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Gunnarsson K, Tofiq A, Mathew A, Cao Y, von Euler M, Ström JO. Changes in stroke and TIA admissions during the COVID-19 pandemic: A meta-analysis. Eur Stroke J 2024; 9:78-87. [PMID: 37776062 PMCID: PMC10916820 DOI: 10.1177/23969873231204127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023] Open
Abstract
PURPOSE To perform a meta-analysis on how the admissions of stroke and transient ischemic attack (TIA) changed during the Corona Virus infection-19 (COVID-19) pandemic and evaluate if the effect was depending on stroke severity. METHODS Observational cohort studies comparing the number of stroke and/or TIA admissions during a period of the pandemic compared to a period before the pandemic were identified in PubMed and Embase. After excluding studies with overlapping populations and studies without satisfactory case ascertainment, data was extracted and meta-analyzed. FINDINGS A total of 59 studies were included. During the pandemic, there was a decrease in admissions of ischemic stroke (admission rate ratio (ARR) = 0.77, 95% confidence interval (CI): 0.72, 0.82), intracerebral hemorrhage (ARR = 0.79, 95% CI: 0.70, 0.90) and TIA (ARR = 0.66, 95% CI: 0.58, 0.75). Albeit admission rates of both mild (ARR = 0.61, 95% CI: 0.49, 0.77) and severe (ARR = 0.82, 95% CI = 0.71, 0.95) strokes decreased, milder strokes decreased more (proportion ratio (PR) = 0.76, 95% CI: 0.65, 0.89). DISCUSSION Potential causes for the admission reduction could be strict prioritizations within the health care, patients' fear of acquiring COVID-19, or decreased access to health care due to lockdowns. CONCLUSION During the COVID-19 pandemic, there was a reduction in admissions of stroke and TIA, possibly caused by reluctance to seek medical care.
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Affiliation(s)
- Karin Gunnarsson
- Department of Neurology and rehabilitation, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Avin Tofiq
- Department of Neurology and rehabilitation, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Alen Mathew
- Department of Neurology and rehabilitation, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Department of Neurology and rehabilitation, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Jakob O Ström
- Department of Neurology and rehabilitation, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
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Ramachandran D, George GB, Panicker P, Aravind R, Suresh MK, Iype T. COVID-19 and Stroke Trends in A Tertiary Care Center from South India -Our Monsoon Experience. Neurol India 2022; 70:1942-1946. [PMID: 36352591 DOI: 10.4103/0028-3886.359188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The unprecedented challenges during the COVID pandemic and the subsequent lockdown had resulted in a delay in treatment metrics for acute stroke. There is a rising concern that COVID-19 co-infection can adversely affect stroke outcome. We aim to investigate the impact of COVID-19 in the management of stroke patients. We also compared the differences in stroke manifestations, etiological pattern, treatment course, and outcome of acute stroke patients in COVID-19 confirmed cases. METHODOLOGY A single-center retrospective study was done at the Stroke Unit, Government Medical College, Thiruvananthapuram. Consecutive patients of acute stroke confirmed by imaging, presenting within 24 hours of the onset of symptoms in May to July 2020 and May to July 2019, were included. The primary data variables included baseline demographics, risk factors, admission NIHSS, stroke timings, thrombolysis rate, TOAST etiology, mRS at discharge, and in-hospital mortality. RESULTS Strokes with higher NIHSS, arrival blood sugar and blood pressure, and delays in door-to-CT and door-to-needle time were more during the pandemic. Intravenous thrombolysis was less and mortality was higher in COVID-19 strokes during the pandemic. COVID-19-positive stroke patients had more hemorrhagic strokes, more severe strokes with low CT ASPECTS, more hemorrhagic transformation, high in-hospital mortality, and poor functional outcome at discharge and 3 months. CONCLUSION Our study was a hypothesis-generating study with a limited number of patients. This study has reconfirmed the higher severity of the stroke, with a higher mRS score and mortality during the pandemic, especially among COVID-19-positive stroke patients.
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Affiliation(s)
- Dileep Ramachandran
- Departments of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Githin Benoy George
- Departments of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Praveen Panicker
- Departments of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - R Aravind
- Department of Infectious Disease, Government Medical College, Thiruvananthapuram, Kerala, India
| | - M K Suresh
- Department of General Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Thomas Iype
- Departments of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
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Akhtar N, Abid F, Singh R, Kamran S, Imam Y, Al-Jerdi S, Salamah S, Al Attar R, Yasir M, Shabir H, Morgan D, Joseph S, AlMaslamani M, Shuaib A. Ischemic stroke in patients that recover from COVID-19: Comparisons to historical stroke prior to COVID-19 or stroke in patients with active COVID-19 infection. PLoS One 2022; 17:e0270413. [PMID: 35749524 PMCID: PMC9232148 DOI: 10.1371/journal.pone.0270413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background and purpose Understanding the relationship of COVID-19 to stroke is important. We compare characteristics of pre-pandemic historical stroke (Pre-C), cases in acute COVID infection (Active-C) and in patients who have recovered from COVID-19 infection (Post-C). Methods We interrogated the Qatar stroke database for all stroke admissions between Jan 2019 and Feb 2020 (Pre-C) to Active-C (Feb2020-Feb2021) and Post-C to determine how COVID-19 affected ischemic stroke sub-types, clinical course, and outcomes prior to, during and post-pandemic peak. We used the modified Rankin Scale (mRS) to measure outcome at 90-days (mRS 0–2 good recovery and mRS 3–6 as poor recovery). For the current analysis, we compared the clinical features and prognosis in patients with confirmed acute ischemic stroke. Results There were 1413 cases admitted (pre-pandemic: 1324, stroke in COVID-19: 46 and recovered COVID-19 stroke: 43). Patients with Active-C were significantly younger, had more severe symptoms, fever on presentation, more ICU admissions and poor stroke recovery at discharge when compared to Pre-C and Post-C. Large vessel disease and cardioembolic disease was significantly more frequent in Active-C compared to PRE-C or post-C. Conclusions Stroke in Post-C has characteristics similar to Pre-C with no evidence of lasting effects of the virus on the short-term. However, Active-C is a more serious disease and tends to be more severe and have a poor prognosis.
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Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Fatma Abid
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Cardiology Research, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yahia Imam
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Sarah Salamah
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Rand Al Attar
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Yasir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Hammad Shabir
- Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Deborah Morgan
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Muna AlMaslamani
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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Akhtar N, Abid F, Singh R, Kamran S, Imam Y, Al Jerdi S, Salameh S, Al Attar R, Yasir M, Shabir H, Morgan D, Joseph S, AlMaslamani M, Shuaib A. Characteristics and comparisons of acute stroke in "recovered" to "active COVID-19 and "pre-pandemic" in Qatar database. J Thromb Thrombolysis 2022; 53:824-828. [PMID: 35244832 PMCID: PMC8894126 DOI: 10.1007/s11239-021-02581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 12/02/2022]
Abstract
Understanding the relationship of COVID-19 to stroke is important. We compare characteristics of pre-pandemic stroke (PPS), cases in acute COVID infection (CS) and in patients who have recovered from COVID-19 infection (RCS). We interrogated the Qatar stroke database for all stroke admissions between Jan 2020 and Feb 2021 (PPS) to CS and RCS to determine how COVID-19 affected ischemic stroke sub-types, clinical course, and outcomes prior to, during and post-pandemic peak. There were 3264 cases admitted (pre-pandemic: 3111, stroke in COVID-19: 60 and recovered COVID-19 stroke: 93). Patients with CS were significantly younger, had more severe symptoms, fever on presentation, more ICU admissions and poor stroke recovery at discharge when compared to PPS and RCS. Large vessel disease and cardioembolic disease was significantly higher in CS compared to PPS or RCS. There was a significant decline in stroke mimics in CS. Stroke in RCS has characteristics similar to PPS with no evidence of lasting effects of the virus on the short-term. However, CS is a more serious disease and tends to be more severe and have a poor prognosis.
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Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Fatma Abid
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Cardiology Research, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yahia Imam
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Sarah Salameh
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Rand Al Attar
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Yasir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Hammad Shabir
- Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Deborah Morgan
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Muna AlMaslamani
- Infectious Diseases Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, AB Canada
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Akhtar N, Kamran S, Al-Jerdi S, Imam Y, Joseph S, Morgan D, Abokersh M, Uy RT, Shuaib A. Trends in stroke admissions before, during and post-peak of the COVID-19 pandemic: A one-year experience from the Qatar stroke database. PLoS One 2022; 17:e0255185. [PMID: 35324905 PMCID: PMC8947388 DOI: 10.1371/journal.pone.0255185] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/10/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several reports document a decrease in the rates of stroke hospital admissions during the covid-19 pandemic. There is very little information whether the admission rates will change as the infection is controlled. We report on our rates of admissions before, during and following the peak of covid-19 infections in a prospective database from Qatar. METHODS AND RESULTS The stroke admissions in the six months prior to COVID-19 pandemic averaged 229/month. There was a decrease to 157/month in March-June during the peak of the pandemic. In the 6 months following the peak, as covid-19 numbers began to decrease, the average numbers increased back to 192/month. There was an increase in severe ischemic strokes and decreased in functional recovery. The decreased admissions were mainly driven by fewer stroke mimics. Patients presenting with ischemic stroke or cerebral hemorrhage remained unchanged. CONCLUSIONS Fewer stroke mimics presenting to the hospital can explain the fewer admissions and poor outcome at the height of the covid-19 pandemic. The continued decrease in the number of ischemic stroke and stroke mimic admissions following the pandemic peak requires more study.
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Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Salman Al-Jerdi
- Weill Cornell Medical College- Qatar Foundation, Doha, Qatar
| | - Yahia Imam
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Deborah Morgan
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Abokersh
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - R. T. Uy
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, Canada
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Ishaque N, Butt AJ, Kamtchum-Tatuene J, Nomani AZ, Razzaq S, Fatima N, Vekhande C, Nair R, Akhtar N, Khan K, Saqqur M, Shuaib A. Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis. J Stroke 2022; 24:65-78. [PMID: 35135061 PMCID: PMC8829489 DOI: 10.5853/jos.2021.01571] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 09/05/2021] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Noman Ishaque
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Asif Javed Butt
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ali Zohair Nomani
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Red Deer Regional Hospital Center, Red Deer, AB, Canada
| | - Sarah Razzaq
- Department of Medicine, Fatima Jinnah Medical University, Lahore, Pakistan
| | - Nida Fatima
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chetan Vekhande
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Naveed Akhtar
- Division of Neurology, Department of Medicine, Hamad General Hospital, Doha, Qatar
| | - Khurshid Khan
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Maher Saqqur
- Department of Neurology, Trillium Health Care, University of Toronto, Mississauga, ON, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Correspondence: Ashfaq Shuaib Division of Neurology, Department of Medicine, University of Alberta, Edmonton T6G 2G3, AB, Canada Tel: +1-780-248-1660 Fax: +1-780-248-1807 E-mail:
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Al Hashmi A, von Bandemer S, Shuaib A, Mansour OY, Wassy M, Ozdemir AO, Farhoudi M, Al Jehani H, Khan A, John S, Saqqur M. 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. J Neurol Sci 2022; 432:120060. [PMID: 34864375 PMCID: PMC8626147 DOI: 10.1016/j.jns.2021.120060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 10/22/2021] [Accepted: 11/17/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Amal Al Hashmi
- Neuroscience Directorate, Khoula Hospital Ministry of Health of Oman, Muscat, Sultanate of Oman.
| | - Stephan von Bandemer
- Division of Health Service Research, Institute of Work and Technology, Gelsenkirchen, Germany.
| | - Ashfaq Shuaib
- Medicine and Neurology, Director Stroke Program, University of Alberta, Edmonton, AB, Canada.
| | - Ossama Yassin Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt.
| | | | - Atilla Ozcan Ozdemir
- Interventional Neurology &Neurocritical Care Program, Eskisehir Osmangazi University, Turkey.
| | - Mehdi Farhoudi
- Neuroscience Research Center, Tabriz University, Islamic Republic of Iran.
| | - Hosam Al Jehani
- Department of Neurosurgery and Interventional Radiology, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Adnan Khan
- Department of Medicine, Research Division, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Seby John
- Neurology and Neurointerventional Surgery, Neurological Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates.
| | - Maher Saqqur
- University of Alberta Edmonton, Canada; Trillium Hospital, University of Toronto at Mississauga, Mississauga, ON. Canada.
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