American Heart Association


Impact of COVID-19 on Stroke Workflow: Assessment from Comprehensive Hospitals in Connecticut

Shashank Shekhar, MD, MS

Jasne AS, Chojecka P, Maran I, Mageid R, Eldokmak M, Zhang Q, Nystrom K, Vlieks K, Askenase M, Petersen N, et al. Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic. Stroke. 2020.

Stroke management requires quick and timely evaluation by medical personnel and transfer to a primary stroke center to provide appropriate medical care. The American Heart Association/American Stroke Association recently revised the stroke guidelines in 2019 to reflect the recent advancement in clinical research to clinical practice. However, after the COVID-19 pandemic started in the United States in January 2020, the whole medical system came under severe strain. Around 72% of United States adults were no longer going to public places, including hospitals, to avoid COVID-19 exposure.

This study estimates this decline in stroke volume in the Comprehensive Stroke Centers (CSC) in Connective and eventually aims to increase public awareness. The aims of the study were: compare the volume of stroke codes before and during the COVID-19 local spread; describe the demographics and clinical characteristics of patients presented with acute stroke-like symptoms during this pandemic; and find the association between the onset of the pandemic and acute stroke metrics and outcomes.

This study is a retrospective pre and during event cohort analysis and was approved by the Yale-New Haven Hospital (YNHH) Institutional Review Board with a waiver of informed consent. The date was including from pre-pandemic cohort and pandemic cohort from 2019 and corresponding months in 2020. The number of stroke codes at three hospitals was analyzed from January 1 to April 28, 2020, and compared from the previous year.

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.

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.”

Infection Impact on Stroke Outcome Beyond Hospital Discharge

Elena Zapata-Arriaza, MD

Boehme AK, Kulick ER, Canning M, Alvord T, Khaksari B, Omran S, et al. Infections Increase the Risk of 30-Day Readmissions Among Stroke Survivors: Analysis of the National Readmission Database. Stroke. 2018;49:2999–3005.

Infection is a most frequent medical complication after stroke. It is well recognized that acute stroke induces both the central nervous system and peripheral inflammatory responses, and, infection during stroke admission increases acute and longer-term inflammatory responses, complicating stroke outcomes. However, up to now, clinical trials with prophylactic aim in infection after stroke have failed. Therefore, stroke and infection develop a negative feedback between them.

Based on the known association between infection and stroke outcomes, the authors performed a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30-day readmission (30dRA) among ischemic stroke survivors. The main goal of this paper was to confirm the relation between stroke infection and 30dRA. The novelty of the paper is the identification of stroke associated infection as a predictor of readmission, not only as the most frequent cause of a new hospitalization. The authors employed the International Classification of Disease Ninth Revision [ICD-9] codes to identify ischemic stroke patients with ICD-9 codes present in the first diagnostic position ischemic stroke (referred as primary ischemic stroke patients) and patients with ischemic stroke code at any diagnostic position (referred as all ischemic stroke patients). The primary outcome, 30dRA, was classified as any hospitalization occurring within the 30-day postdischarge window and classified into planned or unplanned readmissions using previously validated ICD-9 codes. Secondary outcomes, 7dRA and 60dRA, were also assessed and were classified as any hospitalization occurring within the 7 days, or 60 days, postdischarge window.

The ARISTOPHANES Study: Real-World Evidence About Oral Anticoagulants

Lina Palaiodimou, MD

Lip GYH, Keshishian A, Li X, Hamilton M, Masseria C, Gupta K, et al. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients: The ARISTOPHANES Study. Stroke. 2018

The ARISTOPHANES study is a large retrospective observational study with real-world data pooled from 5 data sources in the United States, in order to compare stroke/systemic embolism (SE) and major bleeding (MB) among nonvalvular atrial fibrillation patients treated with either non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin.

The researchers of this study collected data about a total of 321182 patients with a diagnosis of AF, who had an active medical and pharmacy health plan enrollment and were prescribed treatment with either NOAC or warfarin according to pharmacy claims. Exclusion criteria were the following: evidence of valvular heart disease, venous thromboembolism, previous oral anticoagulant treatment, transient AF due to treatable causes (pericarditis, hyperthyroidism, thyrotoxicity), heart valve replacement or transplant, pregnancy and recent surgical operations. Demographic data, Charlson Comorbidity Index score, baseline bleeding and stroke/SE history, comorbidities, baseline comedication and dose of NOAC were recorded about all patients. In contrast, reason for lose-dose NOAC prescription, creatinine clearance, international normalized ratio (INR) measurements in warfarin-treatment group and patient adherence data were not available. The outcome measures were time to stroke (either ischemic or hemorrhagic) or systemic embolism and time to major bleeding, either gastrointestinal or intracranial or at other key sites (eyes, pericardium, urinary tract, joints). Identification of these events were based just on hospitalization incidence with stroke/SE or MB as the principal diagnosis according to International Classification of Diseases, Ninth Revision (ICD-9). Mortality due to all-causes was also evaluated, but just for the patients enlisted in only one out of five data sources. Patients were followed up each for a different period, according to drug discontinuation date, switch to another drug date, death, end of medical and pharmacy health plan enrollment, or end of study period, whichever occurred first. In the conducted sensitivity analysis, the follow-up period was restricted to 1 year, to better achieve balance between the cohorts.

Utility Weighted Modified Rankin Scale and the Future of Patient-Centered Outcomes in Stroke Research

Kevin S. Attenhofer, MD

Dijkland SA, Voormolen DC, Venema E, Roozenbeek B, Polinder S, Haagsma JA, et al. Utility-Weighted Modified Rankin Scale as Primary Outcome in Stroke Trials: A Simulation Study. Stroke. 2018

As stroke neurologists, we are all intimately familiar with the modified Rankin Scale (mRS) as a measure of degree of disability. It is a common outcome measure in stroke research and can be statistically analyzed as a simple dichotomization or ordinal shift (among other options). The dichotomized outcome takes varied and complex neurological outcomes and simplifies them down to nominal variables of “good” or “bad.” This is statistically more straightforward, but does result in some outcome information being discarded. The ordinal shift retains more of this information, but typically requires larger sample size to maintain adequate power. Even when well powered, however, the mRS still has a disproportionate focus on motor function when compared to other neurological domains, such as cognition or patient metrics such as quality of life.

Insights from Modeling Stroke Systems of Care in Philadelphia

Neal S. Parikh, MD

Mullen MT, Pajerowski W, Messe SR, Mechem CC, Jia J, Abboud M, et al. Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies. Stroke. 2018

Dr. Mullen and colleagues performed a geographic modeling study to understand the implications of several pre-hospital triage strategies on transport times. The rationale for this and related studies is that optimizing stroke systems of care requires accounting for regional and local constraints. Because most of the U.S. population lives in urban areas, investigating urban stroke systems of care is worthwhile.

Philadelphia has only one EMS provider. So, the researchers were able to use EMS data to identify and geocode all ambulance-transported patients with possible stroke and then use a maps application programming interface (API) to estimate travel times. They also had actual travel times as reported by EMS.

The PLUMBER Study Yields an Important Piece of the Stroke Systems of Care Puzzle

Neal S. Parikh, MD 

Dozois A, Hampton L, Kingston CW, Lambert G, Porcelli TJ, Sorenson D, et al. PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response). Stroke. 2017

Optimizing access to endovascular therapy has become a public health priority. While various national guidelines seek to shape acute stroke EMS triage practices broadly, regulatory bodies have also acknowledged the need to tailor protocols to local and regional environments.

In deciding whether to triage an individual patient with suspected stroke to an endovascular center instead of a primary stroke center, EMS may consider factors such as relative travel distances, stroke severity, and the likelihood of a large vessel occlusion (LVO).

LVO screening tools have inherent imprecision, and the positive predictive value, of course, depends on the prevalence of LVO. For this reason, knowing the prevalence of LVO among acute ischemic stroke 9-1-1 dispatches is of importance. Further, at an organizational level, the accuracy and precision of LVO detection in the field has upstream implications for case load at endovascular and non-endovascular centers. The importance of these considerations varies by locale.