American Heart Association

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Stroke in the COVID-19 Era

Kevin O’Connor, MD

Katsanos AH, Palaiodimou L, Zand R, Yaghi S, Kamel H, Navi BB, Turc G, Benetou V, Sharma VK, Mavridis D, et al. Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Stroke. 2021.

COVID-19 complicates many aspects of clinical care, including care of stroke patients. Katsanos et al. conducted a meta-analysis on the impact of COVID-19 on the provision of stroke care, independent of SARS-CoV-2 infection status. They collected 46 studies capturing data from 129,491 patients across Africa, Asia, Europe, and the Americas comparing common stroke care variables pre- and post-pandemic onset. These included demographic information, vascular risk factors, intravenous thrombolysis (IVT) administration, endovascular thrombectomy (EVT) performance, relevant time metrics, and hospitalization outcomes.

A Good Reminder: Adherence to Quality Indicators Associated with Decreased 7-Day Mortality

Melanie R. F. Greenway, MD

Haas K, Rücker V, Hermanek P, Misselwitz B, Berger K, Seidel G, Janssen A, Rode S, Burmeister C, Matthis C, et al. Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke. Stroke. 2020;51:3664–3672.

In the age of checklists, quality metrics, and frequent audits, sometimes the importance of these indicators is taken for granted. Instead of serving as a guiding light for quality care, they may be seen as an annoyance, slowing down an already inefficient system. This study reviewing the association between quality indicators (QI) and outcomes is a good reminder of the importance of tending to these quality indicators. 

This study utilized the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutschprachiger Schlaganfall Register), which is a network of nine stroke registers, comprising multiple regions throughout the country. 388,012 patients with acute ischemic stroke admitted to 736 hospitals were reviewed from 2015-2016. Of the hospitals participating, 55.6% of them had stroke unit services. Overall, 7-day in-hospital mortality was 3.4%, and median length of stay was 8 days. 

The Road Less Traveled? Reassessing Triage Strategies in Prehospitalized Stroke Patients

Yasmin Aziz, MD

Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke. 2020;51:3310–3319.

Patients with acute large vessel occlusions (LVOs) have better outcomes if they are sent to the endovascular suite expeditiously. Yet, many times these patients are taken to the nearest primary stroke center under the “drip and ship” model.

In this study, the authors used geographic information, census data, and stroke center accreditor information to build an origin to destination matrix analyses of patient location to nearest primary stroke center and to nearest intervention center. To do so, four different triage strategies were compared: (1) always going directly to the nearest primary stroke center, (2) always going directly to an endovascular center; (3) using the current AHA algorithm suggesting direct transfer to endovascular center if driving time is less than 30 minutes when LVO is suspected and won’t preclude tPA administration; (4) using a modified algorithm that would allow for additional driving time if an LVO is suspected if thrombolysis isn’t precluded (adding <30 minutes of driving time, <60 minutes of driving time, or not restricting by driving time at all). 

Another Prehospital Model Favoring Liberal Transport to Thrombectomy Center, But Clinical Trials Still Elusive

Walter Valesky, MD

Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke. 2020;51:3310–3319.

With the increasing importance of endovascular therapy in acute ischemic stroke care, triage and emergency transport strategies have taken on renewed importance. Current recommendations advise preferential transport to a comprehensive stroke center (CSC) if a large vessel occlusion (LVO) is suspected based on prehospital screening and when the total transport time is less than 30 minutes. The study summarized here evaluated alternative triage strategies in comparison with the current American Heart Association (AHA) recommendations.

A previously utilized decision-tree model referred to in a prior study2 was used to map outcomes of a suspected LVO to either a primary stroke center (PSC) and then transferred for thrombectomy or directly to an intervention center. A base scenario was applied to the model in which emergency medical services (EMS) was activated for a hypothetical patient with a suspected stroke within 4.5 hours of symptom onset with several time assumptions corresponding to “Get With the Guidelines” recommendations. LVO prevalence was estimated at 20% among suspected stroke patients based on prior studies,2-3 and prehospital assessment applied the rapid arterial occlusion evaluation (RACE) with an assumed sensitivity of 84% and specificity of 60% at a cutoff of 5 points. 

COVID-19 Pandemic Disrupts Acute Stroke Care

Tyler Owens, DO

Montaner J, Barragán-Prieto A, Pérez-Sánchez S, Escudero-Martínez I, Moniche F, Sánchez-Miura JA, Ruiz-Bayo L, González A. Break in the Stroke Chain of Survival due to COVID-19. Stroke. 2020;51:2307–2314.

How has the COVID-19 pandemic affected our modern systems of acute stroke care? Montaner et al. performed a descriptive analysis before and during the current COVID-19 era, giving a glimpse into how the pandemic can negatively affect acute stroke care. The study was done in a southern region of Spain. Key metrics in the study were taken from pre-hospital and hospital acute care.

Data was collected from a region comprised of 2 stroke units and 2 large hospitals. One of the hospitals served as a thrombectomy referral center and the other as a tele-stroke referral center for several community hospitals. Data for the study was collected from an ongoing stroke registry. The study samples included 41 thrombectomies, 32 tele-stroke consults, and 51 patients treated with thrombolysis therapy. The bulk of the analyses focused on data 15 days prior to the outbreak to 15 days after (March 31, 2020).

Article Commentary: “Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era”

Burton J. Tabaac, MD

Diegoli H, Magalhães PSC, Martins SCO, Moro CHC, França PHC, Safanelli J, Nagel, V, Venancio VG, Liberato RB, Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020.

On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic. As of this writing, the global number of cases exceeds 8.1 million. However, despite the rapidly increasing prevalence of COVID-19, many questions remain regarding this unusual and highly lethal disease. The pathogenesis of COVID-19–associated neurologic injury remains to be established. SARS-CoV-2 has been shown to induce a hypercoagulable state, thus increasing the risk of arterial thrombosis with acute ischemic stroke.(1)

From late 2019 to early 2020, COVID-19 started to disrupt the healthcare systems of many nations. From the beginning of the pandemic, it has been a major concern for doctors and public authorities that resources needed to treat other conditions such as stroke are diverted for COVID-19.(2) The authors are keen to note that “patients may be unwilling to go to a hospital for stroke treatment due to fear of becoming contaminated with the disease.” Using a population-based stroke registry, the authors of this original contribution investigated the impact of the onset of the COVID-19 pandemic on stroke admissions in Joinville, Brazil. The authors’ hypotheses were as follows: First, hospital admissions for stroke were reduced after the onset of the COVID-19 pandemic. Next, the reduction occurred only in transient ischemic attacks (TIA) and mild cases. Also, there was a change in the time between stroke onset and hospital admissions. Finally, the number of patients receiving reperfusion therapies (IVT and MT) has decreased.

Endovascular Thrombectomy With Improved Reperfusion Leads to Long-Term Public Health and Societal Cost Benefits

Melissa Trotman-Lucas, PhD

Kunz WG, Almekhlafi MA, Menon BK, Saver JL, Hunink MG, Dippel DWJ, et al. Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke. Stroke. 2020;51:899–907.

The number of deaths due to stroke is 10 million per year globally, with a prevalence of 42 million. Large vessel occlusions (LVO) account for a third of all occlusive ischemic strokes and are the largest contributor to the morbidity and mortality associated with ischemic stroke. The evolution and use of endovascular thrombectomy (EVT) for these patients have transformed stroke treatment and care; clinical trials utilizing EVT demonstrated the benefits of this technique during post-stroke recovery, including reduced disability and improved outcome. In multiple countries, EVT has been adopted as the standard of care for LVO and is recommended for use where possible in other countries — limits come from availability of suitably trained staff and equipment.

Educate and Empower EMS for Expedited Acute Stroke Treatment

Rohan Arora, MD

Gu H-Q, Rao Z-Z, Yang X, Wang C-J, Zhao X-Q, Wang Y-L, et al. Use of Emergency Medical Services and Timely Treatment Among Ischemic Stroke: Findings From the China Stroke Center Alliance. Stroke. 2019;50:1013–1016.

Despite the progress in stroke treatment protocols in the United States, the rate of tPA use remains low due to the inability of ischemic stroke patients to reach the hospital within the narrow therapeutic window. EMS plays a very crucial role in acute stroke care by decreasing prehospital delay and by providing prenotification for the stroke team activation, which leads to decrease in door-to-needle time.

Gu et al. analyzed data from the Chinese Stroke Centre Alliance for patients with ischemic stroke from 2015 to 2018 to study the pattern of EMS use, factors associated and its impact on prehospital delay and the treatment. Absolute standardized difference and multivariate logistic models were used. Of 560447 patients with ischemic stroke, only 12.5% used EMS for transportation to the hospital. EMS use was significantly less in the younger population, low income group, milder stroke symptoms, HTN, DM and PVD, while its use was significantly more in patients with history of CVD. Perhaps EMS education regarding stroke in the young might still be something to continually work on. EMS transport was significantly associated with less prehospital delay, shorter onset-to-door time, shorter door-to-needle time (if prenotification is sent) and more rapid treatment. The authors concluded that a low proportion of AIS patients using EMS could be due to lack of accessibility to EMS or lack of awareness for urgent stroke treatment.

Author Interview: Dr. Houman Khosravani, MD, PhD, on “Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic”

Houman Khosravani
Houman Khosravani

A conversation with Houman Khosravani, MD, PhD, Assistant Professor, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada. Twitter: @neuroccm

Interviewed by Victor J. Del Brutto, MD, Assistant Professor, Stroke Division, Department of Neurology, University of Miami Miller School of Medicine, Florida. Twitter: @vdelbrutto

They will be discussing the paper “Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic,” published in Stroke.

Dr. Del Brutto: First of all, I would like to thank you and your team for putting together these thoughtful recommendations on how to evaluate patients with suspected stroke during the Coronavirus Disease 2019 (COVID-19) pandemic. As a stroke neurologist, I share the global feeling of uncertainty that this pandemic has caused and look forward to modifying my institution practices in order to maximize patients’ outcomes, their safety, and the safety of the professionals involved in their care. In your article, you mention that stroke patients are at an increased risk of suboptimal outcomes during the COVID-19 pandemic. Could you please comment on the factors that may influence patient outcomes?

Dr. Khosravani: During the COVID-19 pandemic, patients are affected at several junctions in stroke care, including during the hyperacute phase. For example, paramedics responding to a stroke call, in some jurisdictions, will begin the screening process prior to arrival and then again on scene. When screening is positive, pre-notification to the hospital should occur, and this triggers a protected code stroke (PCS). Patients being brought directly to the ED will require additional screening. The necessary use of PPE, with a Safety Lead observing, will add some delays to the front-end processes, but these are essential to keeping providers safe. It is very plausible that, for example, door-to-needle/door-to-groin puncture times will be impacted. Similarly, at the point-of-care, a COVID-19–suspected patient going to imaging will result in having special precautions used in the scanner or neuroangiography suite, which will add additional time (for cleaning as well); this impacts scenarios with back-to-back code strokes as well.

The Trials of tPA

Rachel Forman, MD

Haslett JJ, Genadry L, Zhang X, LaBelle LA, Bederson J, Mocco J, et al. Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. Stroke. 2019

When I read the title of this article, the first thing that came to mind was the bleeding risk associated with tPA. After all, we carefully read through the tPA contraindications checklist making sure we will not cause harm to our patients. It turns out that there is a lot more to worry about! 

In the article “Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke,” Haslett et al. discuss characteristics of malpractice cases related to acute stroke management. 

It was helpful that the authors first defined some legal terms, specifically that “to prove medical malpractice occurred, a plaintiff must show that during the course of treatment, the physician deviated from the standard of care as defined by the medical community, and that caused injury to the patient.”