Changed pattern of hospital admission in stroke during COVID-19 pandemic period in Iran: a retrospective study

Epidemiology of Stroke 2 Years Before and During COVID-19 Pandemic in Kerman (south of Iran): a Hospital-Based Study

INTRODUCTION

Stroke is the second leading cause of death worldwide. Recent studies have shown that the COVID-19 pandemic has been associated with a higher frequency of stroke. This study aimed to investigate the epidemiologic aspects of stroke two years before and during the COVID-19 pandemic in Kerman.

METHOD

This cross-sectional study was conducted in Kerman. The participants included all patients with a confirmed diagnosis of stroke. COVID-19 confirmation was based on a positive PCR test. The data was analyzed with SPSS.V24 software.

RESULTS

In this study, 4152 patients with stroke were evaluated. The frequency of stroke before and during the COVID-19 pandemic was the same. The total number of stroke patients with COVID-19 was 298 (8.16%). The frequency of ischemic stroke patients before the COVID-19 pandemic was 1751 and during the pandemic was 1770. Before and after the pandemic, the mean age of ischemic stroke patients was 67.42±14.14 and 64.49±14.46 respectively, which showed a statistically significant difference (P>0.001). Our findings showed a significant difference between the NIHSS of ischemic stroke before and after the pandemic (P<0.001). The mortality rate of stroke patients was 111 before COVID-19 and 115 patients in the first two years of COVID-19. Except for the mortality rate (P<0.001), there was no significant difference in other demographic variables between ischemic stroke patients with and without COVID-19.

CONCLUSION

The patients with ischemic stroke during the COVID-19 pandemic were younger and had more neurological deficits than the ischemic stroke patients before the pandemic. COVID-19 was associated with higher mortality in patients with ischemic stroke.

Association of the COVID-19 pandemic on stroke admissions and treatment globally: a systematic review

OBJECTIVES

The COVID-19 pandemic has highlighted insufficiencies and gaps within healthcare systems globally. In most countries, including high-income countries, healthcare facilities were over-run and occupied with too few resources beyond capacity. We carried out a systematic review with a primary aim to identify the influence of the COVID-19 pandemic on the presentation and treatment of stroke globally in populations≥65 years of age.

DESIGN

A systematic review was completed. In total, 38 papers were included following full-text screening.

DATA SOURCES

PubMed, MEDLINE and Embase.

ELIGIBILITY CRITERIA

Eligible studies included observational and real-world evidence publications with a population who have experienced stroke treatment during the COVID-19 pandemic. Exclusion criteria included studies comparing the effect of the COVID-19 infection on stroke treatment and outcomes.

DATA EXTRACTION AND SYNTHESIS

Primary outcome measures extracted were the number of admissions, treatment times and patient outcome. Secondary outcomes were severity on admission, population risk factors and destination on discharge. No meta-analysis was performed.

RESULTS

This review demonstrated that 84% of studies reported decreased admissions rates during the COVID-19 pandemic. However, among those admitted, on average, had higher severity of stroke. Additionally, in-hospital stroke treatment pathways were affected by the implementation of COVID-19 protocols, which resulted in increased treatment times in 60% of studies and increased in-hospital mortality in 82% of studies by 100% on average. The prevalence of stroke subtype (ischaemic or haemorrhagic) and primary treatment methods (thrombectomy or thrombolysis) did not vary due to the COVID-19 pandemic.

CONCLUSIONS

During the COVID-19 pandemic, many populations hesitated to seek medical attention, decreasing hospital admissions for less severe strokes and increasing hospitalisation of more severe cases and mortality. The effect of the pandemic on society and healthcare systems needs to be addressed to improve stroke treatment pathways and prepare for potential future epidemics.

PROSPERO REGISTRATION NUMBER

CRD42021248564.

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.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses

Background

Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems.

Objective

To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic.

Methods

Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel.

Result

There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients.

Conclusions

COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00836-2.

Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis

Background and Purpose There are reports of decline in the rates of acute emergency presentations during coronavirus disease 2019 (COVID-19) pandemic including stroke. We performed a meta-analysis of the impact of COVID-19 pandemic on rates of stroke presentations and on rates of reperfusion therapy.Methods Following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, we systematically searched the literature for studies reporting changes in stroke presentations and treatment rates before and during the COVID-19 pandemic. Aggregated data were pooled using meta-analysis with random-effect models.Results We identified 37 observational studies (n=375,657). Pooled analysis showed decline in rates of all strokes (26.0%; 95% confidence interval [CI], 22.4 to 29.7) and its subtypes; ischemic (25.3%; 95% CI, 21.0 to 30.0), hemorrhagic (27.6%; 95% CI, 20.4 to 35.5), transient ischemic attacks (41.9%; 95% CI, 34.8 to 49.3), and stroke mimics (45.6%; 95% CI, 33.5 to 58.0) during months of pandemic compared with the pre-pandemic period. The decline was most evident for mild symptoms (40% mild vs. 25%–29% moderate/severe). Although rates of intravenous thrombolytic (IVT) and endovascular thrombectomy (EVT) decreased during pandemic, the likelihood of being treated with IVT and EVT did not differ between the two periods, both in primary and in comprehensive stroke centers (odds ratio [OR], 1.08; 95% CI, 0.94 to 1.24 and OR, 0.95; 95% CI, 0.83 to 1.09, respectively).Conclusions Rates of all strokes types decreased significantly during pandemic. It is of paramount importance that general population should be educated to seek medical care immediately for stroke-like symptoms during COVID-19 pandemic. Whether delay in initiation of secondary prevention would affect eventual stroke outcomes in the long run needs further study.

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.