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Background The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. Methods This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. Results During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE=0.24, P <0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS<5) ischemic stroke (P<0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; P=0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (P<0.0001). Conclusion In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.

There have been limited cases linking SARS-CoV-2 infection with the development of reversible cerebral vasoconstriction syndrome (RCVS). We hereby report a rare case of RCVS in the setting of mild SARS-CoV-2 respiratory infection successfully treated with nimodipine and aspirin. SARS-CoV-2 attacks the ACE2-receptors, which are expressed in various body organs including the lungs, kidneys, and blood vessels. Vasoconstriction can result from down-regulation of the ACE2-receptors that can lead to sympathetic hypertonia of the cerebral blood vessel walls and/or over-activation of the renin-angiotensin axis.

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Hemochromatosis is an autosomal recessive disorder which leads to abnormal iron deposition in the parenchyma of multiple organs causing tissue damage. Accumulation of iron in the brain has been postulated to be associated with several neurodegenerative diseases including Parkinson's disease. The excess iron promotes Parkin and α-synuclein aggregation in the neurons. Excess iron has also been noted in substantia nigra on MRI especially using susceptibility weighted imaging in patients with Parkinson's disease. We present a case of a young male with alleles for both C282Y and H63D who presented with signs of Parkinsonism and demonstrated significant improvement with levodopa treatment.

PBA remains an under-treated condition with significant psychosocial burden on both effected stroke survivors and their families. Advances have been made in developing consensus-based clinical diagnostic criteria for PBA. Early identification and prompt initiation of therapeutic measures are required in these stroke patients. Further research is needed to develop better PBA diagnostic criteria and more cost-effective therapeutic treatment options.

Introduction: Researchers have looked at medical expenses directly associated with stroke care, however, there is a paucity of data regarding indirect costs associated with productivity loss, especially in young adults. Methods: Direct and indirect medical costs were compared between stroke and non-stroke patients using the 2003-2014 Medical Expenditure Panel Survey-Household components. Direct costs include expenditures from hospitalizations, emergency room/clinic visits, medications, home health services etc. Indirect costs depend on employment, wages, missed work days (limited to 18-64 age group), and productivity loss from premature death. Two-part econometric models were used to estimate the adjusted incremental direct expenditure for patients with stroke. We used a generalized linear model with family gamma, log link for the adjusted analysis of annual wage and a negative binomial regression model for the adjusted analysis of missed work day. Loss of productivity due to premature death was computed across all age groups using Present value of one life and annual number of deaths obtained from the 2014 National Vital Statistics. Results: We identified 8,101,160 stroke and 245,133,892 non-stroke patients of all age groups. Weighted samples of 10,175 stroke and 314,694 non-stroke patients were compared. Total adjusted incremental direct cost for a stroke patient (vs. non-stroke) was $4,317 (95% CI $3,828-4,807) causing a $35 billion increment in total direct cost annually. Stroke patients had $14,254 (95% CI $16,023-12,485) lower adjusted annual wage, 4.2 (95% CI 2.9-5.6) more missed workdays and nearly 60% (OR 0.41; 95% CI 0.36-0.46) lower employment compared to non-stroke patients yielding an estimated annual $38.1 billion indirect-cost due to productivity loss. Indirect-cost from premature death was estimated to be $30.4 billion. Total (direct + indirect) annual cost for stroke patients was $103.5 billion. Conclusion: Two-thirds of the estimated $103.5 billion annual cost involved with stroke patients is attributed to indirect expenditures. Loss of productivity due to premature death is heavily concentrated in the economically productive age group. Our findings renew the call for greater emphasis on stroke prevention strategies.

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