Global impact of COVID-19 on stroke care

International Controlled Study of Revascularization and Outcomes Following COVID-Positive Mechanical Thrombectomy

Background and purpose

Previous studies suggest that mechanisms and outcomes in patients with COVID‐19‐associated stroke differ from those in patients with non‐COVID‐19‐associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID‐19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors.

Methods

A cross‐sectional, international multicenter retrospective study was conducted in consecutively admitted COVID‐19 patients with concomitant acute LVO, compared to a control group without COVID‐19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable‐adjusted analysis was conducted.

Results

In this cohort of 697 patients with acute LVO, 302 had COVID‐19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID‐19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID‐19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23–0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12–0.77; p = 0.012). Moreover, endovascular complications, in‐hospital mortality, and length of hospital stay were significantly higher among COVID‐19 patients (p < 0.001).

Conclusion

COVID‐19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID‐19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Effect of Stay-at-Home Orders and Other COVID-Related Policies on Trauma Hospitalization Rates and Disparities in the United States: A Statewide Time-Series Analysis.. [PMID: 35898348 PMCID: PMC9327631 DOI: 10.1101/2022.07.11.22277511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background:

To combat the coronavirus pandemic, states implemented several public health policies to reduce infection and transmission. Increasing evidence suggests that these prevention strategies also have had a profound impact on non-COVID healthcare utilization. The goal of this study was to determine the impact of a statewide Stay-at-Home and other COVID-related policies on trauma hospitalizations, stratified by race/ethnicity, age, and sex.

Methods:

We used the North Carolina Trauma Registry, a statewide registry of trauma hospitalizations to 18 hospitals across North Carolina, including all North Carolina trauma centers, to calculate weekly assault, self-inflicted, unintentional motor vehicle collision (MVC), and other unintentional injury hospitalization rates between January 1, 2019 and December 31, 2020. Interrupted time-series design and segmented linear regression were used to estimate changes in hospitalizations rates after several COVID-related executive orders, overall and stratified by race/ethnicity, age, and gender. Hospitalization rates were compared after 1) U.S. declaration of a public health emergency; 2) North Carolina statewide Stay-at-Home order; 3) Stay-at-Home order lifted with restrictions (Phase 2: Safer-at-Home); and 4) further lifting of restrictions (Phase 2.5: Safer-at-Home).

Results.

There were 70,478 trauma hospitalizations in North Carolina from 2019–2020. In 2020, median age was 53 years old and 59% were male. Assault hospitalization rates (per 1,000,000 NC residents) increased after the Stay-at-Home order, but only among Black/African American residents (incidence rate difference [IRD]=7.9; other racial/ethnic groups’ IRDs ranged 0.9 to 1.7) and 18–44 year-old males (IRD=11.9; other sex/age groups’ IRDs ranged −0.5 to 3.6). After major restrictions were lifted, assault rates returned to pre-COVID levels. Unintentional injury hospitalizations decreased after the public health emergency, especially among older adults, but returned to 2019 levels within several months.

Conclusions:

Statewide Stay-at-Home orders put Black/African American residents at higher risk for assault hospitalizations, exacerbating pre-existing disparities. Fear of COVID-19 may have also led to decreases in unintentional non-MVC hospitalization rates, particularly among older adults. Policy makers must anticipate possible negative effects and develop approaches for mitigating harms that may disproportionately affect already disadvantaged communities.

Did COVID-19 impact stroke services? A multicenter study

Background

It has been reported that acute stroke services were compromised during COVID-19 due to various pandemic-related issues. We aimed to investigate these changes by recruiting centers from different countries.

Methods

Eight countries participated in this cross-sectional, observational, retrospective study by providing data from their stroke data base. We compared 1 year before to 1 year during COVID-19 as regards onset to door (OTD), door to needle (DTN), door to groin (DTG), duration of hospital stay, National Institute of Health Stroke Scale (NIHSS) at baseline, 24 h, and at discharge as well as modified Rankin score (mRS) on discharge and at 3 months follow-up.

Results

During the pandemic year, there was a reduction in the number of patients, median age was significantly lower, admission NIHSS was higher, hemorrhagic stroke increased, and OTD and DTG showed no difference, while DTN time was longer, rtPA administration was decreased, thrombectomy was more frequent, and hospital stay was shorter. mRS was less favorable on discharge and at 3 months.

Conclusion

COVID-19 showed variable effects on stroke services. Some were negatively impacted as the number of patients presenting to hospitals, DTN time, and stroke outcome, while others were marginally affected as the type of management.

The Effect of Endurance Training on Serum BDNF Levels in the Chronic Post-Stroke Phase: Current Evidence and Qualitative Systematic Review

Research in modern neurorehabilitation focusses on cognitive and motor recovery programmes tailored to each stroke patient, with particular emphasis on physiological parameters. The objectives of this review were to determine whether a single bout of endurance activity or long-term endurance activity regulates exercise-dependent serum brain-derived neurotrophic factor (BDNF) levels and to evaluate the methodological quality of the studies. To assess the effectiveness of endurance exercise among patients in the chronic post-stroke phase, a systematic review was performed, including searching EBSCOhost, PEDro, PubMed, and Scopus for articles published up to the end of October 2021. The PRISMA 2020 outline was used, and this review was registered on PROSPERO. Of the 180 papers identified, seven intervention studies (comprising 200 patients) met the inclusion criteria. The methodological quality of these studies was evaluated by using the Physiotherapy Evidence Database (PEDro) criteria. The effect of exercise was evaluated in four studies with a single bout of endurance activity, two studies with long-term endurance activity, and one study with a single bout of endurance activity as well as long-term endurance activity. The results of our systematic review provide evidence that endurance exercise might augment the peripheral BDNF concentration in post-stroke individuals.

Clinical Characteristics of Patients with Acute Ischemic Stroke Previously Vaccinated Against COVID-19

Objectives

The aim of this study was to examine the clinical characteristics of patients with acute ischemic stroke which were previously vaccinated against Coronavirus Disease 2019 (COVID-19) and determine whether the vaccine had impact on outcome.

Materials and Methods

In this observational cohort study we analyzed the clinical characteristics of 58 patients with ischemic stroke, previously vaccinated against COVID-19. We analyzed demographic characteristics, risk factors, type of stroke and outcome. We also compared outcome of those patients with outcome in stroke patients hospitalized in the same period but not vaccinated, patients hospitalized during the pandemic, before vaccination began, and stroke patients hospitalized before the pandemic. Further, we compared mortality rate with mortality rate in patients who had acute ischemic stroke and COVID-19 simultaneously.

Results

The mean age of the patients was 71.0 years, most were male (58.6%), mostly with risk factors for stroke. In the largest number of patients, 17 (29.3%), the etiopathogenetic mechanism of stroke was atherosclerosis of the large arteries. Mortality in vaccinated patients was identical to mortality in stroke patients before pandemic, without significant difference from mortality in unvaccinated patients (13.8% versus 8.6%; p= 0.23). The mean NIHSS and mRS score at discharge for all examined groups were without significant difference. A significant difference in mortality was found between COVID-19 positive and COVID-19 negative stroke patients (37.8% versus 18.1%; p=0.001).

Conclusions

There are no significant differences in clinical characteristics of stroke in vaccinated compared to unvaccinated patients. We did not find a connection between vaccination and stroke.

Hereditary Thrombophilia in the Era of COVID-19

Thrombophilia, also called hypercoagulability or prothrombotic condition, usually reflects a certain imbalance that occurs either in the coagulation cascade or in the anticoagulation/fibrinolytic system. A similar imbalance may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thrombotic complications are associated with multiorgan failure and increased mortality. In this context, activation of coagulation and thrombocytopenia appeared as prognostic markers in COVID-19. Our work provides a structured and updated analysis of inherited thrombophilia and its involvement in COVID-19, emphasizing the importance of diagnosing and initiating thromboprophylaxis. Since the state of hypercoagulation is directly correlated with COVID-19, we consider that studies on the genetic profiles of proteins involved in thrombophilia in patients who have had COVID-19 and thrombotic events are of great importance, both in treating and in preventing deaths due to COVID-19.

Long-term evaluation of the COVID-19 pandemic impact on acute stroke management: an analysis of the 21-month data from a medical facility in Tokyo

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis and profoundly impacted acute treatment delivery. This study conducted long-term evaluations of the impact of the pandemic on acute stroke management.

Methods

Data from a university-owned medical facility in Tokyo, Japan, were retrospectively analyzed. The number of hospital admissions for stroke and time metrics in the management of patients with acute ischemic stroke were evaluated. A year-over-year comparison was conducted using data from April 2019 to December 2021 to assess the impact of the pandemic.

Results

The year-over-year comparison demonstrated that the number of admissions of patients with stroke and patients who underwent magnetic resonance imaging (MRI), intravenous recombinant tissue plasminogen activator (rt-PA), and thrombectomy during the pandemic remained comparable to the pre-COVID data. However, we found a decrease in the number of admissions of patients with stroke alerts and stroke when hospital cluster infection occurred at this facility and when the region hosted the Tokyo Olympics games during the surge of infection. The door-to-computed tomography time in 2021 was affected. This is plausibly due to the reorganization of in-hospital stroke care pathways after hospital cluster infection. However, no significant difference was observed in the onset-to-door, door-to-MRI, door-to-needle, or door-to-groin puncture times.

Conclusions

We did not observe long-term detrimental effects of the pandemic at this site. Prevention of hospital cluster infections remains critical to provide safe and timely acute stroke management during the pandemic.

The impact of the first wave of COVID-19 on stroke admissions across three tertiary hospitals in Brisbane

Background

COVID‐19 has caused a global shift in healthcare‐seeking behaviour; however, presentation rates with serious conditions, such as stroke in low COVID‐19‐prevalence cities, has received less attention.

Aims

To determine if there was a significant reduction in stroke admissions, delivery of acute reperfusion therapies, or increased delays to presentation during the first wave of the COVID‐19 pandemic.

Methods

A multicentre, retrospective, observational cohort study was performed across three tertiary hospitals in Brisbane, Australia. Cases were identified using ICD‐10 codes and then individually reviewed for eligibility using prespecified inclusion and exclusion criteria. All metrics were compared over 3 months from 1 March to 31 May 2020 with two corresponding 3‐month periods in 2018 and 2019.

Results

There was a mean of 2.15 (95% CI 1.87–2.48) stroke admissions per day in the examined pandemic months compared with 2.13 (95% CI 1.85–2.45) and 2.26 (95% CI 1.97–2.59) in March to May 2018 and 2019 respectively, with no significant difference found (P = 0.81). There was also no difference in rates of intravenous thrombolysis (P = 0.82), endovascular thrombectomy (P = 0.93) and time from last known well to presentation (P = 0.54). Conversely, daily emergency department presentations (including non‐stroke presentations) significantly reduced (P < 0.0001).

Conclusions

During the early months of the COVID‐19 pandemic there was no significant reduction in stroke presentations, use of acute reperfusion therapies or delays to presentation, despite a reduction in ED presentations for any cause. Our results differ from the global experience, with possible explanations, including differences in public health messaging and healthcare infrastructure.

Emergency hospital admissions, prognosis, and population mortality in Norway during the first wave of the Covid-19 epidemic

Background:

During the first wave of the Covid-19 epidemic, a national lockdown was established in Norway, and inhabitants were asked to contact healthcare only if absolutely necessary. We investigated hospital admissions and mortality due to non-Covid-19 disease during the lockdown compared to previous years.

Methods:

We compared the number of emergency admissions and in-hospital fatality for diagnoses probably unaffected (acute myocardial infarction, acute abdominal conditions, cerebrovascular diseases) and affected by the lockdown (infections, injuries) in the South-Eastern Health Region of Norway during weeks 12–22, 2020, compared to the mean of the same period in the years 2017–2019. We also compared population mortality March–May 2020, to the mean of the same period in years 2017–2019.

Results:

A total of 280,043 emergency admissions were observed; 20,911 admissions probably unaffected, and 30,905 admissions probably affected by the lockdown. Admissions due to diagnoses probably unaffected was reduced by 12% (95% confidence interval (CI) 9–15%), compared to 2017–2019. Admissions for diagnoses probably affected was reduced by 30% (95% CI 28–32%). There was a 34% reduction in in-hospital fatality due to acute myocardial infarction (95% CI 4–56%), 19% due to infections (95% CI 1–33%), and no change for the other diagnoses, compared to 2017–2019. The risk of in-hospital mortality to total mortality was lower for acute myocardial infarction (relative risk 0.85, 95% CI 0.73–0.99) and injuries (relative risk 0.83, 95% CI 0.70–0.98).

Conclusions:

Even though fewer patients were admitted to hospital, there was no increase in in-hospital fatality or population mortality, indicating that those who were most in need still received adequate care.

Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Stroke Recovery During the COVID-19 Pandemic: A Position Paper on Recommendations for Rehabilitation

Health care delivery shifted and adapted with the COVID-19 pandemic caused by the novel severe acute respiratory syndrome coronavirus 2. Stroke care was negatively affected across the care continuum and may lead to poor community living outcomes in those who survived a stroke during the ongoing pandemic. For instance, delays in seeking care, changes in length of stays, and shifts in discharge patterns were observed during the pandemic. Those seeking care were younger and had more severe neurologic effects from stroke. Increased strain was placed on caregivers and public health efforts, and community-wide lockdowns, albeit necessary to reduce the spread of COVID-19, had detrimental effects on treatment and recommendations to support community living outcomes. The American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group Health and Wellness Task Force convened to (1) discuss international experiences in stroke care and rehabilitation and (2) review recently published literature on stroke care and outcomes during the pandemic. Based on the findings in the literature, the task force proposes recommendations and interdisciplinary approaches at the (1) institutional and societal level; (2) health care delivery level; and (3) individual and interpersonal level spanning across the care continuum and into the community.

Cerebrovascular Complications of COVID-19 and COVID-19 Vaccination

The risk of stroke and cerebrovascular disease complicating infection with SARS-CoV-2 has been extensively reported since the onset of the pandemic. The striking efforts of many scientists in cooperation with regulators and governments worldwide have rapidly brought the development of a large landscape of vaccines against SARS-CoV-2. The novel DNA and mRNA vaccines have offered great flexibility in terms of antigen production and led to an unprecedented rapidity in effective and safe vaccine production. However, as mass vaccination has progressed, rare but catastrophic cases of thrombosis have occurred in association with thrombocytopenia and antibodies against PF4 (platelet factor 4). This catastrophic syndrome has been named vaccine-induced immune thrombotic thrombocytopenia. Rarely, ischemic stroke can be the symptom onset of vaccine-induced immune thrombotic thrombocytopenia or can complicate the course of the disease. In this review, we provide an overview of stroke and cerebrovascular disease as a complication of the SARS-CoV-2 infection and outline the main clinical and radiological characteristics of cerebrovascular complications of vaccinations, with a focus on vaccine-induced immune thrombotic thrombocytopenia. Based on the available data from the literature and from our experience, we propose a therapeutic protocol to manage this challenging condition. Finally, we highlight the overlapping pathophysiologic mechanisms of SARS-CoV-2 infection and vaccination leading to thrombosis.

Effect of the COVID-19 Pandemic in the Prehospital Management of Patients with Suspected Acute Stroke: A Retrospective Cohort Study

Acute Ischemic Stroke (AIS) can be successfully handled if it is noticed early in the prehospital setting and immediately diagnosed in the emergency department (ED). The coronavirus pandemic has altered the way health care is delivered and has had a profound impact on healthcare delivery. The effects could include prioritizing the prevention of COVID-19 spread, which could result in the discontinuation or deferral of non-COVID-19 care. We used the National Emergency Medical Service Command Support System, a register of medical interventions performed by emergency medical services (EMS) in Poland, to assess the impact of the COVID-19 epidemic across the Masovian Voivodeship on suspected stroke patients’ baseline characteristics, prehospital vital parameters, clinical and neurological status, emergency procedures performed on the prehospital phase and EMS processing times. Between 1 April 2019 and 30 April 2021, the study population included 18,922 adult suspected stroke patients who were treated by EMS teams, with 18,641 admitted to the emergency departments. The overall number of suspected stroke patients treated by EMS remained unchanged during COVID-19 compared to the pre-COVID-19 period; however, the average time from call to hospital admission increased by 15 min.

Risk of ischemic stroke in patients with COVID-19 infection: A systematic review and meta-analysis

An ongoing global pandemic, the coronavirus disease 2019 is posing threat to people all over the world. The association between COVID-19 and the risk of ischemic stroke remains unclear. This study systematically reviewed published studies and conducted meta-analysis to evaluate the association between the risk of ischemic stroke and COVID-19. This study was conducted according to guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The protocol used in this study had been registered in the International Prospective Register of Systematic Reviews. EMBASE, PubMed, Cochrane Library and Web of Science were searched from 1st December 2019-19th February 2021. This systematic review and meta-analysis analysed the combined effect estimations based on odds ratios (OR) with the random-effects model. Four studies were screened from 31,634 participants including 171 COVID-19 positive patients with ischemic stroke were included. The mean age of COVID-19 positive patients with ischemic stroke was 69.45 years (Range: 63-77 years) and the male patients were 56%. Countries covered by these articles were USA, Italy and France. Three of the articles were retrospective cohort studies and one was prospective cohort study. Our analysis revealed that the risk of ischemic stroke (combined OR: 2.41; 95% CI: 1.08-5.38) was significantly increased. Four included studies were significantly heterogeneous (I2 = 75.2%, P = 0.007). Significant association between the risk of ischemic stroke and COVID-19 was observed in the North America group (combined OR: 2.90; 95% CI: 0.45-18.80, I2 = 89.60%, P = 0.002). This study found that the risk for ischemic stroke was increased in COVID-19 patients, especially in patients from North America. Further studies with larger sample sizes that include different ethnic populations are required to confirm our analysis.

Lessons learned in stroke care during COVID-19 pandemic and preparing for future pandemics in the MENA+ region: A consensus statement from the MENA+-SINO

BACKGROUND

COVID-19 pandemic has negatively impacted stroke care services at multiple levels. There was a decline in acute stroke admissions. Fewer interventions have been performed. Increased "door-to-needle times and "door-to-groin puncture" during this pandemic. These factors combined have led to declining in the favoured outcomes of stroke patients' globally. Yet this pandemic permits an opportunity for higher preparedness for future pandemics.

OBJECTIVES AND METHODS

This paper aims to shed light on the main lessons learned in the field of stroke care during the first wave of COVID-19 pandemic. Here we are presenting proposals and initiatives for better preparedness in future similar emergencies. These proposals are based primarily on literature review of COVID-19 publications, as well as the first-hand experience gained during the first wave at the regional level. In addition to the consensus and collective ride of stroke experts in the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA+-SINO) and interaction and collaboration with international stroke specialists from the Stroke World Organization (WSO), European Stroke Organization (ESO) and stroke and COVID-19 papers authors.

CONCLUSION

Stroke care is very complex, particularly in the initial hours after onset of symptoms. A successful outcome requires very close collaboration between clinical personnel from multiple specialties. Preparedness for future pandemics requires the improvement of care plans that allow for rapid assessment of stroke patients and ensuring that regular 'mock exercises' familiarize quintessential services that care for the stroke patients.

The Impact of COVID-19 on Hospital Admissions for Twelve High-Burden Diseases and Five Common Procedures in the Philippines: A National Health Insurance Database Study 2019-2020

BACKGROUND

The Philippines has the highest cumulative COVID-19 cases and deaths in the Western-Pacific. To explore the broader health impacts of the pandemic, we assessed the magnitude and duration of changes in hospital admissions for 12 high-burden diseases and the utilization of five common procedures by lockdown stringency, hospital level, and equity in patient access.

METHODS

Our analysis used Philippine social health insurance data filed by 1,295 hospitals in 2019 and 2020. We calculated three descriptive statistics of percent change comparing 2020 to the same periods in 2019: (1) year-on-year, (2) same-month-prior-year, and (3) lockdown periods.

FINDINGS

Disease admissions declined (-54%) while procedures increased (13%) in 2020 versus 2019. The increase in procedures was caused by hemodialysis surpassing its 2019 utilization levels in 2020 by 25%, overshadowing declines for C-section (-5%) and vaginal delivery (-18%). Comparing months in 2020 to the same months in 2019, the declines in admissions and procedures occurred at pandemic onset (March-April 2020), with some recovery starting May, but were generally not reversed by the end of 2020. Non-urgent procedures and respiratory diseases faced the largest declines in April 2020 versus April 2019 (range: -60% to -70%), followed by diseases requiring regular follow-up (-50% to -56%), then urgent conditions (-4% to -40%). During the strictest (April-May 2020) and relaxed (May-December 2020) lockdown periods compared to the same periods in 2019, the declines among the poorest (-21%, -39%) were three-times greater than in direct contributors (-7%, -12%) and two-times more in the south (-16%, -32%) than the richer north (-8%, -10%). Year-on-year admission declines across the 12 diseases and procedures (except for hemodialysis) was highest for level three hospitals. Compared to public hospitals, private hospitals had smaller year-on-year declines for procedures, because of increases in utilization in lower level private hospitals.

INTERPRETATION

COVID-19's prolonged impact on the utilization of hospital services in the Philippines suggests a looming public health crisis in countries with frail health systems. Through the periodic waves of COVID-19 and lockdowns, policymakers must employ a whole-of-health strategy considering all conditions, service delivery networks, and access for the most vulnerable.

FUNDING

Open Philanthropy.

Shortening Door-to-Needle Time by Multidisciplinary Collaboration and Workflow Optimization During the COVID-19 Pandemic

OBJECTIVES

This study aims to evaluate shortening door-to-needle time of intravenous recombinant tissue plasminogen activator of acute ischemic stroke patients by multidisciplinary collaboration and workflow optimization based on our hospital resources.

MATERIALS AND METHODS

We included patients undergoing thrombolysis with intravenous recombinant tissue plasminogen activator from January 1, 2018, to September 30, 2020. Patients were divided into pre- (January 1, 2018, to December 31, 2019) and post-intervention groups (January 1, 2020, to September 31, 2020). We conducted multi-department collaboration and process optimization by implementing 16 different measures in prehospital, in-hospital, and post-acute feedback stages for acute ischemic stroke patients treated with intravenous thrombolysis. A comparison of outcomes between both groups was analyzed.

RESULTS

Two hundred and sixty-three patients received intravenous recombinant tissue plasminogen activator in our hospital during the study period, with 128 and 135 patients receiving treatment in the pre-intervention and post-intervention groups, respectively. The median (interquartile range) door-to-needle time decreased significantly from 57.0 (45.3-77.8) min to 37.0 (29.0-49.0) min. Door-to-needle time was shortened to 32 min in the post-intervention period in the 3rd quarter of 2020. The door-to-needle times at the metrics of ≤ 30 min, ≤ 45 min, ≤ 60 min improved considerably, and the DNT> 60 min metric exhibited a significant reduction.

CONCLUSIONS

A multidisciplinary collaboration and continuous process optimization can result in overall shortened door-to-needle despite the challenges incurred by the COVID-19 pandemic.

Utilization and Outcomes of Acute Revascularization Treatments in Ischemic Stroke Patients with SARS-CoV-2 Infection

OBJECTIVES

Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy).

MATERIALS AND METHODS

We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and determined the odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders.

RESULTS

Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5-0.8, p = 0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8-5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9-2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p = 0.9) or death or non-routine discharge (p = 0.2).

CONCLUSIONS

Patients with acute ischemic stroke with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.

Hospitalization for ischemic stroke was affected more in independent cases than in dependent cases during the COVID-19 pandemic: An interrupted time series analysis

Background

The pandemic of the coronavirus disease 2019 (COVID-19) has affected health care systems globally. The aim of our study is to assess the impact of the COVID-19 pandemic on the number of hospital admissions for ischemic stroke by severity in Japan.

Methods

We analysed administrative (Diagnosis Procedure Combination—DPC) data for cases of inpatients aged 18 years and older who were diagnosed with ischemic stroke and admitted during the period April 1 2018 to June 27 2020. Levels of change of the weekly number of inpatient cases with ischemic stroke diagnosis after the declaration of state of emergency were assessed using interrupted time-series (ITS) analysis. The numbers of patients with various characteristics and treatment approaches were compared. We also performed an ITS analysis for each group (“independent” or “dependent”) divided based on components of activities of daily living (ADL) and level of consciousness at hospital admission.

Results

A total of 170,294 cases in 567 hospitals were included. The ITS analysis showed a significant decrease in the weekly number of ischemic stroke cases hospitalized (estimated decrease: −156 cases; 95% confidence interval (CI): −209 to −104), which corresponds to −10.4% (95% CI: −13.6 to −7.1). The proportion of decline in the independent group (−21.3%; 95% CI: −26.0 to −16.2) was larger than that in the dependent group (−8.6%; 95% CI: −11.7 to −5.4).

Conclusions

Our results show a marked reduction in hospital admissions due to ischemic stroke after the declaration of the state of emergency for the COVID-19 pandemic. The independent cases were affected more in proportion than dependent cases.

Investigating host-virus interaction mechanism and phylogenetic analysis of viral proteins involved in the pathogenesis

Since the emergence of yellow fever in the Americas and the devastating 1918 influenza pandemic, biologists and clinicians have been drawn to human infecting viruses to understand their mechanisms of infection better and develop effective therapeutics against them. However, the complex molecular and cellular processes that these viruses use to infect and multiply in human cells have been a source of great concern for the scientific community since the discovery of the first human infecting virus. Viral disease outbreaks, such as the recent COVID-19 pandemic caused by a novel coronavirus, have claimed millions of lives and caused significant economic damage worldwide. In this study, we investigated the mechanisms of host-virus interaction and the molecular machinery involved in the pathogenesis of some common human viruses. We also performed a phylogenetic analysis of viral proteins involved in host-virus interaction to understand the changes in the sequence organization of these proteins during evolution for various strains of viruses to gain insights into the viral origin's evolutionary perspectives.

Impact of the first COVID-19 pandemic peak and lockdown on the interventional management of carotid artery stenosis in France

OBJECTIVE

The aim of this study was to evaluate the impact of the COVID-19 pandemic on the trends of carotid revascularization (endarterectomy (CEA), transfemoral stenting (TFCAS)) for symptomatic and asymptomatic carotid stenosis before, during and after the end of the first lockdown in 2020 in France.

METHODS

Nationwide data were provided by the French National Hospital Discharge database (Programme de Médicalisation des Systèmes d'Information). We retrospectively analyzed patients admitted for CEA or TFCAS in all French public and private hospitals during a nine-month period (January-September) in 2017, 2018, 2019 and 2020. Procedures were identified using the French Common Classification of Medical Procedures. Stenoses were considered symptomatic in the presence of stroke and/or transient ischemic attack codes (according to the International Classification of Diseases-Tenth Revision) during the stay, and asymptomatic in the absence of these codes. Hospitalization rates in 2020 were compared with the rates in the same period in the three previous years.

RESULTS

Between January and September 2020, 12 546 patients were hospitalized for carotid artery surgery (CEA and TFCAS) in France. Compared with the three previous years, there was a decline in hospitalization rates for asymptomatic (-68.9%) and symptomatic (-12.6%) CEA procedures in April, starting at the pandemic peak concomitant with the first national lockdown. This decrease was significant for asymptomatic CEA (p<0.001). After the lockdown, while CEA for asymptomatic stenosis returned to usual activity, CEA for symptomatic stenosis presented a significant rebound, up 18.52% in August compared with previous years. Lockdown also had consequences on TFCAS procedures, with fewer interventions for both asymptomatic (-60.53%) and symptomatic stenosis (-16.67%) in April.

CONCLUSIONS

This study demonstrates a severe drop for all interventions during the first peak of the COVID-19 pandemic in France. However, the trends in the post-lockdown period were different for the various procedures. These data can be used to anticipate future decisions and organization for cardiovascular care.

Safety and Outcomes of Intravenous Thrombolytic Therapy in Ischemic Stroke Patients with COVID-19: CASCADE Initiative

BACKGROUND

There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19.

METHODS

This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes.

RESULTS

A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054).

CONCLUSION

IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.

Delays in Presentation Time Under the COVID-19 Epidemic in Patients With Transient Ischemic Attack and Mild Stroke: A Retrospective Study of Three Hospitals in a Japanese Prefecture

Background: Coronavirus Disease 2019 (COVID-19) has spread worldwide with collateral damage and therefore might affect the behavior of stroke patients with mild symptoms seeking medical attention.

Methods: Patients with ischemic stroke who were admitted to hospitals within 7 days of onset were retrospectively registered. The clinical characteristics, including onset-to-door time (ODT), of patients with a transient ischemic attack (TIA)/mild stroke (National Institutes of Health Stroke Scale [NIHSS] score of ≤ 3 on admission) or moderate/severe stroke were compared between those admitted from April 2019 to March 2020 (pre-COVID-19 period) and from April to September 2020 (COVID-19 period). Multivariable regression analysis was performed to identify factors associated with the ODT.

Results: Of 1,100 patients (732 men, median age, 73 years), 754 were admitted during the pre-COVID-19 period, and 346 were admitted during the COVID-19 period. The number and proportion of patients with TIA/minor stroke were 464 (61.5%) in the pre-COVID-19 period and 216 (62.4%) during the COVID-19 period. Among patients with TIA/mild stroke, the ODT was longer in patients admitted during the COVID-19 period compared with that of the pre-COVID-19 period (median 864 min vs. 508 min, p = 0.003). Multivariable analysis revealed the COVID-19 period of admission was associated with longer ODT (standardized partial regression coefficient 0.09, p = 0.003) after adjustment for age, sex, route of arrival, NIHSS score on admission, and the presence of hypertension, diabetes mellitus, and wake-up stroke. No significant change in the ODT was seen in patients with moderate/severe stroke.

Conclusions: The COVID-19 epidemic might increase the ODT of patients with TIA/mild stroke.

Emergency Department Visits, Care, and Outcome After Stroke and Myocardial Infarction During the COVID-19 Pandemic Phases

Background

It is not known if initial reductions in hospitalization for stroke and myocardial infarction early during the coronavirus disease–2019 pandemic were followed by subsequent increases. We describe the rates of emergency department visits for stroke and myocardial infarction through the pandemic phases.

Methods

We used linked administrative data to compare the weekly age- and sex-standardized rates of visits for stroke and myocardial infarction in Ontario, Canada in the first 9 months of 2020 to the mean baseline rates (2015-2019) using rate ratios (RRs) and 95% confidence intervals (CIs). We compared care and outcomes by pandemic phases (pre-pandemic was January-March, lockdown was March-May, early reopening was May-July, and late reopening was July-September).

Results

We identified 15,682 visits in 2020 for ischemic stroke (59.2%; n = 9279), intracerebral hemorrhage (12.2%; n = 1912), or myocardial infarction (28.6%; n = 4491). The weekly rates for stroke visits in 2020 were lower during the lockdown and early reopening than at baseline (RR 0.76, 95% CI [0.66, 0.87] for the largest weekly decrease). The weekly rates for myocardial infarction visits were lower during the lockdown only (RR 0.61, 95% CI [0.46, 0.77] for the largest weekly decrease), and there was a compensatory increase in visits following reopening. Ischemic stroke 30-day mortality was increased during the lockdown phase (11.5% pre-coronavirus disease; 12.2% during lockdown; 9.2% during early reopening; and 10.6% during late reopening, P = 0.015).

Conclusion

After an initial reduction in visits for stroke and myocardial infarction, there was a compensatory increase in visits for myocardial infarction. The death rate after ischemic stroke was higher during the lockdown than in other phases.

Changes in the epidemiology of patients hospitalized in France with deep venous thrombosis and pulmonary embolism during the COVID-19 pandemic

INTRODUCTION

The onset of the COVID-19 pandemic and the first national lockdown implemented might have disrupted the epidemiology of deep venous thrombosis (DVT) and pulmonary embolism (PE). This study aimed to analyze time trends in patients hospitalized for DVT and PE in France and related in-patient and 90-day post-admission mortality rates.

MATERIALS AND METHODS

All patients hospitalized in France for DVT or PE between January and September (weeks 1-40) for each year from 2017 to 2020, were selected. Weekly incidence rate ratios (IRR) were computed to compare the rates of patients hospitalized in 2020 with those hospitalized in 2017-2019.

RESULTS

Compared with the 2017-2019 study period, the rates of patients hospitalized with a primary diagnosis (PD) of DVT or PE in 2020 were significantly (50 and 40%, respectively) lower during weeks 12-13. The rate of patients hospitalized with an associated diagnosis (AD) of PE during weeks 12-19 of 2020 was twice as high as in the same period in 2017-2019. The prevalence of COVID-19 in patients hospitalized with a PD of DVT and PE, and in those hospitalized with an AD of DVT and PE reached respectively 4.0, 9.6, 17.2 and 44.6 during the country's first lockdown. Inpatients case-fatality rates in patients hospitalized with an AD of PE increased significantly during weeks 12-13.

CONCLUSIONS

Epidemiology of VT and PE was seriously impacted by the COVID-19 pandemic in 2020 in France, with a significant decrease in the rate of patients hospitalized for PE and a threefold increase in the related in-patient mortality rate. This highlight the need to inform the general population about the symptoms of PE and about the need to immediately seek medical care, particularly those infected with SARS-CoV-2.

The impact of COVID-19 on acute stroke care in Belgium

A worldwide decline in stroke hospitalizations during the COVID-19 pandemic has been reported. Information on stroke care during the pandemic in Belgium is lacking. This study aims to analyze the impact of COVID-19 on acute stroke care in eight Belgian stroke centers. This Belgian study is part of an international observational and retrospective study in 70 countries and 457 stroke centers. We compared volumes of COVID-19 and stroke hospitalizations, intravenous thrombolysis and endovascular treatment rates, acute treatment time intervals and functional outcome at 90 days during the first wave of the pandemic to two control intervals (March–May 2019 and December–February 2020). From March 2020 to May 2020, 860 stroke patients were hospitalized. In the same time period, 2850 COVID-19 patients were admitted, of which 37 (1.3%) were diagnosed with a stroke. Compared to the months prior to the pandemic and the same time epoch one year earlier, stroke hospitalizations were reduced (relative difference 15.9% [p = 0.03] and 14.5% [p = 0.05], respectively). Despite a reduction in absolute volumes, there was no difference in the monthly proportion of thrombolysis or endovascular treatment provided to the overall stroke hospitalizations. Acute treatment time metrics did not change between COVID-19 pandemic and control time epochs. We found no difference in 90-day functional outcomes nor in mortality after stroke between patients admitted during the pandemic versus control periods. We found a decline in the volume of stroke hospitalizations during the first wave of the COVID-19 pandemic in Belgium. Stroke care quality parameters remained unchanged.

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

Background and purpose

The experience gained during the first COVID‐19 wave could have mitigated the negative impact on stroke care in the following waves. Our aims were to analyze the characteristics and outcomes of patients with stroke admitted during the second COVID‐19 wave and to evaluate the differences in the stroke care provision compared with the first wave.

Methods

This retrospective multicenter cohort study included consecutive stroke patients admitted to any of the seven hospitals with stroke units (SUs) and endovascular treatment facilities in the Madrid Health Region. The characteristics of the stroke patients with or without a COVID‐19 diagnosis were compared and the organizational changes in stroke care between the first wave (25 February to 25 April 2020) and second wave (21 July to 21 November 2020) were analyzed.

Results

A total of 550 and 1191 stroke patients were admitted during the first and second COVID‐19 waves, respectively, with an average daily admission rate of nine patients in both waves. During the second wave, there was a decrease in stroke severity (median National Institutes of Health Stroke Scale 5 vs. 6; p = 0.000), in‐hospital strokes (3% vs. 8.1%) and in‐hospital mortality (9.9% vs. 15.9%). Furthermore, fewer patients experienced concurrent COVID‐19 (6.8% vs. 19.1%), and they presented milder COVID‐19 and less severe strokes. Fewer hospitals reported a reduction in the number of SU beds or deployment of SU personnel to COVID‐19 dedicated wards during the second wave.

Conclusions

During the second COVID‐19 wave, fewer stroke patients were diagnosed with COVID‐19, and they had less stroke severity and milder COVID‐19.

Impact of Coronavirus Disease 2019 on Time Delay and Functional Outcome of Mechanical Thrombectomy in Tokyo, Japan

Objectives

An association has been reported between delays in the onset-to-door (O2D) time for mechanical thrombectomy (MT) and outbreaks of coronavirus disease 2019 (COVID-19). However, the association between other MT time courses or functional outcomes and COVID-19 outbreaks remains unclear. We compared the time courses of stroke pathways or functional outcomes in 2020 (the COVID-19 era) with those in 2019 (the pre-COVID-19 era) in Tokyo, Japan.

Materials and methods

This retrospective observational study used data from the Tokyo-tama-REgistry of Acute endovascular Thrombectomy (TREAT), a multicenter registry of MT for acute large vessel occlusion in the Tokyo Metropolitan Area. Patients who had undergone acute MT from January 2019 to December 2020 were included. Patients were classified by the year they had undergone MT (2019 or 2020).

Results

In total, 477 patients were analyzed. O2D time was significantly longer in 2020 (146.0 min) than in 2019 (105.0 min; p = 0.034). No significant difference in door-to-puncture time (D2P) time or modified Rankin Scale (mRS) score 0–2 at 90 days was seen between 2019 and 2020. In the subgroup analysis, O2D time was significantly longer in the first half of 2020 compared with 2019. Multivariable logistic regression analysis revealed that the year 2020 was a independent predictor of longer O2D time, but not for mRS score 0–2 at 90 days.

Conclusions

Although O2D time was significantly longer in the COVID-19 compared with the pre-COVID-19 era, D2P may not be significantly delayed and functional outcomes may not be different, despite the COVID-19 pandemic.

Evaluation of Workflow Delays in Stroke Reperfusion Therapy: A Comparison between the Year-Long Pre-COVID-19 Period and the with-COVID-19 Period

Aim: We evaluated the delay in stroke reperfusion therapy between the pre-coronavirus disease 2019 (COVID-19) period and the with-COVID-19 period, and compared this delay between each phase of the with-COVID-19 period.

Methods: Patients with acute ischemic stroke (AIS) undergoing intravenous thrombolysis and/or mechanical thrombectomy were selected from our single-center prospective registry. The time to perform reperfusion therapy were compared between patients admitted from March 2019 to February 2020 (pre-COVID-19 group) and those from March 2020 to February 2021 (with-COVID-19 group). Patients in the with-COVID-19 group were further divided into three 4-month-long subgroups (first-phase: March to June 2020; second-phase: July to October 2020; third-phase: November 2020 to February 2021), and the time delay of reperfusion therapy were compared between these subgroups.

Results: Of 1,260 patients with AIS hospitalized in the study period, 265 patients were examined. Compared with the pre-COVID-19 group (133 patients; median age, 79 years), the with-COVID-19 group (132 patients; median age, 79 years) had a longer median door-to-imaging time (25 min vs. 27 min,P=0.04), and a longer door-to-groin puncture time (65 min vs. 72 min,P=0.02). In the three 4-month-long subgroups, the median door-to-needle time (49 min, 43 min, and 38 min, respectively;P=0.04) and door-to-groin puncture time (83 min, 70 min, and 61 min,P＜0.01, respectively) decreased significantly during the with-COVID-19 period.

Conclusions: The delay in reperfusion therapy increased during the with-COVID-19 period compared with the pre-COVID-19 period. However, the door-to-needle time and door-to-groin puncture time decreased as time elapsed during the with-COVID-19 period.

ClinicalTrials.gov Identifier: NCT02251665

Impact of natural selection on global patterns of genetic variation, and association with clinical phenotypes, at genes involved in SARS-CoV-2 infection

We investigated global patterns of genetic variation and signatures of natural selection at host genes relevant to SARS-CoV-2 infection (ACE2, TMPRSS2, DPP4, and LY6E). We analyzed novel data from 2,012 ethnically diverse Africans and 15,997 individuals of European and African ancestry with electronic health records, and integrated with global data from the 1000GP. At ACE2, we identified 41 non-synonymous variants that were rare in most populations, several of which impact protein function. However, three non-synonymous variants were common among Central African hunter-gatherers from Cameroon and are on haplotypes that exhibit signatures of positive selection. We identify strong signatures of selection impacting variation at regulatory regions influencing ACE2 expression in multiple African populations. At TMPRSS2, we identified 13 amino acid changes that are adaptive and specific to the human lineage. Genetic variants that are targets of natural selection are associated with clinical phenotypes common in patients with COVID-19.

Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature

BACKGROUND

COVID-19 infection has been known to predispose patients to both arterial and venous thromboembolic events such as deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke. A few reports from the literature suggest that Cerebral Venous Sinus Thrombosis (CVSTs) may be a direct complication of COVID-19.

OBJECTIVE

To review the clinical and radiological presentation of COVID-19 positive patients diagnosed with CVST.

METHODS

This was a multicenter, cross-sectional, retrospective study of patients diagnosed with CVST and COVID-19 reviewed from March 1, 2020 to November 8, 2020. We evaluated their clinical presentations, risk factors, clinical management, and outcome. We reviewed all published cases of CVST in patients with COVID-19 infection from January 1, 2020 to November 13, 2020.

RESULTS

There were 8 patients diagnosed with CVST and COVID-19 during the study period at 7 out of 31 participating centers. Patients in our case series were mostly female (7/8, 87.5%). Most patients presented with non-specific symptoms such as headache (50%), fever (50%), and gastrointestinal symptoms (75%). Several patients presented with focal neurologic deficits (2/8, 25%) or decreased consciousness (2/8, 25%). D-dimer and inflammatory biomarkers were significantly elevated relative to reference ranges in patients with available laboratory data. The superior sagittal and transverse sinuses were the most common sites for acute CVST formation (6/8, 75%). Median time to onset of focal neurologic deficit from initial COVID-19 diagnosis was 3 days (interquartile range 0.75-3 days). Median time from onset of COVID-19 symptoms to CVST radiologic diagnosis was 11 days (interquartile range 6-16.75 days). Mortality was low in this cohort (1/8 or 12.5%).

CONCLUSIONS

Clinicians should consider the risk of acute CVST in patients positive for COVID-19, especially if neurological symptoms develop.

The impact of the COVID-19 pandemic on cerebrovascular disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a systemic disease that affects nearly all organ systems through infection and subsequent dysregulation of the vascular endothelium. One of the most striking phenomena has been a coronavirus disease 2019 (COVID-19)–associated coagulopathy. Given these findings, questions naturally emerged about the prothrombotic impact of COVID-19 on cerebrovascular disease and whether ischemic stroke is a clinical feature specific to COVID-19 pathophysiology. Early reports from China and several sites in the northeastern United States seemed to confirm these suspicions. Since these initial reports, many cohort studies worldwide observed decreased rates of stroke since the start of the pandemic, raising concerns for a broader impact of the pandemic on stroke treatment. In this review, we provide a comprehensive assessment of how the pandemic has affected stroke presentation, epidemiology, treatment, and outcomes to better understand the impact of COVID-19 on cerebrovascular disease. Much evidence suggests that this decline in stroke admissions stems from the global response to the virus, which has made it more difficult for patients to get to the hospital once symptoms start. However, there does not appear to be a demonstrable impact on quality metrics once patients arrive at the hospital. Despite initial concerns, there is insufficient evidence to ascribe a causal relationship specific to the pathogenicity of SARS-CoV-2 on the cerebral vasculature. Nevertheless, when patients infected with SARS-CoV-2 present with stroke, their presentation is likely to be more severe, and they have a markedly higher rate of in-hospital mortality than patients with either acute ischemic stroke or COVID-19 alone.

The Impact of Coronavirus Disease 2019 Epidemic on Dizziness/Vertigo Outpatients in a Neurological Clinic in China

Objective: This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) epidemic on dizziness/vertigo outpatients in a neurological clinic in China. Methods: Against the background of the COVID-19 epidemic, the data of patients who visited the neurological clinic of Beijing Chaoyang Hospital West Branch during the pandemic (February 1-May 30, 2020) and the corresponding period in 2019 (February 1-May 30, 2019) were analyzed, and patients with dizziness/vertigo from these two periods were compared to discover their demographic features and etiologic distribution according to their age and sex. Result: The absolute number of neurological outpatients decreased from 14,670 in 2019 to 8,763 in 2020 (-40.3%), with a corresponding decline in dizziness/vertigo patients (2019: n = 856; 2020: n = 1,436, -40.4%). Dizziness/vertigo was more common in women than men in these two periods (2019: women = 63.6%; 2020: women = 63.1%, p = 0.82). The overall etiology distribution was different among all disorders between the two periods (p < 0.001). There was an increase in benign paroxysmal positional vertigo (BPPV) (2019 vs. 2020: 30.7 vs. 35%, p < 0.05) and psychogenic/persistent postural perceptual dizziness (PPPD) (2019 vs. 2020: 28.5 vs. 34.6%, p < 0.05) while a decrease in vascular vertigo during the epidemic (2019 vs. 2020: 13 vs. 9.6%, p < 0.05). During the epidemic, the top three causes of dizziness/vertigo were BPPV (35%), psychogenic/PPPD (34.6%), and vascular vertigo (9.6%). A female predominance was observed in BPPV (women = 67.7%, p < 0.05) and psychogenic/PPPD (women = 67.6%, p < 0.05). In addition, the etiology ratio of different age groups was significantly different (p < 0.001). The most common cause for young and young-old patients was BPPV, and the most common cause for middle-aged and old-old patients was psychogenic/PPPD. Conclusion: The absolute number of outpatients with dizziness/vertigo during the COVID-19 pandemic was reduced during the early period of the COVID-19 outbreak. BPPV and psychogenic/PPPD were more abundant, and vascular vertigo was less frequent. Based on those data, health-care management policy for dizziness/vertigo and mental disorder should be developed during the outbreak of COVID-19 and other infective diseases.