Acute stroke treatment during coronavirus disease 2019 pandemic

Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

We systematically evaluated the impact of the coronavirus 2019 (COVID-19) pandemic on stroke care across the world.

METHODS

Observational studies comparing characteristics, acute treatment delivery, or hospitalization outcomes between patients with stroke admitted during the COVID-19 pandemic and those admitted before the pandemic were identified by Medline, Scopus, and Embase databases search. Random-effects meta-analyses were conducted for all outcomes.

RESULTS

We identified 46 studies including 129 491 patients. Patients admitted with stroke during the COVID-19 pandemic were found to be younger (mean difference, -1.19 [95% CI, -2.05 to -0.32]; I²=70%) and more frequently male (odds ratio, 1.11 [95% CI, 1.01-1.22]; I²=54%) compared with patients admitted with stroke in the prepandemic era. Patients admitted with stroke during the COVID-19 pandemic, also, had higher baseline National Institutes of Health Stroke Scale scores (mean difference, 0.55 [95% CI, 0.12-0.98]; I²=90%), higher probability for large vessel occlusion presence (odds ratio, 1.63 [95% CI, 1.07-2.48]; I²=49%) and higher risk for in-hospital mortality (odds ratio, 1.26 [95% CI, 1.05-1.52]; I²=55%). Patients with acute ischemic stroke admitted during the COVID-19 pandemic had higher probability of receiving endovascular thrombectomy treatment (odds ratio, 1.24 [95% CI, 1.05-1.47]; I²=40%). No difference in the rates of intravenous thrombolysis administration or difference in time metrics regarding onset to treatment time for intravenous thrombolysis and onset to groin puncture time for endovascular thrombectomy were detected.

CONCLUSIONS

The present systematic review and meta-analysis indicates an increased prevalence of younger patients, more severe strokes attributed to large vessel occlusion, and higher endovascular treatment rates during the COVID-19 pandemic. Patients admitted with stroke during the COVID-19 pandemic had higher in-hospital mortality. These findings need to be interpreted with caution in view of discrepant reports and heterogeneity being present across studies.

Effect of the COVID-19 Pandemic on Patient Volumes, Acuity, and Outcomes in Pediatric Emergency Departments: A Nationwide Study

OBJECTIVES

The aim of this study was to quantify the effect of the COVID-19 pandemic on pediatric emergency department (ED) utilization and outcomes.

METHODS

This study is an interrupted-time-series observational study of children presenting to 11 Canadian tertiary-care pediatric EDs. Data were grouped into weeks in 3 study periods: prepandemic (January 1, 2018-January 27, 2020), peripandemic (January 28, 2020-March 10, 2020), and early pandemic (March 11, 2020-April 30, 2020). These periods were compared with the same time intervals in the 2 preceding calendar years. Primary outcomes were number of ED visits per week. The secondary outcomes were triage acuity, hospitalization, intensive care unit (ICU) admission, mortality, length of hospital stay, ED revisits, and visits for trauma and mental health concerns.

RESULTS

There were 577,807 ED visits (median age, 4.5 years; 52.9% male). Relative to the prepandemic period, there was a reduction [-58%; 95% confidence interval (CI), -63% to -51%] in the number of ED visits during the early-pandemic period, with concomitant higher acuity. There was a concurrent increase in the proportion of ward [odds ratio (OR), 1.39; 95% CI, 1.32-1.45] and intensive care unit (OR, 1.20; 95% CI, 1.01-1.42) admissions, and trauma-related ED visits among children less than 10 years (OR, 1.51; 95% CI, 1.45-1.56). Mental health-related visits in children declined in the early-pandemic period (in <10 years, -60%; 95% CI, -67% to -51%; in children ≥10 years: -56%; 95% CI, -63% to -47%) relative to the pre-COVID-19 period. There were no differences in mortality or length of stay; however, ED revisits within 72 hours were reduced during the early-pandemic period (percent change: -55%; 95% CI, -61% to -49%; P < 0.001).

CONCLUSIONS

After the declaration of the COVID-19 pandemic, dramatic reductions in pediatric ED visits occurred across Canada. Children seeking ED care were sicker, and there was an increase in trauma-related visits among children more than 10 years of age, whereas mental health visits declined during the early-pandemic period. When faced with a future pandemic, public health officials must consider the impact of the illness and the measures implemented on children's health and acute care needs.

[Association of COVID-19 and Stroke: Pathophysiology and Clinical Relevance]

Dass COVID-19 mit einem erhöhten Risiko für das Auftreten ischämischer Schlaganfälle einhergeht, wurde bereits in den ersten Monaten nach dem weltweiten Bekanntwerden des Ausbruchs der Pandemie im Ground Zero Wuhan deutlich. Spätere Kohortenanalysen, Fallserien und Meta-Analysen bestätigten diesen Zusammenhang. Eine nicht unerhebliche geographische Variabilität der Prävalenz COVID-19-bezogener Schlaganfälle verdeutlicht allerdings den fortbestehenden Bedarf an umfassenden epidemiologischen Analysen. Im Übrigen fanden sich zunehmend Hinweise dafür, dass dem mit COVID-19 assoziierten Schlaganfall ein multifaktorieller pathophysiologischer Mechanismus zugrundeliegenden könnte. Neben einer durch die SARS-CoV-2-Infektion verursachten Hyperkoagubilität, die sowohl im mikrovaskulären System als auch in Großgefäßen thrombogen wirkt, scheinen vaskulitische arterielle Veränderungen und kardiogene Embolien infolge virusassoziierter myokardialer Schädigung bei der Ätiologie des COVID-19-assoziierten Schlaganfalls eine Rolle zu spielen. Die Versorgung von Schlaganfallpatienten/innen in Zeiten der Pandemie durch multidisziplinäre Teams scheint in insgesamt kompensierten Kliniken im Wesentlichen nicht kompromittiert zu sein. Hinweise, dass Patienten/innen mit COVID-19-assoziiertem Schlaganfall von einem intensivierten Monitoring und einer aggressiveren Sekundärprävention profitieren, bedarf klinischer Prüfung.