger for acute stroke care encounters. OBJECTIVE The purpose of this mixed methods exploratory study is to assess if defined sets of patient-reported stroke symptom terms and expressions in free-text unstructured documentation within electronic health records (EHRs) map to stroke diagnoses, neuroimaging qualitative descriptors and quantitative lesion measures in acute stroke patients seen in four hospital emergency departments of an urban regional health care system. METHODS A corpus of EHR data will be created from a pre-existing cohort of 639 de-identified patient EHRs included in the retrospective arm of the WISHeS (Women’s Imaging of Stroke Hemodynamics Study) study from January 2015 to January 2019. Patient-reported symptoms and expressions within free-text unstructured documentation in EHR forms for patient care encounters will be mapped to (a) the stroke diagnosis as documented by the stroke specialist following physical assessment and imaging review; (b) CT and MRI qualitative descriptors of stroke lesion location, quality and severity as written in imaging reports; and (c) neuroimaging gold standard quantitative measures of perfusion delay, lesion volume, and cerebral collateral function. Findings will be synthesized into a tripartite stroke type taxonomy that includes a qualitative stroke type data cluster taxonomy, a quantitative stroke type data cluster taxonomy, and a mixed stroke type data cluster taxonomy. Exploratory factor analysis will then be applied to the mixed stroke type data cluster taxonomy to elucidate the strength of relationships between qualitative and quantitative variables. This will allow us to identify which defined sets of patient-reported symptom terms and expressions are most associated with stroke diagnoses and neuroimaging measures as classified by stroke type. RESULTS We anticipate finalizing data selection for inclusion in our corpus by May 2022, and completing our data analysis by October 2022. Findings will be used to inform the development of pre-neuroimaging decision-making algorithms for stroke treatment. These algorithms have great potential for aiding timely diagnosis in circumstances when access to neuroimaging is delayed or unavailable. CONCLUSIONS Not applicable. We plan to report results in a follow-up paper no later than October 2022. CLINICALTRIAL N/A
BACKGROUND As the pandemic has evolved, there has been a growing concern on the probable adverse effect of isolation and social distancing on different aspects of stroke. There is, however, limited data on the possible effects of the pandemic on maintaining stroke quality time metrics. OBJECTIVE The purpose of this study was to identify the impact of COVID-19-related “shelter in place” restrictions on critical time metrics for treatment and outcomes of stroke patients in two metropolitan Texas cities with known historical differences in stroke risk, incidence, and prevalence: Austin and San Antonio. METHODS Patient data from stroke program accreditation registries in Austin and San Antonio were compared between two treatment periods: (1) during the state’s COVID-19 “shelter in place” restriction period, and (2) the corresponding period during the previous year. Timing metrics were time last known well (TLKW) to arrival ≤ 3 hours, arrival to imaging initiation ≤ 25 minutes, and arrival to administration of thrombolytic ≤ 60 minutes. Primary outcomes included dichotomized process measures: TLKW to arrival, arrival to brain imaging initiation, and arrival to administration of thrombolytic therapy. Secondary outcomes were clinical endpoints: independent ambulation at discharge, discharge to home, in-hospital mortality. RESULTS Presentation and process measure trends for Austin patients during pre- and COVID-19 restriction periods were comparable other than TLKW to arrival, which increased during COVID-19. For San Antonio patients during COVID-19, there was increased TLKW to hospital arrival and increased time between hospital arrival to imaging initiation, even though the number of hospital arrivals < 4.5 hours from symptom onset decreased. Differences in pre- and during-COVID periods were found primarily in outcome measures for both Austin and San Antonio patients. Compared to the pre-COVID period, Austin patients had decreased length of stay (LOS), a decrease in number of discharges to hospice, and increase in patients with no symptoms on final assessment. On the other hand, more post-COVID-19 San Antonio patients than pre-COVID-19 had independent ambulation at discharge and were discharged to home, with a larger proportion of patients ranging from moderate disability/able to walk unassisted to no symptoms. CONCLUSIONS Austin and San Antonio patients did not hesitate to seek treatment for stroke symptoms during the COVID-19 restriction period, and longer times between TLKW and hospital arrival did not impact arrival-to-imaging and arrival-to-treatment times nor patient outcomes, even in patients at higher risk for stroke. Future studies should continue to assess the impact of COVID-19 on stroke care and outcomes pre- and post-introduction of the COVID-19 vaccine, and as infectivity rates spike or recede. CLINICALTRIAL Not applicable
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