Effects of the COVID-19 pandemic on stroke response times: a systematic review and meta-analysis

Recent Updates on COVID-19 Associated Strokes

The SARS-CoV-2 virus is primarily a respiratory virus, but, as it spread worldwide, it became apparent that there are multiple extrapulmonary manifestations. Reports arose of young and otherwise healthy patients presenting to emergency departments with large-vessel occlusions. Because of a rapidly evolving pandemic, conflicting data sometimes arose regarding the impact of the pandemic on strokes. COVID-19 can induce a hypercoagulable and a proinflammatory state through the interactions with the ACE-2 receptor. These mechanisms may lead to the strokes, both ischemic and hemorrhagic, that are seen in this infection. Strokes, in conjunction with COVID-19 infection, tended to be more disabling and portended a higher mortality. Treatment of these strokes was challenging, as emergency departments were strained with the high burden of COVID-19 admissions. Finally, vaccines against COVID-19 were widely administered, and their potential to cause stroke as an adverse event are discussed. This article will provide an in depth review of the recent updates about the incidence, epidemiology, pathophysiology, clinical presentation and treatment of strokes that are associated with COVID-19.

Did the COVID-19 pandemic reshape equity in healthcare use in Europe?

Promoting equity in healthcare use requires to respect both principles of horizontal equity, that guarantees everyone the same use of healthcare for a given level of need, and vertical equity, that requires the sickest to receive more care than others, in a proportion deemed appropriate. This study explores the extent to which horizontal and vertical equity in healthcare use among individuals aged 50+ in Europe has been restructured during the COVID-19 pandemic. Using the variance as an inequality measure, we assess horizontal equity in healthcare use based on the fairness gap approach and propose two new measures of vertical equity. The sample includes 24,965 respondents of the SHARE survey from 18 European countries, who participated in wave 8 just before the pandemic and the second SHARE Corona survey in 2021. These data provide information on use of physician and hospital care over the year for each period, as well as on a wide range of health and socio-economic variables. Although pro-rich inequities in healthcare use were observed in some countries before the outbreak, our results do not reveal any significant evolution in horizontal equity during the pandemic. Conversely, vertical equity in healthcare use would have significantly declined in most countries, especially in Central or Eastern Europe. Telemedicine appears to have played a protective role against this decline in vertical equity in countries where it was heavily used during the pandemic. Our results support the case for public policies aimed at restoring access to care for individuals with the highest needs.

Performance and clinical outcomes in telestroke remain robust during the COVID-pandemic: insight into the NEVAS network

BACKGROUND

The COVID-19 pandemic had significant impact on global healthcare, including stroke management. Telemedical stroke networks have emerged with positive results for patient outcome in rural areas without stroke expertise. However, telestroke faced enormous on-site challenges during the pandemic. So far, data on performance and clinical outcomes in telestroke settings during the COVID-pandemic are scarce.

METHODS

We retrospectively analyzed data from stroke patients treated in four spoke hospitals of the Bavarian telestroke network NEVAS in 2020-2021 and 2019 as reference year and compared the 3 years for various parameters. Primary outcome was functional outcome according to the modified Rankin scale (mRS). Secondary outcome parameters included time intervals, periprocedural intracranial hemorrhage rates, and mortality.

RESULTS

In 2019-2021, 2820 patients were treated for acute ischemic stroke with an admission decrease of 10% during the pandemic. Of those, 241 received only IVT and 204 were transferred to our center for MT. Door-to-imaging, door-to-needle, and symptom-onset-to-groin times remained comparable in the 3 years. Complication rates remained at a low level. Good clinical outcome rates (mRS 0-2) at discharge remained stable for all stroke patients (82-84%) and for those treated with IVT (64-77%). Good clinical outcome rates at 3 month follow-up for MT patients declined in 2020 (23% vs. 35% in 2019) but recovered again in 2021 (42%). Mortality rates did not increase for all patient groups analyzed.

CONCLUSIONS

Stroke care remained robust during the COVID-pandemic within our network, indicating that well-established telestroke networks can overcome unexpected critical challenges such as a pandemic, guaranteeing best practice stroke care in rural areas.

Development and Validation of a Predictive Score for Three-Year Mortality in Acute Ischemic Stroke Patients

Background and Objectives: Acute ischemic stroke (AIS) is a leading cause of death and disability with poor long-term outcomes. Creating a predictive score for long-term mortality in AIS might be important for optimizing treatment strategies. The aim of this study is to develop and validate a predictive score for three-year mortality in patients with AIS using several demographic, clinical, laboratory and imaging parameters. Materials and Methods: This study included 244 AIS patients admitted to a tertiary center and followed up for three years. The patients' data included demographics, clinical features, laboratory tests (including resistin and leptin levels) and imaging parameters. The patients were randomly divided into a predictive group (n = 164) and a validation group (n = 80). Results: Advanced age, a high NIHSS score, low levels of hemoglobin, elevated resistin levels and the presence of carotid plaques were independently associated with three-year mortality. The predictive model incorporated these variables, and it was validated in a separate cohort. Leptin levels did not significantly predict mortality. Conclusions: This study developed and validated a promising predictive score for three-year mortality in patients with AIS. Advanced age, high NIHSS scores, low hemoglobin levels, elevated resistin levels and the presence of carotid plaques were the independent predictors of long-term mortality.

Angiographic demonstration of a cutoff sign as an unfavorable prognostic indicator for patients with acute ischemic stroke undergoing mechanical thrombectomy

OBJECTIVES

The aim was to investigate whether the angiographic demonstration of a cutoff sign on the initial angiogram could predict recanalization and prognosis in acute ischemic stroke patients treated by endovascular thrombectomy.

METHODS

The angiographic and clinical data of patients who underwent endovascular treatment from October 2018 to April 2023 were retrospectively reviewed. The pretreatment angiographic appearance of the thrombus's proximal part was assessed and classified as either the cutoff sign (+) or (-). Patients' baseline characteristics and angiographic and clinical outcomes between the two groups were analyzed using propensity score matching. Then, the two commonly used techniques, stent retrieval and contact aspiration, were compared in terms of successful reperfusion and clinical outcome in patients with the cutoff sign.

RESULTS

The cutoff sign was observed in 77 (36.2%) of 213 patients. Patients with the cutoff sign were younger and were less likely to have involvement of the anterior circulation. Compared with the cutoff sign (-) group, the cutoff sign (+) group had a significantly longer procedure time (103 versus 80 min, P =0.002) and a lower percentage of 3-month good functional outcomes (18.2% versus 36%, P =0.006). After propensity score matching, the procedure time (100 versus 75 min, P =0.002) and the 3-month good outcome (19.2% versus 41.4%, P =0.004) remained significantly different. No significant differences were observed in the radiological (OR 0.758, 95% CI 0.157 to 3.658; P =0.730) and clinical (OR 0.747, 95% CI 0.147 to 3.787; P =0.725) outcomes between the two techniques.

CONCLUSIONS

The cutoff sign might be an unfavorable prognostic indicator in patients undergoing mechanical thrombectomy, and the efficacy of mechanical thrombectomy techniques does not differ in patients positive for the cutoff sign.

Patient factors associated with treatment time for stroke before and after the onset of COVID-19

OBJECTIVES

Prior to our study, little was known about factors related to time-to-treatment for stroke pre- and post-COVID-19.

DESIGN

This was a retrospective cohort study to evaluate factors associated with delayed door-to-needle time among patients with acute ischemic stroke over two time-periods.

RESULTS

Final sample consisted of 932 charts with mean age of 68.1(±15.6). Significant factors associated with shorter door-to-needle time included ≤ four hours since symptom onset and stroke occurring during post-Covid-19 time-period. Those on anti-coagulants had 72 % higher odds of longer door-to-needle time. As patients got older and stroke symptoms were more severe, less time was spent in door-to-imaging.

CONCLUSION

Results highlight the importance of early recognition of stroke symptoms and rapid transport to the hospital. Faster response times in post-Covid-19 time-period may be attributable to systematic processes put in place to address pandemic-related challenges. Outcomes may depend on research to identify gaps in stroke treatment.

Epidemiology, pathogenesis, and management of Coronavirus disease 2019-associated stroke

The Coronavirus disease 2019 (COVID-19) epidemic has triggered a huge impact on healthcare, socioeconomics, and other aspects of the world over the past three years. An increasing number of studies have identified a complex relationship between COVID-19 and stroke, although active measures are being implemented to prevent disease transmission. Severe COVID-19 may be associated with an increased risk of stroke and increase the rates of disability and mortality, posing a serious challenge to acute stroke diagnosis, treatment, and care. This review aims to provide an update on the influence of COVID-19 itself or vaccines on stroke, including arterial stroke (ischemic stroke and hemorrhagic stroke) and venous stroke (cerebral venous thrombosis). Additionally, the neurovascular mechanisms involved in SARS-CoV-2 infection and the clinical characteristics of stroke in the COVID-19 setting are presented. Evidence on vaccinations, potential therapeutic approaches, and effective strategies for stroke management has been highlighted.

Cost-Effectiveness of Cerebrolysin after Ischemic Stroke: Secondary Analysis of the CARS Study

The cost-effectiveness of Cerebrolysin as an add-on therapy for moderate-severe acute ischemic stroke is a topic that remains understudied. This study aims to address this gap by performing a comprehensive cost-utility analysis using both deterministic and probabilistic methods from a payer perspective and within the Romanian inpatient care setting. Quality-adjusted life years (QALYs) were calculated using partial individual patient data from the 2016 Cerebrolysin and Recovery After Stroke (CARS) trial, utilizing three different health state valuation models. Cost data was extracted from actual acute care costs reported by Romanian public hospitals for reimbursement purposes for patients included in the CARS study. Incremental cost-effectiveness ratios were calculated for each treatment arm for the duration of the clinical trial. Deterministic analysis based on sample mean values indicates Cerebrolysin would be cost-effective at a threshold between roughly 18.8 and 29.9 thousand EUR, depending on valuation techniques. Probabilistic sensitivity analysis results indicate an 80% chance probability of cost-effectiveness of Cerebrolysin as an add-on therapy for acute ischemic stroke, considering a willingness-to-pay threshold of 50,000 EUR in a 90-day timeframe after stroke. Further economic evaluations of Cerebrolysin are needed to strengthen these findings, covering a timeframe of at least 12 months after the acute incident, which would account for treatment effects spanning beyond the first 90 days after ischemic stroke. These should be conducted to determine its cost-effectiveness under various care settings and patient pathways. Most importantly, modelling techniques are needed to answer important questions such as the estimates of population gain in QALYs after acute administration of Cerebrolysin and the potential offsetting of direct medical costs as a result of administering the intervention.

Neurological consequences of COVID-19

In December 2019, cases of pneumonia caused by infection with the previously unknown severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to coronavirus disease 2019 (COVID-19), were identified. Typical manifestations of COVID-19 are fever, cough, fatigue and dyspnoea. Initially, it was thought that the mechanism of action of SARS-CoV-2 was only associated with respiratory tract invasion, but it was later revealed that the infection might involve many other organs and systems, including the central and peripheral nervous systems. Neurological complications associated with SARS-CoV-2 infection include encephalopathy, encephalitis, meningitis, acute disseminated encephalomyelitis (ADEM), ischaemic and haemorrhagic stroke and cerebral venous sinus thrombosis. In cases of peripheral nervous system involvement, smell and taste disorders, myopathy or the signs and symptoms of Guillain‒Barré syndrome are observed. The most common early neurological complications, particularly during the first year of the epidemic, were anosmia and taste disorders, which, according to some studies, occurred in over 80 percent of patients with COVID-19. The proportion of patients with serious neurological manifestations was small compared to the global number of patients, but the numbers of SARS-CoV-2 infections and critical patients increased substantially. The experience from 2 years of the pandemic has shown that approximately 13% of infected patients suffer from severe neurological complications. The relationship between SARS-CoV-2 and the nervous system is not only a cause of neurological complications in previously healthy individuals but also directly and indirectly affects the courses of many nervous system diseases.