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Belau MH, Misselwitz B, Meyding-Lamadé U, Bassa B. Trends in stroke severity at hospital admission and rehabilitation discharge before and during the COVID-19 pandemic in Hesse, Germany: a register-based study. Neurol Res Pract 2024; 6:18. [PMID: 38449050 PMCID: PMC10918907 DOI: 10.1186/s42466-024-00308-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has affected acute stroke care, resulting in a decrease in stroke admissions worldwide. We examined trends in stroke severity at hospital admission, including (1) probable need for rehabilitation (National Institutes of Health Stroke Scale score > 6 points) and (2) probable need for assistance (modified Rankin Scale score > 2 points), and discharge to rehabilitation after acute care among inpatients with acute ischemic stroke and intracerebral hemorrhage. METHODS We compared quality assurance data for acute ischemic stroke and intracerebral hemorrhage during the pandemic with the period before the pandemic in Hesse, Germany, using logistic regression analyses. RESULTS Fewer inpatients with a probable need for rehabilitation were present at the beginning of the second wave of the COVID-19 pandemic in September 2020 (adjusted OR (aOR) 0.85, 95% CI [0.73, 0.99]), at the end of the second national lockdown in May 2021 (aOR 0.81, 95% CI [0.70, 0.94]), and at the approaching peak of COVID-19 wave 4 in November 2021 (aOR 0.79, 95% CI [0.68, 091]). Rates of probable need for assistance were significantly lower at the beginning of COVID-19 wave 2 in August 2020 (aOR 0.87, 95% CI [0.77, 0.99]) and at the beginning of COVID-19 wave 3 in March 2021 (aOR 0.80, 95% CI [0.71, 0.91]). Rates of discharge to rehabilitation were lower from the beginning in October 2020 to the peak of COVID-19 wave 2 in December 2020 (aOR 0.83, 95% CI [0.77, 0.90]), at the beginning and end of COVID-19 wave 3 in March 2021 and May 2021 (aOR 0.86, 95% CI [0.79, 0.92]), respectively, and at the beginning of COVID-19 wave 4 in October 2021 (aOR 0.86, 95% CI [0.76, 0.98]). CONCLUSIONS The results suggest that the COVID-19 pandemic had an impact on stroke management during the pandemic, but the absolute difference in stroke severity at hospital admission and discharge to rehabilitation was small.
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Affiliation(s)
- Matthias Hans Belau
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Björn Misselwitz
- Federal State Consortium of Quality Assurance Hesse, Eschborn, Germany
| | - Uta Meyding-Lamadé
- Department of Neurology, Krankenhaus Nordwest, Frankfurt (Main), Germany
| | - Burc Bassa
- Department of Neurology, Krankenhaus Nordwest, Frankfurt (Main), Germany
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Assylbek MI, Kocyigit BF, Yessirkepov M, Zimba O. Post-stroke rehabilitation in the peri-pandemic COVID-19 era. Rheumatol Int 2024; 44:399-411. [PMID: 38253904 DOI: 10.1007/s00296-023-05520-1] [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] [Received: 10/31/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024]
Abstract
The coronavirus disease 2019 (COVID-19), which arose in late 2019, caused extensive destruction, impacting a substantial proportion of the worldwide population and leading to millions of deaths. Although COVID-19 is mainly linked to respiratory and pulmonary complications, it has the potential to affect neurologic structures as well. Neurological involvement may manifest as minimal and reversible; however, a notable proportion of cases have exhibited pronounced neurological consequences, such as strokes. Endothelial inflammation, hypercoagulation, renin-angiotensin-aldosterone system alterations, and cardiogenic embolism are the pathophysiological mechanisms of stroke under COVID-19 circumstances. Physical activity and exercise have improved several aspects of post-stroke recovery, including cardiovascular health, walking capacity, and upper limb strength. They are commonly used to assist stroke survivors in overcoming their motor restrictions. Furthermore, stroke rehabilitation can incorporate a range of specific techniques, including body-weight-supported treadmill applications, constraint-induced movement therapy, robotic rehabilitation interventions, transcranial direct current stimulation, transcranial magnetic stimulation, and prism adaptation training. Under pandemic conditions, there were several barriers to neurological rehabilitation. The most significant of these were individual's fear of infection, which caused them to postpone their rehabilitation applications and rehabilitation areas being converted into COVID-19 units. The primary emphasis had turned to COVID-19 treatment. Several valuable data and views were gained in reorganizing rehabilitation during the pandemic, contributing to establishing future views in this regard.
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Affiliation(s)
- Meirgul I Assylbek
- Department of Neurology, Psychiatry, Neurosurgery and Rehabilitation, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
- Department of Social Health Insurance and Public Health, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
- Medical Center ''Mediker'', Shymkent, Kazakhstan
| | - Burhan Fatih Kocyigit
- Department of Physical Medicine and Rehabilitation, Adana Health Practice and Research Center, University of Health Sciences, Adana, Turkey.
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Olena Zimba
- Department of Clinical Rheumatology and Immunology, University Hospital in Krakow, Krakow, Poland
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Internal Medicine N2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
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Hegenberg K, Althammer A, Gehring C, Prueckner S, Trentzsch H. Pre-Hospital Emergency Medical Services Utilization Amid COVID-19 in 2020: Descriptive Study Based on Routinely Collected Dispatch Data in Bavaria, Germany. Healthcare (Basel) 2023; 11:1983. [PMID: 37510425 PMCID: PMC10379196 DOI: 10.3390/healthcare11141983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND AND IMPORTANCE The COVID-19 pandemic affected the utilization of health care services and posed organizational challenges. While many previous studies focused on the misuse of pre-hospital EMS for low-urgency health problems, the pandemic has put more emphasis on the avoidance of medically necessary calls. OBJECTIVE To compare the utilization of pre-hospital emergency medical services before and after specific pandemic periods. DESIGN, SETTING AND PARTICIPANTS This was a retrospective, descriptive analysis of routine data from 26 dispatch centers in Bavaria, Germany. OUTCOMES MEASURE AND ANALYSIS We investigated the number of emergencies per 100,000 population, as well as the relative change in the emergency rates and transport rates in 2020, compared to the two previous years. Boxplots showed the distributions across the Bavarian districts per calendar week. The mean rates and standard deviations as well as the relative changes were presented for the specific periods. A paired samples t-test was used to compare the rates. MAIN RESULTS Compared to the average of the two previous years, the emergency rates in 2020 were lower in 35 out of 52 calendar weeks. The strongest reductions were observed during the first wave, where the average emergency rate declined by 12.9% (SD 6.8, p < 0.001). There was no statistically significant difference in the overall emergency rate during the summer holidays. Lower transport rates were observed throughout the year, especially during the first wave. CONCLUSIONS Utilization of pre-hospital emergency medical services decreased in 2020, especially during the periods with strict measures. This could be due to the lower morbidity from the behavioral changes during the pandemic, but also to the avoidance of medical services for both less urgent and severe conditions. While a reduction in unnecessary care would be beneficial, patients must be encouraged to seek necessary urgent care, even during a pandemic.
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Affiliation(s)
- Kathrin Hegenberg
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Alexander Althammer
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Christian Gehring
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Stephan Prueckner
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Heiko Trentzsch
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
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4
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Pourciau P, Smith BC. Stroke Risk Related to Coronavirus Disease-2019: What Have We Learned? Crit Care Nurs Clin North Am 2023; 35:53-65. [PMID: 36774007 PMCID: PMC9584860 DOI: 10.1016/j.cnc.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Since the intial outbreak of the coronavirus-2019 (COVID-19) in December 2019, a variety of neurologic manifestations have been linked to this virus, including stroke. Comprehensive review of worldwide studies using various methodologies indicated a correlation of increased stroke risk in patients with COVID-19. The literature reivew also revealed increased morbidity and mortality among patients with COVID-19 and stroke as compared to those with only stroke. This pandemic, with its related healthcare staffing shortages, revealed the requisite to utilize innovative technologies such as Tele-Neurology, as well as public health campaigns focusing on stroke recognition and early treatment.
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Affiliation(s)
- Pamela Pourciau
- East Jefferson Neurological Associates, 3800 Houma Boulevard, Suite 325, Metairie, LA 70006, USA.
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5
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Busetto L, Sert M, Herzog F, Hoffmann J, Stang C, Amiri H, Seker F, Purrucker J, Mundiyanapurath S, Ringleb PA, Nagel S, Bendszus M, Wick W, Gumbinger C. "But it's a nice compromise" - Qualitative multi-centre study of barriers and facilitators to acute telestroke cooperation in a regional stroke network. Eur J Neurol 2021; 29:208-216. [PMID: 34582614 DOI: 10.1111/ene.15130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Telemedical services can be used to complement on-site services when demand for specialists exceeds supply or when specialists are not evenly distributed across health systems. Using stroke as an example, this study aimed to explore how patients and staff experience telestroke cooperation in a stroke network in Germany. METHODS We conducted a qualitative multi-method and multi-centre study combining 32 non-participant observations at one hub and four spoke hospitals with 26 semi-structured interviews with hub and spoke staff as well as stroke patients and relatives. Observation protocols and interview transcripts were analysed to identify barriers and facilitators to telestroke cooperation from the perspectives of staff, patients and relatives. RESULTS In terms of barriers to telestroke cooperation, we found technological problems, providing the treatment for one patient from two sites, competing priorities between telestroke and in-house duties in the spoke hospitals, as well as difficulties in participating in the teleneurological examination via a videoconferencing system for older and disabled patients. In terms of facilitators, we found an overall very positive perception of telestroke provision by patients, good professional relationships within the network, and sharing of neurological expertise to be experienced as helpful for telestroke cooperation. CONCLUSIONS We recommend better integration of telemedical services into the care pathway, fostering relationships within the network, improved technological support and resources, and more emphasis within networks, in public awareness efforts as well as in academia on the evaluation of telemedical services from the perspectives of patients and relatives, especially older patients and patients with disabilities.
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Affiliation(s)
- Loraine Busetto
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Melek Sert
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Franziska Herzog
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johanna Hoffmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christina Stang
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hemasse Amiri
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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6
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Veltkamp R, Purrucker JC, Weber R. [Neurovascular manifestations of COVID‑19]. DER NERVENARZT 2021; 92:531-539. [PMID: 33763706 PMCID: PMC7990492 DOI: 10.1007/s00115-021-01104-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/23/2022]
Abstract
Even early at the beginning of the coronavirus disease 2019 (COVID‑19) pandemic, stroke was described as a manifestation or complication of infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Current meta-analyses reported a stroke rate of approximately 1.5%. Stroke in COVID‑19 positive patients occurs more frequently in severe courses of the infection and in older patients with cardiovascular comorbidities; however, young patients without cardiovascular risk factors are also not uncommonly affected. The mechanisms of stroke are predominantly embolic. The thrombi frequently occlude large intracranial vessels and in more than 20% affect multiple vascular territories, whereas infarctions due to small vessel disease are uncommon. The exact source of the embolism remains cryptogenic in more than 40% of patients. The mortality caused by the co-occurrence of a SARS-CoV‑2 infection and a stroke exceeds 15-30%. While acute stroke treatment was severely affected in some European regions, the rates of recanalization treatment in Germany largely remained stable during the first pandemic wave; however, 20-30% fewer patients with minor stroke and transient ischemic attacks (TIA) presented to hospitals during the first wave in spring 2020. The present narrative review summarizes the current evidence regarding the epidemiology and pathogenesis of stroke associated with COVID‑19 and describes the effect of the pandemic so far on the provision of acute stroke treatment.
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Affiliation(s)
- Roland Veltkamp
- Neurologische Klinik, Alfried Krupp Krankenhaus Essen, Alfried Krupp Str. 21, 45131, Essen, Deutschland.
- Department of Brain Sciences, Imperial College London, London, Großbritannien.
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - Jan C Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Ralph Weber
- Neurologische Klinik, Alfried Krupp Krankenhaus Essen, Alfried Krupp Str. 21, 45131, Essen, Deutschland
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Balestrino M, Coccia A, Boffa AS, Furgani A, Bermano F, Finocchi C, Bandettini di Poggio ML, Malfatto L, Farinini D, Schenone A. Request of hospital care dropped for TIA but remained stable for stroke during COVID-19 pandemic at a large Italian university hospital. Intern Emerg Med 2021; 16:735-739. [PMID: 33063236 PMCID: PMC7561243 DOI: 10.1007/s11739-020-02522-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/28/2020] [Indexed: 11/04/2022]
Abstract
Reduced incidence of stroke during COVID-19 pandemic was sometimes reported. While decrease in stroke incidence and fear of patients to go to the hospitals were sometimes invoked to explain this decrease, reduction in urban pollution was also hypothesized as a possible cause. We investigated statistically the incidence of ischemic and hemorrhagic stroke, and of transient ischemic attacks, at a large Italian tertiary stroke center during the pandemic. We analyzed statistically the number of transient ischemic attacks (TIA), ischemic strokes (IS) and hemorrhagic strokes (HS) between March 8 and May 2, 2020, the peak of the COVID-19 epidemic in Italy, and compared them with the identical period of 2019. We also analyzed the concentration of small particulate matter (PM10) in 2019 and 2020, to see if it could account for modified incidence of strokes or TIA. We found a large, significant drop in TIA (- 51%) during the pandemic compared to the same period of 2019. By contrast, the number of HS was identical, and IS showed a not significant - 24% decrease. PM10 concentration, already low in 2019, did not further decrease in 2020. Patients kept seeking hospital care when experiencing permanent neurological symptoms (stroke), but they tended not go to the hospital when their symptoms were transient (TIA). The fact that we did not observe a significant decrease in strokes may be explained by the fact that in our city the concentration of small particulate matter did not change compared to 2019.
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Affiliation(s)
- Maurizio Balestrino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy.
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Alberto Coccia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandra Silvia Boffa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Andrea Furgani
- Dipartimento Regionale di Emergenza Sanitaria Territoriale 118, Genoa, Italy
| | - Francesco Bermano
- Dipartimento Regionale di Emergenza Sanitaria Territoriale 118, Genoa, Italy
| | - Cinzia Finocchi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Monica Laura Bandettini di Poggio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Angelo Schenone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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8
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Aboul Nour H, Affan M, Mohamed G, Mohamud A, Schultz L, Latack K, Brady M, Scozzari D, Haddad Y, Katramados A, Bou Chebl A, Ramadan AR. Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System. J Stroke Cerebrovasc Dis 2021; 30:105746. [PMID: 33780695 PMCID: PMC7997457 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/01/2021] [Accepted: 03/07/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. METHODS in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. RESULTS of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p <0.001), and transfers from outside facilities (p = 0.015). CONCLUSION a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.
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Affiliation(s)
- Hassan Aboul Nour
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States.
| | - Muhammad Affan
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States; Department of Neurology, University of Minnesota, Minneapolis, MN, United States.
| | - Ghada Mohamed
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States.
| | - Ali Mohamud
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States.
| | - Lonni Schultz
- Public Health Sciences, Henry Ford Hospital, Detroit, MI, United States.
| | - Katie Latack
- Public Health Sciences, Henry Ford Hospital, Detroit, MI, United States.
| | - Megan Brady
- Comprehensive Stroke Center, Henry Ford Health System, Detroit, MI, United States.
| | - Dawn Scozzari
- Comprehensive Stroke Center, Henry Ford Health System, Detroit, MI, United States.
| | - Yazeed Haddad
- School of Medicine, Wayne State University, Detroit, MI, United States.
| | - Angelos Katramados
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States.
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States.
| | - Ahmad Riad Ramadan
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States.
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9
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Manganotti P, Naccarato M, Scali I, Cappellari M, Bonetti B, Burlina A, Turinese E, Bogo S, Teatini F, Franchini E, Caneve G, Ruzza G, Gaudenzi A, Bombardi R, Bozzato G, Padoan R, Gentile C, Rana M, Turazzini M, Alessandra D, Brigo F, Nardone R, Quatrale R, Menegazzo E, Masato M, Novello S, Passadore P, Baldi A, Valentinis L, Baracchini C, Pieroni A, Basile AM, Semplicini C, Piffer S, Giometto B, Tonello S, Bonifatti DM, Lorenzut S, Merlino G, Valente MR, Paladin F, Tonon A, de Luca C, Perini F, Centonze S, Bovi P. Stroke management during the coronavirus disease 2019 (COVID-19) pandemic: experience from three regions of the north east of Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige). Neurol Sci 2021; 42:4599-4606. [PMID: 33661482 PMCID: PMC7930104 DOI: 10.1007/s10072-021-05066-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Efficiency of care chain response and hospital reactivity were and are challenged for stroke acute care management during the pandemic period of coronavirus disease 2019 (COVID-19) in North-Eastern Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige), counting 7,193,880 inhabitants (ISTAT), with consequences in acute treatment for patients with ischemic stroke. METHODS We conducted a retrospective data collection of patients admitted to stroke units eventually treated with thrombolysis and thrombectomy, ranging from January to May 2020 from the beginning to the end of the main first pandemic period of COVID-19 in Italy. The primary endpoint was the number of patients arriving to these stroke units, and secondary endpoints were the number of thrombolysis and/or thrombectomy. Chi-square analysis was used on all patients; furthermore, patients were divided into two cohorts (pre-lockdown and lockdown periods) and the Kruskal-Wallis test was used to test differences on admission and reperfusive therapies. RESULTS In total, 2536 patients were included in 22 centers. There was a significant decrease of admissions in April compared to January. Furthermore, we observed a significant decrease of thrombectomy during the lockdown period, while thrombolysis rate was unaffected in the same interval across all centers. CONCLUSIONS Our study confirmed a decrease in admission rate of stroke patients in a large area of northern Italy during the lockdown period, especially during the first dramatic phase. Overall, there was no decrease in thrombolysis rate, confirming an effect of emergency care system for stroke patients. Instead, the significant decrease in thrombectomy rate during lockdown addresses some considerations of local and regional stroke networks during COVID-19 pandemic evolution.
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Affiliation(s)
- Paolo Manganotti
- Stroke Unit, Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy.
| | - Marcello Naccarato
- Stroke Unit, Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Ilario Scali
- Stroke Unit, Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Bruno Bonetti
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | - Sabrina Bogo
- Stroke Unit, Ospedale San Martino, Belluno, Italy
| | | | | | | | | | - Anna Gaudenzi
- Stroke Unit, Ospedale Santa Maria dei Battuti, Conegliano, Italy
| | - Roberto Bombardi
- Stroke Unit, Ospedale Santa Maria dei Battuti, Conegliano, Italy
| | - Giulio Bozzato
- Stroke Unit, Ospedale Santa Maria del Prato, Feltre, Italy
| | - Roberta Padoan
- Stroke Unit, Ospedale Santa Maria del Prato, Feltre, Italy
| | | | - Michele Rana
- Stroke Unit, Ospedale di Gorizia, Gorizia, Italy
| | | | | | | | | | | | | | | | - Stefano Novello
- Stroke Unit, Ospedale Santa Maria degli Angeli, Pordenone, Italy
| | - Paolo Passadore
- Stroke Unit, Ospedale Santa Maria degli Angeli, Pordenone, Italy
| | - Antonio Baldi
- Stroke Unit, Ospedale Di Portogruaro, Portogruaro, Italy
| | | | | | - Alessio Pieroni
- Stroke Unit, Azienda Ospedaliera Università di Padova, Padova, Italy
| | | | | | | | | | | | | | - Simone Lorenzut
- Stroke Unit, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Giovanni Merlino
- Stroke Unit, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | | | | | - Agnese Tonon
- Stroke Unit, Ospedale Santi Giovanni e Paolo, Venezia, Italy
| | | | | | - Sandro Centonze
- Struttura Complessa Ricerca, innovazione clinico-assistenziale, qualità, accreditamento e rischio clinico, ASUGI, Trieste, Italy
| | - Paolo Bovi
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Vollmuth C, Miljukov O, Abu-Mugheisib M, Angermaier A, Barlinn J, Busetto L, Grau AJ, Guenther A, Gumbinger C, Hubert N, Hüttemann K, Klingner C, Naumann M, Palm F, Remi J, Rücker V, Schessl J, Schlachetzki F, Schuppner R, Schwab S, Schwartz A, Trommer A, Urbanek C, Volbers B, Weber J, Wojciechowski C, Worthmann H, Zickler P, Heuschmann PU, Haeusler KG, Hubert GJ. Impact of the coronavirus disease 2019 pandemic on stroke teleconsultations in Germany in the first half of 2020. Eur J Neurol 2021; 28:3267-3278. [PMID: 33619788 PMCID: PMC8013200 DOI: 10.1111/ene.14787] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/28/2022]
Abstract
Background and purpose The effects of the coronavirus disease 2019 (COVID‐19) pandemic on telemedical care have not been described on a national level. Thus, we investigated the medical stroke treatment situation before, during, and after the first lockdown in Germany. Methods In this nationwide, multicenter study, data from 14 telemedical networks including 31 network centers and 155 spoke hospitals covering large parts of Germany were analyzed regarding patients' characteristics, stroke type/severity, and acute stroke treatment. A survey focusing on potential shortcomings of in‐hospital and (telemedical) stroke care during the pandemic was conducted. Results Between January 2018 and June 2020, 67,033 telemedical consultations and 38,895 telemedical stroke consultations were conducted. A significant decline of telemedical (p < 0.001) and telemedical stroke consultations (p < 0.001) during the lockdown in March/April 2020 and a reciprocal increase after relaxation of COVID‐19 measures in May/June 2020 were observed. Compared to 2018–2019, neither stroke patients' age (p = 0.38), gender (p = 0.44), nor severity of ischemic stroke (p = 0.32) differed in March/April 2020. Whereas the proportion of ischemic stroke patients for whom endovascular treatment (14.3% vs. 14.6%; p = 0.85) was recommended remained stable, there was a nonsignificant trend toward a lower proportion of recommendation of intravenous thrombolysis during the lockdown (19.0% vs. 22.1%; p = 0.052). Despite the majority of participating network centers treating patients with COVID‐19, there were no relevant shortcomings reported regarding in‐hospital stroke treatment or telemedical stroke care. Conclusions Telemedical stroke care in Germany was able to provide full service despite the COVID‐19 pandemic, but telemedical consultations declined abruptly during the lockdown period and normalized after relaxation of COVID‐19 measures in Germany.
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Affiliation(s)
- Christoph Vollmuth
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Olga Miljukov
- Institute of Clinical Epidemiology and Biometry, Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Mazen Abu-Mugheisib
- Department of Neurology, University Hospital Braunschweig, Braunschweig, Germany
| | - Anselm Angermaier
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Jessica Barlinn
- Department of Neurology, University Hospital Dresden, Dresden, Germany
| | - Loraine Busetto
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Armin J Grau
- Department of Neurology, Hospital Ludwigshafen, Ludwigshafen, Germany
| | - Albrecht Guenther
- Hans Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Nikolai Hubert
- TEMPiS Telemedical Stroke Center, Department of Neurology, Munich Clinic Harlaching, Munich, Germany
| | - Katrin Hüttemann
- NEVAS Telemedical Stroke Network, Department of Neurology, University Hospital Munich, Munich, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Markus Naumann
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Frederick Palm
- Department of Neurology, Hospital Schleswig, Kiel, Germany
| | - Jan Remi
- NEVAS Telemedical Stroke Network, Department of Neurology, University Hospital Munich, Munich, Germany
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Joachim Schessl
- Department of Neurology, Hospital Karlsruhe, Karlsruhe, Germany
| | - Felix Schlachetzki
- TEMPiS Telemedical Stroke Center, Department of Neurology, Center for Vascular Neurology and Intensive Care, Medbo District Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Adrian Trommer
- Department of Neurology, Hospital Hubertusburg, Wermsdorf, Germany
| | - Christian Urbanek
- Department of Neurology, Hospital Ludwigshafen, Ludwigshafen, Germany
| | - Bastian Volbers
- Department of Neurology, University Hospital Erlangen, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Joachim Weber
- Clinic and University Outpatient Clinic for Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | | | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Philipp Zickler
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, Julius Maximilian University of Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, Clinical Trial Center Würzburg, University Hospital Würzburg, Julius Maximillian University of Würzburg, Würzburg, Germany
| | | | - Gordian Jan Hubert
- TEMPiS Telemedical Stroke Center, Department of Neurology, Munich Clinic Harlaching, Munich, Germany
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11
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Tanislav C, Jacob L, Kostev K. Consultations Decline for Stroke, Transient Ischemic Attack, and Myocardial Infarction during the COVID-19 Pandemic in Germany. Neuroepidemiology 2021; 55:1-8. [PMID: 33530092 PMCID: PMC7900477 DOI: 10.1159/000513812] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic raises the concern that other non-COVID conditions will be affected by a decline in care. Therefore, we aimed to investigate the decline in ambulatory presentations for vascular events (stroke, transient ischemic attack [TIA], and myocardial infarction [MI]) during the COVID-19 pandemic. METHODS Patients with a diagnosis of ischemic stroke, TIA, or MI documented anonymously in 1,262 general practices in Germany were included. We studied the differences between 2019 and 2020 (between April and June) in terms of rates and baseline characteristics by comparing monthly absolute frequencies. RESULTS A total of 3,496 patients with stroke (mean age: 72.2 years), 1,608 patients with TIA (mean age: 71.5 years), and 2,385 patients with MI (mean age: 66.8 years) were identified between April and June 2020, indicating a decrease of 10% (stroke), 16% (TIA), and 9% (MI) compared to 2019. For patients with stroke, the decrease in men was 13% (women: -6%) but reached 17% in the age category 51-60 years. For MI, the decrease was only obvious in males (14%). The largest decrease in stroke (-17%) and MI (-19%) was noted in April, while that for TIA occurred in May (-22%). In June for all 3 conditions, the previous year's level was achieved. Only in TIA, the age differs between 2019 and 2020 (mean age: 69.9 vs. 71.5 years; p < 0.05). In patients with stroke and MI, the proportions of men were lower in 2019 than in 2020 (stroke: 54.8-50.5%, p < 0.05 and MI: 64-60.2%, p < 0.05). CONCLUSION Although the decline in the number of patients presenting with stroke, TIA, and MI was not as noticeable in the ambulatory sector as it was in the area of emergency hospital-based care, our data indicate that the COVID-19 pandemic affected all sectors within the medical care system.
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Affiliation(s)
- Christian Tanislav
- Department of Geriatrics and Neurology, Diakonie Hospital Jung Stilling Siegen, Siegen, Germany,
| | - Louis Jacob
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Barcelona, Spain
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12
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Lou M, Yuan D, Liao S, Tong L, Li J. Potential mechanisms of cerebrovascular diseases in COVID-19 patients. J Neurovirol 2021; 27:35-51. [PMID: 33534131 PMCID: PMC7856859 DOI: 10.1007/s13365-021-00948-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 01/08/2023]
Abstract
Since the outbreak of coronavirus disease 2019 (COVID-19) in 2019, it is gaining worldwide attention at the moment. Apart from respiratory manifestations, neurological dysfunction in COVID-19 patients, especially the occurrence of cerebrovascular diseases (CVD), has been intensively investigated. In this review, the effects of COVID-19 infection on CVD were summarized as follows: (I) angiotensin-converting enzyme 2 (ACE2) may be involved in the attack on vascular endothelial cells by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), leading to endothelial damage and increased subintimal inflammation, which are followed by hemorrhage or thrombosis; (II) SARS-CoV-2 could alter the expression/activity of ACE2, consequently resulting in the disruption of renin-angiotensin system which is associated with the occurrence and progression of atherosclerosis; (III) upregulation of neutrophil extracellular traps has been detected in COVID-19 patients, which is closely associated with immunothrombosis; (IV) the inflammatory cascade induced by SARS-CoV-2 often leads to hypercoagulability and promotes the formation and progress of atherosclerosis; (V) antiphospholipid antibodies are also detected in plasma of some severe cases, which aggravate the thrombosis through the formation of immune complexes; (VI) hyperglycemia in COVID-19 patients may trigger CVD by increasing oxidative stress and blood viscosity; (VII) the COVID-19 outbreak is a global emergency and causes psychological stress, which could be a potential risk factor of CVD as coagulation, and fibrinolysis may be affected. In this review, we aimed to further our understanding of CVD-associated COVID-19 infection, which could improve the therapeutic outcomes of patients. Personalized treatments should be offered to COVID-19 patients at greater risk for stroke in future clinical practice.
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Affiliation(s)
- Manxue Lou
- Department of Neurology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dezhi Yuan
- Department of Neurology, First Affiliated Hospital of Army Medical University (Chongqing Southwest Hospital), Chongqing, 400038, China
- Department of Neurology, People's Hospital of Shapingba District, Chongqing, 400038, China
| | - Shengtao Liao
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Linyan Tong
- Department of Neurology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jinfang Li
- Department of Neurology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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13
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Richter D, Eyding J, Weber R, Bartig D, Grau A, Hacke W, Krogias C. Analysis of Nationwide Stroke Patient Care in Times of COVID-19 Pandemic in Germany. Stroke 2021; 52:716-721. [PMID: 33356382 PMCID: PMC7834653 DOI: 10.1161/strokeaha.120.033160] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/20/2020] [Accepted: 11/19/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many countries have introduced strict hygiene measures of social distancing to prevent further spreading of the disease. This may have led to a decreased presentation to hospital of patients with acute medical conditions and time-dependent management, such as stroke. METHODS We conducted a nationwide cohort study using administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke (AIS), transient ischemic attack, or intracerebral hemorrhage. Data from a total of 1463 hospitals in Germany were included. We compared case numbers and treatment characteristics of pandemic (March 16 to May 15, 2020) and prepandemic (January 16 to March 15, 2020) cases and also with corresponding time period in 2019. RESULTS We identified a strong decline for hospitalization of AIS (-17.4%), transient ischemic attack (-22.9%), and intracerebral hemorrhage (-15.8%) patients during the pandemic compared with prepandemic period. IVT rate in patients with AIS was comparable (prepandemic versus pandemic: 16.4% versus 16.6%, P=0.448), whereas mechanical thrombectomy rate was significantly higher during the pandemic (8.1% versus 7.7%, P=0.044). In-hospital mortality was significantly increased in patients with AIS during the pandemic period (8.1% versus 7.6%, P=0.006). CONCLUSIONS Besides a massive decrease in absolute case numbers, our data suggest that patients with AIS who did seek acute care during the pandemic, continued to receive acute recanalization treatment in Germany.
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Affiliation(s)
- Daniel Richter
- Department of Neurology, St Josef-Hospital Bochum (D.R., D.B., C.K.), Ruhr University Bochum, Germany
| | - Jens Eyding
- Medical Faculty (J.E., R.W., C.K.), Ruhr University Bochum, Germany
- Department of Neurology, Gemeinschaftskrankenhaus Herdecke, Germany (J.E.)
| | - Ralph Weber
- Medical Faculty (J.E., R.W., C.K.), Ruhr University Bochum, Germany
- Department of Neurology, Alfried Krupp Krankenhaus Essen, Germany (R.W.)
| | - Dirk Bartig
- Department of Neurology, St Josef-Hospital Bochum (D.R., D.B., C.K.), Ruhr University Bochum, Germany
| | - Armin Grau
- Department of Neurology, Klinikum der Stadt Ludwigshafen, Germany (A.G.)
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Germany (W.H.)
| | - Christos Krogias
- Department of Neurology, St Josef-Hospital Bochum (D.R., D.B., C.K.), Ruhr University Bochum, Germany
- Medical Faculty (J.E., R.W., C.K.), Ruhr University Bochum, Germany
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14
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Dula AN, Gealogo Brown G, Aggarwal A, Clark KL. Decrease in Stroke Diagnoses During the COVID-19 Pandemic: Where Did All Our Stroke Patients Go? JMIR Aging 2020; 3:e21608. [PMID: 33006936 PMCID: PMC7581311 DOI: 10.2196/21608] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/18/2020] [Accepted: 09/27/2020] [Indexed: 12/16/2022] Open
Abstract
Despite the evidence suggesting a high rate of cerebrovascular complications in patients with SARS-CoV-2, reports have indicated decreasing rates of new ischemic stroke diagnoses during the COVID-19 pandemic. The observed decrease in emergency department (ED) visits is unsurprising during this major crisis, as patients are likely to prioritize avoiding exposure to SARS-CoV-2 over addressing what they may perceive as mild symptoms of headache, lethargy, difficulty speaking, and numbness. In the central and south Texas regions where we practice, we suspect that patient admission, treatment, and discharge volumes for acute stroke treatment have decreased significantly since COVID-19–related shelter-at-home orders were issued. Symptoms of stroke are frequently noticed by a family member, friend, or community member before they are recognized by the patients themselves, and these symptoms may be going unnoticed due to limited face-to-face encounters. This possibility emphasizes the importance of patient education regarding stroke warning signs and symptoms during the current period of isolation and social-distancing. The south Texas population, already saddled with above-average rates of cardiovascular and cerebrovascular disease, has a higher stroke mortality rate compared to Texas and U.S. averages; however, the number of patients presenting to EDs with acute ischemic stroke diagnoses is lower than average. In our viewpoint, we aim to present the relative literature to date and outline our ongoing analyses of the highly affected and diverse stroke populations in San Antonio and Austin, Texas, to answer a simple question: where did all our stroke patients go?
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Affiliation(s)
- Adrienne Nicole Dula
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, United States.,Department of Diagnostic Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, United States
| | - Gretchel Gealogo Brown
- School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Aarushi Aggarwal
- Long School of Medicine, University of Texas Health, San Antonio, TX, United States
| | - Kal L Clark
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
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