Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays

Briard, Joel Neves; Ducroux, Célina; Jacquin, Grégory; Alesefir, Walid; Boisseau, William; Daneault, Nicole; Deschaintre, Yan; Eneling, Johanna; Gioia, Laura; Iancu, Dana; Odier, Céline; Raymond, Jean; Roy, Daniel; Stapf, Christian; Weill, Alain; Poppe, Alexandre Y

doi:10.1017/cjn.2020.160

Cited by 19 publications

(18 citation statements)

References 9 publications

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“…In a prior study focused on the early impact of the COVID-19 pandemic at our CSC, we observed increased delays between symptom onset, evaluation, and treatment for acute stroke. 2 This was in line with findings from other stroke centers worldwide. 3 4 However, the impact of increased delays, in addition to decreased neurological monitoring after reperfusion treatment, on 90-day functional outcomes for EVT-treated patients has not yet been described.…”

Section: Discussionsupporting

confidence: 90%

“… 1 We previously reported that the early pandemic was associated with increased delays from symptom onset to hospital presentation and to reperfusion treatment in our high-volume comprehensive stroke center (CSC) located in Montreal, a Canadian pandemic epicentre. 2 This observation has also been documented in other, although not all, CSCs around the globe. 3 4 In response to COVID-19, most CSCs adjusted their hyperacute stroke management procedures and their post-reperfusion monitoring protocols to minimize contact between healthcare professionals and potentially infected patients, as suggested by professional society recommendations and various experts.…”

Section: Introductionmentioning

confidence: 57%

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Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

Briard

Dufort

Jacquin

et al. 2021

J NeuroIntervent Surg

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BackgroundThe COVID-19 pandemic has disrupted acute stroke care logistics, including delays in hyperacute management and decreased monitoring following endovascular therapy (EVT). We aimed to assess the impact of the pandemic on 90-day functional outcome among patients treated with EVT.MethodsThis is an observational cohort study including all patients evaluated for an acute stroke between March 30, 2020 and September 30, 2020 (pandemic cohort) and 2019 (reference cohort) in a high-volume Canadian academic stroke center. We collected baseline characteristics, acute reperfusion treatment and management metrics. For EVT-treated patients, we assessed the modified Rankin score (mRS) at 90 days. We evaluated the impact of the pandemic on a 90-day favourable functional status (defined as mRS 0–2) and death using multivariable logistic regressions.ResultsAmong 383 and 339 patients included in the pandemic and reference cohorts, baseline characteristics were similar. Delays from symptom onset to evaluation and in-house treatment were longer during the early first wave, but returned to reference values in the subsequent months. Among the 127 and 136 EVT-treated patients in each respective cohort, favourable 90-day outcome occurred in 53/99 (53%) vs 52/109 (48%, p=0.40), whereas 22/99 (22%) and 28/109 (26%, p=0.56) patients died. In multivariable regressions, the pandemic period was not associated with 90-day favourable functional status (aOR 1.27, 95% CI 0.60 to 2.56) or death (aOR 0.74, 95% CI 0.33 to 1.63).ConclusionIn this single-center cohort study conducted in a Canadian pandemic epicenter, the first 6 months of the COVID-19 pandemic did not impact 90-day functional outcomes or death among EVT-treated patients.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 57%

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

Briard

Dufort

Jacquin

et al. 2021

J NeuroIntervent Surg

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“…This is in stark contrast with previous data reporting either no significant difference or longer treatment times for either or both IVT and MT. 27 , 28 , 29 Taken together, these findings illustrate the greater efficiency of our ED, stroke, neurointerventional and anesthesia teams in triaging and managing AIS during the pandemic. This can be explained in part by the unusually small numbers of stroke patients presenting to two busy centers that ordinarily manage multiple stroke codes simultaneously.…”

Section: Discussionmentioning

confidence: 76%

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

Nour

Affan

Mohamed

et al. 2021

Journal of Stroke and Cerebrovascular Diseases

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Background COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. Methods in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. Results of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods ( p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations ( p <0.001), and transfers from outside facilities ( p = 0.015). Conclusion a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.

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“…Some centers have reported increased door to needle times during the COVID-19 pandemic attributed to the institution of infection control measures and the inrotation of inexperienced staff [ 48 , 49 , 50 ], while some have noted no change [ 51 , 52 ]. Efforts should continue to use advanced imaging modalities in patients with suspected COVID-19 and administer revascularization therapies to eligible patients even in late time windows, as acute stroke patients may be delayed arriving to the hospital, while managing the need to screen for COVID-19 and instituting infection control measures.…”

Section: Methodsmentioning

confidence: 99%

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review

Venketasubramanian

Anderson

et al. 2021

Cerebrovasc Dis

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Background: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. Summary: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

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Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays

Cited by 19 publications

References 9 publications

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review

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