Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES

COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.

METHODS

This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).

RESULTS

Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).

DISCUSSION

Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.

TRIAL REGISTRATION INFORMATION

The study was registered under ClinicalTrials.gov identifier NCT04895462.

006 A novel approach in the management of functional neurological disorder in the hyper-acute setting

Introduction

Functional Neurological Disorder (FND) is common and can lead to multiple emergency department (ED) presentations and unnecessary investigation. Early identification and intervention have been shown to reduce health care costs and re-presentation to acute services by more than 50%1.

We created a pilot model to provide early access to a multi-disciplinary FND team for patients assessed by the ED-embedded neurology team (Stroke or Neurology SDEC pathway) to have a new diagnosis of FND. The MDT provided patients with individualised information about FND, pathway navigation, and shown self-management tools.

Methods

We reviewed data for all patients seen to date by the pilot service.

Results

Since commencement in November 2021, nine patients have been seen by the MDT. All patients were seen within two weeks by a neurophysiotherapist and neuropsychiatrist with neurology support.

6 were female and median age was 41 years. All presented with limb weakness and/or sensory distur- bance. 7 reported prior anxiety or depression. 6 had psychiatric factors, including Emotionally Unstable Personality Disorder and health anxiety. Follow up, 2 of the 9 patients so far demonstrated reduced health anxiety and increased confidence.

Conclusion

An acute FND pathway can provide timely intervention and reduce symptoms for new presentations with FND.

1. Stepped care for functional neurological disorder, A new approach to improving outcomes for a common neurological problem in Scotland. Report and Recommendations, NHS Improvement, February 2012

022 Preliminary results from a consultant-led acute neurology service based in the emergency department

Background and aim

5-10% of emergency department (ED) presentations are primarily neurological. We investigated the impact of the introduction of an acute neurology service to the ED, using the same day emergency care (SDEC) model.

Methods

We performed a retrospective review of consecutive referrals to a consultant-led service at University College London Hospital during weekday afternoons from 5th May 2021 to 20th Jan 2022.

Results

Of 664 Neurology referrals, female sex was more common than male (60% vs 35.8%, p<0.0001, Fig. 1).

Most referrals were from ED Majors (30%, Fig. 2). The most common presenting complaints were headache(n=187), weakness(n=34), dizziness(n=28), and numbness(n=26). Referrers’ working diagnoses included no diagnosis (n=69), unspecified headaches(n=62), migraines(n=42), and stroke(n=23) (Fig. 3). The most common diagnoses after Neurology review were migraines(n=160), vascular events(n=21), functional(n=16), and seizures(n=12) (Fig 4).

Following review, working diagnosis changed in 307(46.2%), and the following planned actions were cancelled: hospital admission in 204(30.7%); stroke referral in 190(28.6%); imaging in 45 and lumbar puncture in 33. 170(25%) cases were fully managed in SDEC which would otherwise have followed the urgent 2-week-wait pathway.

Conclusions

Acute Neurology input in the ED had major impacts on working diagnoses, hospital admis- sions, urgent outpatient referrals, and emergency investigations.

083 Intravenous magnesium for acute presentations of migraine to A&E

Background and aim

Studies have demonstrated the role of magnesium on acute migraine attacks and prophylaxis via voltage-dependent blockade of N-methyl-D-aspartate (NMDA)-coupled channels. Our aim was to study the tolerability of intravenous (IV) magnesium in the treatment of migraine in the Emergency Department (ED) and the Same Day Emergency Care (SDEC) unit of University College Hospital, London.

Methods

We performed a non-randomised open-label trial to establish the safety of IV magnesium sulfate. Patients were recruited from the ED or the SDEC unit of the hospital after being reviewed by consultant Neurologists from Aug 2021 – Jan 2022. Magnesium levels were measured prior to administration of the drug and complications were closely monitored.

Results

35 patients with status migrainosus were recruited; 30 were females and their mean age was 39 years (SD: 13.5 in years). All had normal serum magnesium levels prior to drug administration. No ECG changes were identified. None developed serious adverse symptoms during or immediately after infusion. A beneficial effect was noted in 15 patients, no effect in 10, and missing data in 10.

Conclusion

Administration of IV Magnesium is an effective and tolerated adjunct for the management of migraine. Efficacy studies are currently underway.

Invasive Methicillin-Resistant Staphylococcus aureus USA500 Strains from the U.S. Emerging Infections Program Constitute Three Geographically Distinct Lineages

USA500 isolates are clonal complex 8 (CC8) Staphylococcus aureus strains closely related to the prominent community- and hospital-associated USA300 group. Despite being relatively understudied, USA500 strains cause a significant burden of disease and are the third most common methicillin-resistant S. aureus (MRSA) strains identified in the U.S. Emerging Infections Program (EIP) invasive S. aureus surveillance. To better understand the genetic relationships of the strains, we sequenced the genomes of 539 USA500 MRSA isolates from sterile site infections collected through the EIP between 2005 and 2013 in the United States. USA500 isolates fell into three major clades principally separated by their distribution across different U.S. regions. Clade C1 strains, found principally in the Northeast, were associated with multiple IS256 insertion elements in their genomes and higher levels of antibiotic resistance. C2 was associated with Southern states, and E1 was associated with Western states. C1 and C2 strains all shared a frameshift in the gene encoding AdsA surface-attached surface protein. We propose that the term "USA500" should be used for CC8 strains sharing a recent common ancestor with the C1, C2, and E1 strains but not in the USA300 group.IMPORTANCE In this work, we have removed some of the confusion surrounding the use of the name "USA500," placed USA500 strains in the context of the CC8 group, and developed a strategy for assignment to subclades based on genome sequence. Our new phylogeny of USA300/USA500 will be a reference point for understanding the genetic adaptations that have allowed multiple highly virulent clonal strains to emerge from within CC8 over the past 50 years.