Background and Objectives:Declines in stroke admission, intravenous thrombolysis, and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the impact of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), intravenous thrombolysis (IVT), and mechanical thrombectomy over a one-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020).Methods:We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, intravenous thrombolysis treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases.Results:There were 148,895 stroke admissions in the one-year immediately before compared to 138,453 admissions during the one-year pandemic, representing a 7% decline (95% confidence interval [95% CI 7.1, 6.9]; p<0.0001). ICH volumes declined from 29,585 to 28,156 (4.8%, [5.1, 4.6]; p<0.0001) and IVT volume from 24,584 to 23,077 (6.1%, [6.4, 5.8]; p<0.0001). Larger declines were observed at high volume compared to low volume centers (all p<0.0001). There was no significant change in mechanical thrombectomy volumes (0.7%, [0.6,0.9]; p=0.49). Stroke was diagnosed in 1.3% [1.31,1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82,2.97], 5,656/195,539) of all stroke hospitalizations.Discussion:There was a global decline and shift to lower volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared to the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year.Trial Registration Information:This study is registered underNCT04934020.
Acute colonic pseudo-obstruction (Ogilvie’s syndrome) is a rare disorder associated with spontaneous colonic dilatation with signs and symptoms of mechanical bowel obstruction and dilatation on imaging. We report a 37 year-old female, with three-month history of Caesarian Section at 38th week of pregnancy due to fetal malpresentation. Abdominal CT-scan revealed chronic diffuse colonic distention, 17 cm in diameter. No cause of obstruction could be determined. A diagnosis of Ogilvie’s syndrome was made. The increased size of the colon with leukocytosis warranted urgent colonoscopic decompression. The patient recovered well. If not managed appropriately, Ogilvie’s syndrome can progress to bowel ischemia and perforation with significant morbidity and mortality. The first line of treatment of early disease is conservative management with neostigmine or colonoscopic decompression. Our purpose is to review the diagnosis and management of this potentially lethal rare condition.
Coronavirus disease 2019 (COVID-19 -severe acute respiratory syndrome coronavirus 2 {SARS-CoV-2}) infection has been associated with thromboembolic events and coagulopathy, leading to a surge in the use of anticoagulants. The dose and duration of therapy differ according to the followed protocol. Several case reports documented fatal bleeding as an adverse effect of anticoagulation.We report a case of nearly fatal retroperitoneal bleed in an otherwise healthy 60-year-old man who developed severe COVID-19 requiring ICU stay and mechanical ventilation. The development of retroperitoneal bleed led to a 50% drop in his hemoglobin. The patient happens to be a Jehovah's Witness, and the family refused blood transfusion, which added to the complexity of the situation.Anticoagulation is associated with a potential risk of fatal bleed in critically ill COVID-19 patients. There are different protocols of anticoagulation in the management of SARS-CoV-2. The risk of bleeding vs thrombosis should be weighed on a case-by-case basis. A high degree of suspicion, early intervention, and knowledge of alternatives to blood transfusion can improve outcomes.
Methadone is a long-acting opioid medication that is used as maintenance therapy for heroin addiction. We present a case of a patient on methadone maintenance therapy for chronic back pain who developed neurological complications. The patient presented with mental status changes and choreiform movements. Workup revealed lesions involving the subcortical white matter and basal ganglia. Choreiform movements improved after the initiation of treatment with topiramate, clonazepam, and risperidone. This combination was chosen as several prior case reports published significant benefit and improvement in choreiform movements with the mentioned regimen.
Introduction Administration of intravenous thrombolytics (IVT) within 4.5 hoursof symptoms onset, prior to performing mechanical thrombectomy(MT) in patients with acute ischemic stroke (AIS) secondary tolarge vessel occlusion (LVO) is thoroughly studied and hassuggested to improve reperfusion rates and clinical outcomes. [1,2] The outcomes of combined IVT and MT in STEMI patientshavebeen studied comprehensively and revealed worsening clinicaloutcomes when a shorter Lapse of Time (LoT) isintroduced.[3,4]Those studies stemmed the question of whetherLoTbetween IVT and MT in AIS patients has any significance. We investigated the effects of theLoTbetween IVT and MT onoutcomes of MT revascularization, as well as on the functionaloutcomes in patient with AIS with LVO. Methods We performed a retrospective analysis ofgathereddataduring a 6‐year period (2016‐2021) for all ourpatients with AIS and LVO who received both IVT and MT. We analyzed the MT revascularization outcomes using thethrombolysis in cerebral infarction(TICI)scale, as well as thestroke functional outcomes using the modified Rankin Scale(mRS)at discharge and 90 days to detectany significant differencesin positive or negative direction.LoT was measured as minutes from tPA administration and reperfusion on a continuous scale. Nonparametric tests (Kruskal‐Wallis analysis of variance on ranks, K‐W H) were used to determine if there were differences between mRS at discharge and at 90 days (as an ordinal variable, possible score 0–6) based on LoT. Results A total of 48 patients who received both IVT and MT were includedin the study.Those included were primarilyBlack (57.1%) and male(59.2%). Mean age was62.5 years (sd = 15.5, range 21–89 years).Median minutes between tPA and reperfusion was 74 minutes (min‐max = 44‐143 minutes). There were no significant differences betweenmRSatdischarge (K‐W H = 5.13, p = 0.40), nor at 90 days (K‐W H = 8.71, p = 0.19) as a function of theLoTbetween IVT and MT. There were no significant differences between TICI scores, as afunction of theLoTbetween IVT and MT, (K‐W H = 5.49,p = 0.14). Conclusions In this study we compared the impact of the time differencebetween IVT and MT on revascularization and functionaloutcome in patients with AIS and LVO.Unlike the findings in STEMI, we did not detect any significant outcomedifferences in MT results (TICI scale) and functional outcomes(mRSat discharge and 90 days), when IVT was given at differentLoTbeforeMT.
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