Background and Purpose: Patient care-seeking has likely changed during the coronavirus disease 2019 (COVID-19) pandemic. In stroke, delayed or avoided care may translate to substantial morbidity. We sought to determine the effect of the pandemic on patterns of stroke patient presentation and quality of care. Methods: We analyzed data from 25 New England hospitals: one urban, academic comprehensive stroke center and telestroke hub, and 24 spoke hospitals in the telestroke network. We included all telestroke consultations from the 24 spokes, and all stroke admissions to the comprehensive stroke center hub from November 1, 2019 through April 30, 2020. We compared rates of presentation, timeliness presentation, and quality of care pre- versus post-March 1, 2020. We examined trends in patient demographics, stroke severity, timeliness, diagnoses including large vessel occlusion, alteplase use, and endovascular thrombectomy among eligible subjects. We compared proportions and bivariate comparisons to examine for changes pre- versus post-March 1, 2020 and used linear regression to examine trends over time. Results: Among 1248 patient presentations (844 telestroke consultations, 404 comprehensive stroke center admissions), telestroke consultations and ischemic stroke patient admissions decreased among the spokes and hub. Age and stroke severity were unchanged over the study period. We found no change in alteplase administration at telestroke spoke hospitals but did note a decrease in both alteplase use and thrombectomy at our comprehensive stroke center. Time metrics for patient presentation and care delivery were unchanged; however, rates of adherence for the quality measures dysphagia screening, early antithrombotic initiation, and early venous thromboembolism prophylaxis were reduced during the pandemic. Conclusions: In this regional analysis, we found decreasing telestroke consultations and ischemic stroke admissions, and reduced performance on stroke quality of care measures during the COVID-19 pandemic. Contrary to prior reports, we did not find an increase in thrombectomy nor decrease in clinical severity that might be expected if patients with milder symptoms avoided hospitalization.
OBJECTIVE: To compare angiographic findings in patients with Reversible Cerebral Vasoconstriction Syndrome (RCVS), Primary Angiitis of the CNS (PACNS, the closest mimic of RCVS), and Controls.
Background: There is limited information concerning stroke thrombolysis in developing countries like India. We investigated the frequency, barriers and outcomes after thrombolysis in 5 high-volume hospitals across India. Methods: The Indo-US Stroke Registry and Infrastructure Development Project, jointly funded by NINDS and the Indian Department of Biotechnology, currently include 5 geographically diverse centers in North and South India and one in Boston, USA. Trained MD co-investigators and research coordinators prospectively collect data on consecutive adult patients with imaging-confirmed ischemic stroke <2 weeks after symptom onset. Data is entered into a central web-based electronic database. Results: From Nov-2012 to July-2014, 1944 patients were enrolled. Two hundred and eighty six were eligible for tPA. A total of 215 patients (11% of the total cohort and 75% of tPA-eligible patients) received thrombolysis including 139 of 188 patients who arrived <3h after onset and 76 of 98 who arrived between 3-4.5 h. Mean age was 59±15 years (range 48-69 years) and 68% were male. Stroke risk factors included hypertension (75%), diabetes (48%), hyperlipidemia (18%), coronary artery disease (27%), rheumatic heart disease (12%), atrial fibrillation (9%) and myocardial infarction (10%).The median NIHSS score was 10 (Interquartile range: 6-14). Hospital arrival was via EMS (3%), private transportation (50%) and transfer from another hospital (49%). Symptomatic intracranial hemorrhage was documented in 15 patients. Barriers of thrombolysis among patients otherwise eligible for thrombolysis included inability to afford tPA (n=15), patients/family refusal (n=32), delay in stroke diagnosis (n=6), and/or other in-hospital delays (n=9). Conclusions: Thrombolysis is frequently administered in large academic hospitals in India, with acceptable safety. The relative lack of ambulance services, delay in arrival and diagnosis, and high cost of tPA are opportunities for infrastructure development.
Intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is increasingly controversial. Recent trials support MT without IVT for patients presenting directly to MT-capable "hub" centers. However, bypassing IVT has not been evaluated for patients presenting to IVT-capable "spoke" hospitals that require hub transfer for MT. A perceived lack of efficacy of IVT to result in LVO early recanalization (ER) is often cited to support bypassing IVT, but ER data for IVT in patients that require interhospital transfer is limited. Here we examined LVO ER rates after spoke-administered IVT in our hub-and-spoke stroke network.
Background Altered cerebrovascular tone is implicated in reversible cerebral vasoconstriction syndrome (RCVS). We evaluated vasomotor reactivity using bedside transcranial Doppler in RCVS patients. Methods In this retrospective case-control study, middle cerebral artery (MCA) blood flow velocities were compared at rest and in response to breath-hold in RCVS ( n = 8), Migraineurs ( n = 10), and non-headache Controls ( n = 10). Hyperventilation response was measured in RCVS. Results In RCVS, Breath Holding Index (BHI) was severely reduced in seven of eight patients and 14/16 MCAs; seven of 16 MCAs showed exhausted (BHI < 0.1) or inverted (BHI < 0) vasomotor reactivity. Mean BHI in RCVS (0.23 ± 0.5) was significantly lower than Migraine (1.52 ± 0.57) and Controls (1.51 ± 0.32), p < 0.001. Triphasic velocity responses were seen in all groups. The maximum V mean decline during the middle negative phase was −15.5 ± 9.2% in RCVS, −15.4 ± 7% in Migraine, and −10.3 ± 5% in Controls ( p = 0.04). In the late positive phase, average V mean increase was 6.2 ± 14% in RCVS, which was significantly lower ( p < 0.001) than Migraine (30.5 ± 11%) and Controls (30.2 ± 6%). With hyperventilation, RCVS patients showed 23% decrease in V mean . Conclusion Cerebral arterial tone is abnormal in RCVS, with proximal vasoconstriction and abnormally reduced capacity for vasodilation. Further studies are needed to determine the utility of BHI to diagnose RCVS before angiographic reversibility is established, and to estimate prognosis.
ABSTRACT Hyperacute, spontaneous, and severe parenchymal postischemic hemorrhage is considered rare but might be frequently misdiagnosed as primary intracerebral hemorrhage. The authors report 2 patients with catastrophic postischemic hemorrhage unrelated to anticoagulation, thrombolytics, or coagulopathy. Patient 1 was a 73‐year‐old woman with left posterior frontal lobe infarction, followed at 5.5 hours by massive postischemic hemorrhage leading to death. Patient 2 was a 52‐year‐old man with recent brain irradiation who developed left middle cerebral artery occlusion and basal ganglia infarction. Initial gradient‐echo magnetic resonance imaging (MRI) showed petechial hemorrhage within areas of infarction and widespread old microbleeds. He developed massive postischemic hemorrhage at 12 hours, leading to death. The authors conclude that early brain imaging is essential to distinguish postischemic from primary brain hemorrhage. In patients with ischemic stroke, MRI findings such as hyperacute petechial hemorrhage or chronic cerebral microbleeds might predict subsequent parenchymal hemorrhage and thus have implications for tissue plasminogen activator use.
