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Chmiela T, Rzepka M, Kuca M, Serwońska K, Laskowski M, Koperczak A, Siuda J. Intravenous Thrombolysis for Acute Ischemic Stroke during the COVID-19 Pandemic-Polish Single-Center Retrospective Cohort Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071068. [PMID: 35888156 PMCID: PMC9321477 DOI: 10.3390/life12071068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022]
Abstract
COVID-19 has affected the entire world and has had a great impact on healthcare, influencing the treatment of patients with acute ischemic stroke (AIS). The aim of this study was to determine the impact of the COVID-19 pandemic on the care of patients with AIS. We performed a retrospective analysis of 1599 patients diagnosed with AIS and hospitalized in the authors' institution from January 2018 to December 2021. The final sample consisted of 265 patients treated with thrombolysis without a diagnosis of COVID-19. The initiation of thrombolytic treatment during the pandemic was delayed (2:42 ± 0:51 vs. 2:25 ± 0:53; p = 0.0006). The delay was mainly related to the pre-hospital phase (1:41 ± 0:48 vs. 1:26 ± 0:49; p = 0.0014), and the door-to-needle time was not affected. There were no differences in stroke severity and patients' outcomes. Patients with AIS were less likely to have previously been diagnosed with atrial fibrillation (16.9% vs. 26.7%; p = 0.0383), ischemic heart disease (25.3% vs. 46.5%; p = 0.0003) and hyperlipidemia (31.2% vs. 46.5%; p = 0.0264). Patients treated during the pandemic had higher glycemia (149.45 ± 54. vs. 143.25 ± 60.71 mg/dL; p= 0.0012), while no significant differences in their lipid profiles were found. Conclusions: The COVID-19 pandemic affected the treatment of AIS patients locally at our stroke center. It caused treatment delay and hindered the recognition of risk factors prior to the occurrence of AIS.
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Affiliation(s)
- Tomasz Chmiela
- Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.R.); (J.S.)
- Correspondence:
| | - Michalina Rzepka
- Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.R.); (J.S.)
| | - Maciej Kuca
- Students’ Scientific Association, Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.K.); (K.S.); (M.L.); (A.K.)
| | - Karolina Serwońska
- Students’ Scientific Association, Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.K.); (K.S.); (M.L.); (A.K.)
| | - Maciej Laskowski
- Students’ Scientific Association, Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.K.); (K.S.); (M.L.); (A.K.)
| | - Agnieszka Koperczak
- Students’ Scientific Association, Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.K.); (K.S.); (M.L.); (A.K.)
| | - Joanna Siuda
- Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (M.R.); (J.S.)
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2
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Shokri H, Nahas NE, Basiony AE, Nguyen TN, Abdalkader M, Klein P, Lavados PM, Olavarría VV, Amaya P, Llanos-Leyton N, Brola W, Michał L, Fariña DEDM, Cardozo A, Caballero CD, Pedrozo F, Rahman A, Hokmabadi ES, Jalili J, Farhoudi M, Aref H, Roushdy T. Did COVID-19 impact stroke services? A multicenter study. Neurol Sci 2022; 43:4061-4068. [PMID: 35338400 PMCID: PMC8956331 DOI: 10.1007/s10072-022-06018-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/13/2022] [Indexed: 11/29/2022]
Abstract
Background It has been reported that acute stroke services were compromised during COVID-19 due to various pandemic-related issues. We aimed to investigate these changes by recruiting centers from different countries. Methods Eight countries participated in this cross-sectional, observational, retrospective study by providing data from their stroke data base. We compared 1 year before to 1 year during COVID-19 as regards onset to door (OTD), door to needle (DTN), door to groin (DTG), duration of hospital stay, National Institute of Health Stroke Scale (NIHSS) at baseline, 24 h, and at discharge as well as modified Rankin score (mRS) on discharge and at 3 months follow-up. Results During the pandemic year, there was a reduction in the number of patients, median age was significantly lower, admission NIHSS was higher, hemorrhagic stroke increased, and OTD and DTG showed no difference, while DTN time was longer, rtPA administration was decreased, thrombectomy was more frequent, and hospital stay was shorter. mRS was less favorable on discharge and at 3 months. Conclusion COVID-19 showed variable effects on stroke services. Some were negatively impacted as the number of patients presenting to hospitals, DTN time, and stroke outcome, while others were marginally affected as the type of management.
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Affiliation(s)
- Hossam Shokri
- Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | | | - Ahmed El Basiony
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Thanh N Nguyen
- Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Piers Klein
- Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Pablo M Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología Y Psiquiatría Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología Y Psiquiatría Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Pablo Amaya
- Stroke Program, Neurology Department, Fundación Valle del Lili, Cali, Colombia
| | | | - Waldemar Brola
- Department of Neurology, Specialist Hospital Konskie, Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Lipowski Michał
- Department of Neurology, Specialist Hospital Konskie, Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | | | - Analia Cardozo
- Stroke Unit of the Instituto de Previsión Social Central Hospital, Asunción, Paraguay
| | - Cesar David Caballero
- Stroke Unit of the Instituto de Previsión Social Central Hospital, Asunción, Paraguay
| | - Fatima Pedrozo
- Stroke Unit of the Instituto de Previsión Social Central Hospital, Asunción, Paraguay
| | | | | | - Javad Jalili
- Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Farhoudi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hany Aref
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer Roushdy
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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3
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Mogharab V, Ostovar M, Ruszkowski J, Hussain SZM, Shrestha R, Yaqoob U, Aryanpoor P, Nikkhoo AM, Heidari P, Jahromi AR, Rayatdoost E, Ali A, Javdani F, Farzaneh R, Ghanaatpisheh A, Habibzadeh SR, Foroughian M, Ahmadi SR, Akhavan R, Abbasi B, Shahi B, Hakemi A, Bolvardi E, Bagherian F, Motamed M, Boroujeni ST, Jamalnia S, Mangouri A, Paydar M, Mehrasa N, Shirali D, Sanmarchi F, Saeed A, Jafari NA, Babou A, Kalani N, Hatami N. Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses. Global Health 2022; 18:58. [PMID: 35676714 PMCID: PMC9175527 DOI: 10.1186/s12992-022-00836-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/05/2022] [Indexed: 02/06/2023] Open
Abstract
Background Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems. Objective To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic. Methods Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel. Result There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients. Conclusions COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat. Supplementary Information The online version contains supplementary material available at 10.1186/s12992-022-00836-2.
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Affiliation(s)
- Vahid Mogharab
- Department of Pediatrics, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Mahshid Ostovar
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Jakub Ruszkowski
- Department of Nephrology, Transplantology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland.,Department of Pathophysiology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Rajeev Shrestha
- Palliative Care and Chronic Disease Unit, Green Pasteur Hospital, Pokhara, Nepal
| | - Uzair Yaqoob
- Postgraduate trainee, Surgical Department, Hamdard University Hospital Karachi, Karachi, Pakistan
| | - Poorya Aryanpoor
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Amir Mohammad Nikkhoo
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Parasta Heidari
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Athar Rasekh Jahromi
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Esmaeil Rayatdoost
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Anwar Ali
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China.,Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, Central South University, Changsha, China
| | - Farshid Javdani
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Roohie Farzaneh
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Aref Ghanaatpisheh
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Seyed Reza Habibzadeh
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdi Foroughian
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sayyed Reza Ahmadi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Akhavan
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Behzad Shahi
- Department of Emergency Medicine, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Arman Hakemi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Bolvardi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farhad Bagherian
- Department of Emergency Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Mahsa Motamed
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sheida Jamalnia
- Medical Journalism Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Mangouri
- Fellowship of Vascular Surgery and Endovascular Therapy, Division of Vascular Surgery and Endovascular Therapy, Department of General Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Paydar
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Neda Mehrasa
- Shiraz Azad University, Dental Branch, Shiraz, Iran
| | | | - Francesco Sanmarchi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Ayesha Saeed
- Department of Biochemistry, Government College University, Faisalabad, Pakistan
| | - Narges Azari Jafari
- Neuroscience Research Department Center, Kashan University of Medical Science, Kashan, Iran
| | - Ali Babou
- Pharmaceutical Sciences Department, College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Navid Kalani
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran.
| | - Naser Hatami
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran.
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You Y, Niu Y, Sun F, Zhang J, Huang S, Ding P, Wang X. Impact of COVID-19 pandemic on haemorrhagic stroke admissions: a systematic review and meta-analysis. BMJ Open 2021; 11:e050559. [PMID: 34907050 PMCID: PMC8671851 DOI: 10.1136/bmjopen-2021-050559] [Citation(s) in RCA: 3] [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] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND PURPOSE COVID-19 pandemic, a global health crisis, is disrupting the present medical environment. This systematic review and meta-analysis aimed to evaluate the impact of the COVID-19 pandemic on stroke hospitalisations, especially haemorrhagic stroke. METHODS The EMBASE, PubMed, Web of Science, Elsevier, Medline, Cochrane Library and Google Scholar electronic databases were searched for all relevant studies. Two researchers independently screened the studies, extracted data and assessed the quality of the included studies. Odds ratio (OR), total events, OR and 95% CI were considered as the effect size. A fixed-effects model was used to pool the study-specific estimate. The present study was performed by using Review Manager (V.5.3.0) software. We assessed the risk of bias using the Newcastle-Ottawa Scale. RESULTS A total of 17 studies with 14 445 cases were included. Overall, the number of stroke admissions is lower in the pandemic period versus the control period (6252 vs 8193). The difference of haemorrhagic stroke is significant, with 1233 of 6252 cases in the pandemic group and 1621 of 8193 cases in the control group. Intracerebral haemorrhage is present in 461 of 1948 cases in the pandemic group and 618 of 2734 cases in the control group. As for subarachnoid haemorrhage, the difference between the two groups is significant, with 70 of 985 cases in the pandemic group and 202 of 1493 cases in the control group. CONCLUSIONS The number of stroke admissions is lower in the pandemic period compared with the control period. There is a higher rate of haemorrhagic stroke in the pandemic period. Subgroup analysis identifies a significant increase in the occurrence of intracerebral haemorrhage in the pandemic period. Due to limited data and the impact of a single article, the impact of COVID-19 pandemic on subarachnoid haemorrhage is unclear.
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Affiliation(s)
- Yijie You
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Xinhua Hospital Chongming Branch, Shanghai, China
| | - Yunlian Niu
- Department of Neurology, Shanghai Jiaotong University School of Medicine, Xinhua Hospital Chongming Branch, Shanghai, China
| | - Fengbing Sun
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Xinhua Hospital Chongming Branch, Shanghai, China
| | - Jian Zhang
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Xinhua Hospital Chongming Branch, Shanghai, China
| | - Sheng Huang
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Xinhua Hospital Chongming Branch, Shanghai, China
| | - Peiyuan Ding
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Xinhua Hospital Chongming Branch, Shanghai, China
| | - Xuhui Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Jeong HY, Lee EJ, Kang MK, Nam KW, Bae J, Jeon K, Jung KH, Ko SB, Oh MS, Lee JS, Hwang J, Jeong E, Lee J, Do JK, Sohn SI, Kwon SU, Bae HJ, Yoon BW, Park JM. Changes in Stroke Patients' Health-Seeking Behavior by COVID-19 Epidemic Regions: Data from the Korean Stroke Registry. Cerebrovasc Dis 2021; 51:169-177. [PMID: 34592732 PMCID: PMC8678250 DOI: 10.1159/000519093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic has led to changes in stroke patients' healthcare use. This study evaluated changes in Korean stroke patients' health-seeking behaviors and stroke care services using data from the Korean Stroke Registry (KSR). Methods We reviewed data from patients with acute stroke and transient ischemic attack (TIA) during 2019 (before COVID-19 period) and 2020 (COVID-19 period). Outcomes included patient characteristics, time from stroke onset to hospital arrival, and in-hospital stroke pathways. Subgroup analyses were performed for an epidemic region (Daegu city and Gyeongsangbuk-do region, the D-G region). Results The study included 1,792 patients from the pre-COVID-19 period and 1,555 patients from the COVID-19 period who visited hospitals that contribute to the KSR. During the COVID-19 period, the D-G region had two-thirds the number of cases (vs. the pre-COVID-19 period) and a significant decrease in the proportion of patients with TIA (9.97%–2.91%). Unlike other regions, the median onset-to-door time increased significantly in the D-G region (361 min vs. 526.5 min, p = 0.016), and longer onset-to-door times were common for patients with mild symptoms and who were in their 60s or 70s. The number of patients who underwent intravenous thrombolysis also decreased during the COVID-19 period, although the treatment times were not significantly different between the 2 periods. Discussion/Conclusion Korean stroke patients in a COVID-19 epidemic region exhibited distinct changes in health-seeking behaviors. Appropriate triage system and public education regarding the importance of early treatment are needed during the COVID-19 pandemic.
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Affiliation(s)
- Han-Yeong Jeong
- Department of Neurology, Emergency Medical Center, Seoul National University Hospital, Seoul, Republic of Korea,
| | - Eung-Joon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Kyoung Kang
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Ki-Woong Nam
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeonghoon Bae
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kipyoung Jeon
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Jaechun Hwang
- Department of Neurology, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Eunhwan Jeong
- Department of Neurology, S. Pohang Stroke and Spine Center, Pohang, Republic of Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Jin-Kuk Do
- Department of Neurology, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sun U Kwon
- Department of Neurology University of Ulsan Asan Medical Center, Seoul, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
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Roushdy T, Wahid El Din M, Abdel Monem Mohamed A, Ibrahem HK, Bedros RY, Hamid E. Concepts behind epilepsy among Egyptian patients. Is it a disease or a possession?! Epilepsy Res 2021; 177:106760. [PMID: 34534927 DOI: 10.1016/j.eplepsyres.2021.106760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/11/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many epileptic patients visit traditional healers secondary to unaffordability, inaccessibility of medical service and being refractory. This may lead to delay in seeking medical advice and may influence prognosis. OBJECTIVES Studying concepts behind epilepsy among Egyptian epilepsy sufferers including beliefs behind epilepsy and whether there is difference in these beliefs as regards gender, education and urban to rural socioeconomic status. METHODS A semi structured questionnaire designed according to the guidelines of the 9th edition of research methods in psychology and applied to 393 cases presenting to epilepsy clinics at three hospitals representing rural delta, capital, and upper rural Egypt between November 2019 and April 2020. Inclusion criteria included a fulfillment of the international league against epilepsy operational definition and availability of an electroencephalogram supporting the diagnosis of epilepsy. RESULTS 30 % of patients visited traditional healers within the course of their illness with males accounting for 55.9 %, and relatives' impact was more obvious in this decision (83.9 % visited traditional healers secondary to a relative influence). 43.2 % of traditional healers' visitors had a basic education. Low education level was significantly correlated with visiting traditional healers (rho=-0.126, p = 0.012). 43 patients (36.4 %) received traditional therapy and only 3 patients (2.5 %) out of them improved. More males (55.9 %) than females (29.5 %) were found to seek non-medical help with no significant difference (p = 0.852). Additionally, it was noticed that males who lived in rural areas visited traditional healers significantly more than those who lived in urban (72.2 % vs 27.3 %, p = 0.011) while in females, it seems that residency did not affect traditional healers seeking behavior (50 % urban vs 50 % rural). Rural residents were seeking non-medical advice more than urban (28.3 % vs 22 %, p < 0.001) as well as receiving traditional treatments (19.7 % vs 11 %, p = 0.017). CONCLUSIONS Seeking traditional healers in epilepsy sufferers is not uncommon in Egypt. Education, gender, and residency may affect concepts and beliefs regarding epilepsy. Although awareness of epilepsy as a medical condition is also questionable, yet it is needed.
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Affiliation(s)
| | | | | | | | | | - Eman Hamid
- Faculty of Medicine Ain Shams University, Egypt
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7
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Peterson CJ, Sarangi A, Bangash F. Neurological sequelae of COVID-19: a review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021; 57:122. [PMID: 34511868 PMCID: PMC8424148 DOI: 10.1186/s41983-021-00379-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/26/2021] [Indexed: 01/28/2023] Open
Abstract
Background The COVID-19 pandemic has produced a myriad of challenges, including identifying and treating neurological sequelae. Main body COVID-19 can cause olfactory and respiratory dysfunction with average recovery within 1 month and a minority of patients experiencing symptoms at 8-month follow-up. Headaches are also very common (up to 93%) amongst patients with persistent COVID-19 symptoms. COVID-19 illness may also affect cognition, although results are mixed. Conclusion While many studies have focused on acute COVID-19 symptoms, more longitudinal studies will need to assess the neurological sequelae of the disease. Furthermore, care must be taken when attributing sequelae to COVID-19 illness and not an unrelated cause. Finally, there is concern that COVID-19 may be associated with secondary illnesses, such as Guillain–Barre, and may even contribute to the development of diseases, such as Alzheimer’s.
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Affiliation(s)
- Christopher J Peterson
- Menninger Department of Psychiatry, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Ashish Sarangi
- Department of Psychiatry, Texas Tech University Health Sciences Center, 3601 4th St., Lubbock, TX 79430 USA
| | - Fariha Bangash
- SUNY Upstate Medical University, 750E Adams St, Syracuse, NY 13210 USA
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8
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Katsanos AH, Palaiodimou L, Zand R, Yaghi S, Kamel H, Navi BB, Turc G, Benetou V, Sharma VK, Mavridis D, Shahjouei S, Catanese L, Shoamanesh A, Vadikolias K, Tsioufis K, Lagiou P, Sfikakis PP, Alexandrov AV, Tsiodras S, Tsivgoulis G. Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Stroke 2021; 52:3651-3660. [PMID: 34344166 PMCID: PMC8547579 DOI: 10.1161/strokeaha.121.034601] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., L.C., A.S.).,Second Department of Neurology, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.H.K., L.P., G. Tsivgoulis.)
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.H.K., L.P., G. Tsivgoulis.)
| | - Ramin Zand
- Neurosience Institute, Geisinger Health System, Danville, Pennsylvania (R.Z., S.S.)
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, NY (S.Y.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, NY (H.K., B.B.N.)
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, NY (H.K., B.B.N.)
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, France (G. Turc).,Université de Paris, France (G. Turc).,INSERM U1266, Paris, France (G. Turc).,FHU Neurovasc, Paris, France (G. Turc)
| | - Vassiliki Benetou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Greece (V.B., P.L.)
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore and School of Medicine, National University of Singapore (V.K.S.)
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Greece (D.M.).,Université Paris Descartes, Faculté de Médecine, France (D.M.)
| | - Shima Shahjouei
- Neurosience Institute, Geisinger Health System, Danville, Pennsylvania (R.Z., S.S.)
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., L.C., A.S.)
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., L.C., A.S.)
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece (K.V.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Greece (K.T.)
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Greece (V.B., P.L.).,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (P.L.)
| | - Petros P Sfikakis
- Joint Rheumatology Program, First Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Greece (P.P.S.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G. Tsivgoulis)
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.T.).,National Public Health Organization of Greece, Athens (S.T.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.H.K., L.P., G. Tsivgoulis.).,Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G. Tsivgoulis)
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9
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Aref HM, Shokri H, Roushdy TM, Fathalla F, El Nahas NM. Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt. PLoS One 2021; 16:e0254228. [PMID: 34260632 PMCID: PMC8279320 DOI: 10.1371/journal.pone.0254228] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the current study we investigated the causes of pre-hospital delay as this can compromise the patient's chance to receive thrombolytic therapy and thus impact stroke outcome. METHODS We surveyed 254 patients regarding reasons for delayed and early arrival to hospital after acute ischemic stroke. The survey was performed over five months, spanning a period pre- and during COVID-19 (between December 7, 2019 and May 10, 2020). RESULTS A total of 71.2% of patients arrived beyond four hours of onset of ischemic stroke. The commonest cause for delay pre-Covid-19 was receiving treatment in a non-stroke hospital, while that during COVID-19 was fear of infection and lock down issues. Not realizing the urgency of the condition and stroke during sleep were common in both periods. Early arrival because of the patient's previous experience with stroke accounted for approximately 25% of cases in both periods. The effect of media was more evident during COVID-19, accounting for 47.7% of cases. CONCLUSION Pre-hospital delay secondary to misperception of the urgency of stroke and management in a non-stroke hospital reflect the lack of awareness among the public and medical staff. This concept is emphasized by early arrival secondary to previous experience with stroke and the pronounced effect of media in the time of COVID-19.
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Affiliation(s)
- Hany M. Aref
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hossam Shokri
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer M. Roushdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Fatma Fathalla
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nevine M. El Nahas
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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10
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Hameed S, Khan M, Fatmi Z, Wasay M. Exploring the Relationship Between Air Quality and Ischemic Stroke Admissions During the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2021; 30:105860. [PMID: 34029889 PMCID: PMC8106888 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives Amongst all the global catastrophe due to Coronavirus disease 2019, a significant bright spot is a reduction in air pollution as countries undergo lockdowns to limit the spread of infection. Another reduction that has been reported is in the number of strokes presenting to hospitals, despite the virus implicated in causing a hypercoagulable state. Acute exposure to air pollution has been linked to increase in stroke incidence and the improvement in air quality may be responsible for the decrease in stroke presentations. Materials and Methods To explore this hypothesis, we compared the air quality index (AQI) of Karachi, the largest cosmopolitan city of Pakistan, during the lockdown period in 2020 to the same period in the previous year. Results We found a significant drop in AQI depicting an improvement in air quality. Simultaneously, we identified a drop in number of stroke admissions to less than half from 2019 to 2020 at one of the largest tertiary care hospitals of the city, during this period of interest. Conclusion: We hypothesize that one important reason for this drop in stroke admissions, may be an actual reduction in stroke incidence brought about by an improvement in air quality.
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Affiliation(s)
- Sajid Hameed
- Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Maria Khan
- Department of Neurology, Rashid Hospital, Dubai, UAE
| | - Zafar Fatmi
- Section of Environmental-Occupational Health & Injuries, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
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11
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Reddy ST, Satani N, Beauchamp JES, Selvaraj S, Rajan SS, Rahbar MH, Tahanan A, Kim S, Holder T, Jiang X, Chen L, Kamal H, Indupuru HKR, Wu T, Savitz SI. A meta-analysis of the global impact of the COVID-19 pandemic on stroke care & the Houston Experience. Ann Clin Transl Neurol 2021; 8:929-937. [PMID: 33616305 PMCID: PMC8014129 DOI: 10.1002/acn3.51322] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/28/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To review the global impact of the COVID-19 pandemic on stroke care-metrics and report data from a health system in Houston. METHODS We performed a meta-analysis of the published literature reporting stroke admissions, intracerebral hemorrhage (ICH) cases, number of thrombolysis (tPA) and thrombectomy (MT) cases, and time metrics (door to needle, DTN; and door to groin time, DTG) during the pandemic compared to prepandemic period. Within our hospital system, between January-June 2019 and January-June 2020, we compared the proportion of stroke admissions and door to tPA and MT times. RESULTS A total of 32,640 stroke admissions from 29 studies were assessed. Compared to prepandemic period, the mean ratio of stroke admissions during the pandemic was 70.78% [95% CI, 65.02%, 76.54%], ICH cases was 83.10% [95% CI, 71.01%, 95.17%], tPA cases was 81.74% [95% CI, 72.33%, 91.16%], and MT cases was 88.63% [95% CI, 74.12%, 103.13%], whereas DTN time was 104.48% [95% CI, 95.52%, 113.44%] and DTG was 104.30% [95% CI, 81.99%, 126.61%]. In Houston, a total of 4808 cases were assessed. There was an initial drop of ~30% in cases at the pandemic onset. Compared to 2019, there was a significant reduction in mild strokes (NIHSS 1-5) [N (%), 891 (43) vs 635 (40), P = 0.02]. There were similar mean (SD) (mins) DTN [44 (17) vs 42 (17), P = 0.14] but significantly prolonged DTG times [94 (15) vs 85 (20), P = 0.005] in 2020. INTERPRETATION The COVID-19 pandemic led to a global reduction in stroke admissions and treatment interventions and prolonged treatment time metrics.
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Affiliation(s)
- Sujan T. Reddy
- Department of NeurologyMercy HospitalFort SmithArkansasUSA
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Nikunj Satani
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Jennifer E. S. Beauchamp
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
- Cizik School of Nursing at UTHealth Department of ResearchHoustonTexasUSA
| | - Sudhakar Selvaraj
- Louis Faillace, MD, Department of Psychiatry and Behavioral SciencesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Suja S. Rajan
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
- Department of Management, Policy and Community HealthSchool of Public HealthUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Mohammad H. Rahbar
- Biostatistics/Epidemiology/Research Design CoreCenter for Clinical and Translational SciencesUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Amirali Tahanan
- Biostatistics/Epidemiology/Research Design CoreCenter for Clinical and Translational SciencesUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Sori Kim
- Biostatistics/Epidemiology/Research Design CoreCenter for Clinical and Translational SciencesUniversity of Texas Health Science Center at HoustonTexasUSA
- Department of Biostatistics and Data ScienceSchool of Public HealthUniversity of Texas Health Science Center at HoustonTexasUSA
| | | | - Xiaoqian Jiang
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Luyao Chen
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Haris Kamal
- Department of NeurosurgeryWestchester Medical CenterNew YorkUSA
| | - Hari Kishan R. Indupuru
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Tzu‐Ching Wu
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
| | - Sean I. Savitz
- Institute for Stroke and Cerebrovascular DiseasesMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonTexasUSA
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12
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Venketasubramanian N, Anderson C, Ay H, Aybek S, Brinjikji W, de Freitas GR, Del Brutto OH, Fassbender K, Fujimura M, Goldstein LB, Haberl RL, Hankey GJ, Heiss WD, Lestro Henriques I, Kase CS, Kim JS, Koga M, Kokubo Y, Kuroda S, Lee K, Lee TH, Liebeskind DS, Lip GYH, Meairs S, Medvedev R, Mehndiratta MM, Mohr JP, Nagayama M, Pantoni L, Papanagiotou P, Parrilla G, Pastori D, Pendlebury ST, Pettigrew LC, Renjen PN, Rundek T, Schminke U, Shinohara Y, Tang WK, Toyoda K, Wartenberg KE, Wasay M, Hennerici MG. Stroke Care during the COVID-19 Pandemic: International Expert Panel Review. Cerebrovasc Dis 2021; 50:245-261. [PMID: 33756459 PMCID: PMC8089455 DOI: 10.1159/000514155] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. SUMMARY The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.
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Affiliation(s)
| | - Craig Anderson
- The George Institute for Global Health, Camperdown, Washington, Australia
| | - Hakan Ay
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard School of Medicine, Boston, Massachusetts, USA
- Takeda Pharmaceutical Co. Limited, Cambridge, Massachusetts, USA
| | - Selma Aybek
- Department of Neurology, University Hospital Inselspital, Bern University, Bern, Switzerland
| | - Waleed Brinjikji
- Department of Radiology, Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel R de Freitas
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
- Department of Neurology, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Oscar H Del Brutto
- School of Medicine, Universidad Espiritu Santo-Ecuador, Samborondón, Ecuador
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
- Division of Advanced Cerebrovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | - Roman L Haberl
- Department of Neurology and Neurological Intensive Medicine, Munich Clinic gGmbH, Academic Teaching Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, Washington, Australia
| | | | - Isabel Lestro Henriques
- Department of Neurosciences, Neurology Service, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jong S Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Kiwon Lee
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Stephen Meairs
- Department of Neurology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Roman Medvedev
- Research Center of Neurology, Moscow, Russian Federation
| | | | - Jay P Mohr
- Tananbaum Stroke Center, New York, New York, USA
| | - Masao Nagayama
- Department of Neurology, International University of Health and Welfare(IUHW), Graduate School of Medicine, Tokyo, Japan
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte, Germany
- Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Guillermo Parrilla
- Department of Neurology, Interventional Neuroradiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Sarah T Pendlebury
- Departments of Internal Medicine and Geratology, John Radcliffe Hospital, Oxford, United Kingdom
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | | | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ulf Schminke
- Department of Neurology, University Medicine, Greifswald, Germany
| | | | - Wai Kwong Tang
- Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Michael G Hennerici
- Department of Neurology, Medical Faculty, Mannheim University of Heidelberg, Mannheim, Germany
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Delays in the Management of Patients with Acute Ischemic Stroke during the COVID-19 Outbreak Period: A Multicenter Study in Daegu, Korea. Emerg Med Int 2021; 2021:6687765. [PMID: 33833878 PMCID: PMC7988744 DOI: 10.1155/2021/6687765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/04/2021] [Accepted: 03/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Timely treatment is important for patients with acute ischemic stroke (AIS). However, the coronavirus disease 2019 (COVID-19) outbreak may have caused delays in patient management. Therefore, we analyzed the prognosis and the time spent at the prehospital and hospital stages in managing patients diagnosed with AIS during the COVID-19 outbreak. Methods This retrospective study evaluated patients diagnosed with AIS in the emergency department (ED) at five medical centers in Daegu city between February 18 and April 17 each year from 2018 to 2020. Data on the patients' clinical features and time spent on management were collected and compared according to COVID-19 and pre-COVID-19 summaries. Results From a total of 533 patients diagnosed with AIS, 399 patients visited the ED before COVID-19 and 134 during the COVID-19 outbreak. During the COVID-19 outbreak, compared with pre-COVID-19, AIS patients had poor National Institute of Health Stroke Scale scores at the initial hospital visit (6 vs. 4, p=0.013) and discharge (3 vs. 2, p=0.001). During the COVID-19 outbreak, the proportion of direct visits to hospitals through public emergency medical services (EMS) increased, and the onset of symptoms-to-ED door time via the public EMS was delayed (87 min vs. 68 min, p=0.006). Conclusions The prognosis of AIS patients during the COVID-19 outbreak was worse than that of pre-COVID-19 patients with delays at the prehospital stage, despite the need for timely care.
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14
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Siegler JE, Zha AM, Czap AL, Ortega-Gutierrez S, Farooqui M, Liebeskind DS, Desai SM, Hassan AE, Starosciak AK, Linfante I, Rai V, Thon JM, Then R, Heslin ME, Thau L, Khandelwal P, Mohammaden MH, Haussen DC, Nogueira RG, Jillella DV, Nahab F, Kaliaev A, Nguyen TN, Zaidat O, Jovin TG, Jadhav AP. Influence of the COVID-19 Pandemic on Treatment Times for Acute Ischemic Stroke: The Society of Vascular and Interventional Neurology Multicenter Collaboration. Stroke 2021; 52:40-47. [PMID: 33250041 PMCID: PMC7934334 DOI: 10.1161/strokeaha.120.032789] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The pandemic caused by the novel coronavirus disease 2019 (COVID-19) has led to an unprecedented paradigm shift in medical care. We sought to evaluate whether the COVID-19 pandemic may have contributed to delays in acute stroke management at comprehensive stroke centers. METHODS Pooled clinical data of consecutive adult stroke patients from 14 US comprehensive stroke centers (January 1, 2019, to July 31, 2020) were queried. The rate of thrombolysis for nontransferred patients within the Target: Stroke goal of 60 minutes was compared between patients admitted from March 1, 2019, and July 31, 2019 (pre-COVID-19), and March 1, 2020, to July 31, 2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. RESULTS Of the 2955 patients who met inclusion criteria, 1491 were admitted during the pre-COVID-19 period and 1464 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. Patients treated during COVID-19 were at lower odds of receiving thrombolysis within 60 minutes of arrival (odds ratio, 0.61 [95% CI, 0.38-0.98]; P=0.04), with a median delay in door-to-needle time of 4 minutes (P=0.03). The lower odds of achieving treatment in the Target: Stroke goal persisted after adjustment for all variables associated with earlier treatment (adjusted odds ratio, 0.55 [95% CI, 0.35-0.85]; P<0.01). The delay in thrombolysis appeared driven by the longer delay from imaging to bolus (median, 29 [interquartile range, 18-41] versus 22 [interquartile range, 13-37] minutes; P=0.02). There was no significant delay in door-to-groin puncture for patients who underwent thrombectomy (median, 83 [interquartile range, 63-133] versus 90 [interquartile range, 73-129] minutes; P=0.30). Delays in thrombolysis were observed in the months of June and July. CONCLUSIONS Evaluation for acute ischemic stroke during the COVID-19 period was associated with a small but significant delay in intravenous thrombolysis but no significant delay in thrombectomy time metrics. Taking steps to reduce delays from imaging to bolus time has the potential to attenuate this collateral effect of the pandemic.
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Affiliation(s)
- James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Alicia M. Zha
- Department of Neurology, University of Texas Health Science Center at Houston, TX (A.M.Z., A.L.C.)
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Health Science Center at Houston, TX (A.M.Z., A.L.C.)
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics (S.O.-G., M.F.)
| | - Mudassir Farooqui
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics (S.O.-G., M.F.)
| | - David S. Liebeskind
- Department of Neurology, Ronald Reagan University of California at Los Angeles (D.S.L.)
| | - Shashvat M. Desai
- Department of Neurology, University of Pittsburgh Medical Center Mercy Hospital, PA (S.M.D., A.P.J.)
- Department of Neurology, University of Pittsburgh Medical Center Presbyterian Medical Center, PA (S.M.D., A.P.J.)
| | - Ameer E. Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen, TX (A.E.H.)
| | - Amy K. Starosciak
- Center for Research (A.K.S.), Baptist Health South Florida, Coral Gables
| | - Italo Linfante
- Department of Interventional Neuroradiology and Endovascular Neurosurgery (I.L.), Baptist Health South Florida, Coral Gables
| | - Vivek Rai
- OhioHealth Neuroscience Center, Riverside Methodist Hospital, Columbus (V.R.)
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Ryna Then
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Mark E. Heslin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Lauren Thau
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Priyank Khandelwal
- Department of Endovascular Neurological Surgery and Neurology, Robert Wood Johnson University Hospital, New Brunswick, NJ (P.K.)
| | - Mahmoud H. Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (M.H.M., D.C.H., R.G.N.)
| | - Diogo C. Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (M.H.M., D.C.H., R.G.N.)
| | - Raul G. Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (M.H.M., D.C.H., R.G.N.)
| | - Dinesh V. Jillella
- Department of Neurology, Emory University Hospital, Atlanta, GA (D.V.J., F.N.)
| | - Fadi Nahab
- Department of Neurology, Emory University Hospital, Atlanta, GA (D.V.J., F.N.)
| | - Artem Kaliaev
- Department of Interventional Neurology and Neuroradiology, Boston Medical Center, MA (A.K., T.N.N.)
| | - Thanh N. Nguyen
- Department of Interventional Neurology and Neuroradiology, Boston Medical Center, MA (A.K., T.N.N.)
| | - Osama Zaidat
- Department of Neurology, Mercy Health St. Vincent Hospital, Toledo, OH (O.Z.)
| | - Tudor G. Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Ashutosh P. Jadhav
- Department of Neurology, University of Pittsburgh Medical Center Mercy Hospital, PA (S.M.D., A.P.J.)
- Department of Neurology, University of Pittsburgh Medical Center Presbyterian Medical Center, PA (S.M.D., A.P.J.)
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15
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El Nahas N, Roushdy T, Hamid E, Farag S, Shokri H, Fathy M, Abushady E, Hazzou A, Aref H. A case series of ischemic stroke with coronavirus disease 2019 in two Egyptian centers. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020; 56:120. [PMID: 33390723 PMCID: PMC7758736 DOI: 10.1186/s41983-020-00259-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel virus that has been reported to have various neurological manifestations. Cerebrovascular disorders have been encountered as a coronavirus disease 2019 (COVID-19) presentation in our center during the pandemic. CASE PRESENTATION We are presenting 10 cases with cerebrovascular manifestations after having COVID-19 few days prior to stroke. CONCLUSION Cerebrovascular manifestations can occur in association with COVID-19 and may have significant implications on prognosis and management.
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Affiliation(s)
- Nevine El Nahas
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer Roushdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman Hamid
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sherien Farag
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hossam Shokri
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mai Fathy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman Abushady
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Hazzou
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hany Aref
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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16
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Tsivgoulis G, Palaiodimou L, Zand R, Lioutas VA, Krogias C, Katsanos AH, Shoamanesh A, Sharma VK, Shahjouei S, Baracchini C, Vlachopoulos C, Gournellis R, Sfikakis PP, Sandset EC, Alexandrov AV, Tsiodras S. COVID-19 and cerebrovascular diseases: a comprehensive overview. Ther Adv Neurol Disord 2020; 13:1756286420978004. [PMID: 33343709 PMCID: PMC7727052 DOI: 10.1177/1756286420978004] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022] Open
Abstract
Neurological manifestations are not uncommon during infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A clear association has been reported between cerebrovascular disease and coronavirus disease 2019 (COVID-19). However, whether this association is causal or incidental is still unknown. In this narrative review, we sought to present the possible pathophysiological mechanisms linking COVID-19 and cerebrovascular disease, describe the stroke syndromes and their prognosis and discuss several clinical, radiological, and laboratory characteristics that may aid in the prompt recognition of cerebrovascular disease during COVID-19. A systematic literature search was conducted, and relevant information was abstracted. Angiotensin-converting enzyme-2 receptor dysregulation, uncontrollable immune reaction and inflammation, coagulopathy, COVID-19-associated cardiac injury with subsequent cardio-embolism, complications due to critical illness and prolonged hospitalization can all contribute as potential etiopathogenic mechanisms leading to diverse cerebrovascular clinical manifestations. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been described in case reports and cohorts of COVID-19 patients with a prevalence ranging between 0.5% and 5%. SARS-CoV-2-positive stroke patients have higher mortality rates, worse functional outcomes at discharge and longer duration of hospitalization as compared with SARS-CoV-2-negative stroke patients in different cohort studies. Specific demographic, clinical, laboratory and radiological characteristics may be used as ‘red flags’ to alarm clinicians in recognizing COVID-19-related stroke.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National & Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
| | - Ramin Zand
- Department of Neurology, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania, USA
| | | | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Aristeidis H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, YLL School of Medicine, National University of Singapore, Singapore
| | - Shima Shahjouei
- Department of Neurology, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania, USA
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | | | - Rossetos Gournellis
- Second Department of Psychiatry, National and Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, 'Attikon' University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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17
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Kim TJ, Kim BJ, Gwak DS, Lee JS, Kim JY, Lee KJ, Kwon JA, Shim DH, Kim YW, Kang MK, Lee EJ, Nam KW, Bae J, Jeon K, Jeong HY, Jung KH, Hwang YH, Bae HJ, Yoon BW, Ko SB. Modification of Acute Stroke Pathway in Korea After the Coronavirus Disease 2019 Outbreak. Front Neurol 2020; 11:597785. [PMID: 33329352 PMCID: PMC7710988 DOI: 10.3389/fneur.2020.597785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 10/16/2020] [Indexed: 01/14/2023] Open
Abstract
Background: Since the global pandemic of coronavirus disease 2019 (COVID-19), the process of emergency medical services has been modified to ensure the safety of healthcare professionals as well as patients, possibly leading to a negative impact on the timely delivery of acute stroke care. This study aimed to assess the impact of the COVID-19 pandemic on the acute stroke care processes and outcomes in tertiary COVID-19-dedicated centers in South Korea. Methods: We included 1,213 patients with acute stroke admitted to three centers in three cities (Seoul, Seongnam, and Daegu) through the stroke critical pathway between September 2019 and May 2020 (before and during the COVID-19 pandemic). In all three centers, we collected baseline characteristics and parameters regarding the stroke critical pathway, including the number of admitted patients diagnosed with acute stroke through the stroke critical pathway, door to brain imaging time, door to intravenous recombinant tissue plasminogen activator time, door to groin puncture time, and door to admission time. We performed an interrupted time series analysis to determine the impact of the COVID-19 outbreak on outcomes and critical pathway parameters. Results: Three centers modified the protocol of the stroke critical pathway during the COVID-19 pandemic. There was an immediate decrease in the number of patients admitted with acute ischemic stroke after the outbreak of COVID-19 in Korea, especially in the center of Daegu, an epicenter of the COVID-19 outbreak. However, the number of patients with stroke soon increased to equal that before the Covid-19 outbreak. In several critical pathway parameters, door to imaging time showed a temporary increase, and door to admission was transiently decreased after the COVID-19 outbreak. However, there was no significant effect on the timely trend. Moreover, there was no significant difference in the baseline characteristics and clinical outcomes between the periods before and during the COVID-19 pandemic. Conclusion: This study demonstrated that the COVID-19 outbreak immediately affected the management process. However, it did not have a significant overall impact on the trends of stroke treatment processes and outcomes. The stroke management process should be modified according to changing situations for optimal acute management.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Beom Joon Kim
- Department of Neurology and Gyunggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong-Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun Yup Kim
- Department of Neurology and Gyunggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Keon-Joo Lee
- Department of Neurology and Gyunggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jung-A Kwon
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Dong-Hyun Shim
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Min Kyoung Kang
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Eung-Jun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Ki-Woong Nam
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jeonghoon Bae
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Kipyoung Jeon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Han-Yeong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Hee-Joon Bae
- Department of Neurology and Gyunggi Regional Cardiocerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
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18
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Affiliation(s)
- Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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