Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India.

COVID-19 disease caused by the SARS coronavirus has caused significant morbidity and mortality around the world ever since it was first declared as a pandemic by the World Health Organization (WHO) in March 2020. Acute neurological manifestations of this disease have also started emerging and being recognized around the world and acute ischemic stroke (AIS) or thrombotic stroke is becoming one of the major neurological illnesses related to COVID-19. The management of AIS is time-critical and major advances in its management over the recent years, such as bridging thrombolysis and mechanical thrombectomy (MT), are multidisciplinary activities requiring robust coordination and management in the acute setting. All these advances are severely challenged in the COVID-19 pandemic where severe pressures exist on the clinical resources and logistics required to deliver an effective stroke service. This is further compromised by legal and preventive measures during this pandemic like local lockdowns. Reporting of minor or initial symptoms has also been compromised due to the fear of approaching healthcare settings which are perceived as high-risk zones to catch the infection. The purpose of this document is to highlight these challenges and provide a guiding framework for the management of AIS under three principles: (a) Delivering an effective service, (b) Preventing infections within the healthcare setting, and (c) Optimizing resource utilization. How to cite this article: Kakkar G, Zirpe KG, Sapra H, Dixit S, Chugh C, Nagaiyan S, et al. Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India. Indian J Crit Care Med 2020;24(9):757-762.

Neurosurgical image: giant pituitary adenoma and multiple aneurysms.

Pituitary adenomas are associated with intracranial aneurysms. Giant non-functioning pituitary adenomas with aneurysms in their vicinity pose technical surgical challengesas aneurysm rupture can be catastrophic during surgery. We present the case of a middle aged women who presented with progressive visual loss in both eyes caused by a giant pituitary adenoma compressing the optic chiasma. She also had associated mirror image carotid aneurysms embedded in the tumour. They were successfully coiled preoperatively and the tumour was removed safely with improvement of her symptoms.

Cerebral vasospasm and delayed cerebral ischemia: Review of literature and the management approach.

This article highlights the pathogenesis and management of cerebral vasospasm. It discusses the various pharmacological, endovascular, and neurosurgical approaches available for the treatment of cerebral vasospasm. Numerous drugs and procedures have been tried and tested in the management of cerebral vasospasm. We try to highlight the pros and cons of various pharmacological agents and case-based use of other not so popular and investigational techniques.

Acute Ischemic Stroke: Management Approach.

How to cite this article: Chugh C. Acute Ischemic Stroke: Management Approach. Indian J Crit Care Med 2019;23(Suppl 2):S140-S146.

Modern endovascular treatments of occlusive pediatric acute ischemic strokes: case series and review of the literature.

PURPOSE: Literature on the endovascular treatment of occlusive acute ischemic stroke (AIS) in the pediatric population remains nebulous. Clinical trials evaluating the role of systemic and intra-arterial thrombolysis, and mechanical thrombectomy have been strictly isolated to the adult population and largely unknown in their safety and efficacy in the pediatric group. METHODS: The authors present a review of the literature and their own two cases of occlusive acute ischemic stroke in children younger than the age of 10 years who were treated with modern endovascular devices, specifically with stent retrievers, and discuss their clinical and technical considerations as well as their limitations. RESULTS: In both pediatric patients, a combination of stent retriever and Penumbra aspiration were used to achieve Thrombolysis In Cerebral Infarction (TICI) 2a or greater with reduction of overall stroke burden. A reduction of National Institutes of Health Stroke Scale (NIHSS) of 8 or greater was achieved at discharge. At 3-month follow-up, the patients had a NIHSS of 6 and 2, respectively. One patient continued to improve from NIHSS of 6 to 3 at 6 months. CONCLUSION: In carefully, selected pediatric patients, modern endovascular techniques may be used to treat occlusive pediatric AIS. However, larger clinical trials are needed to evaluate the overall safety and effectiveness.

Global impact of COVID-19 on stroke care.

BACKGROUND: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide. AIMS: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior). METHODS: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers. RESULTS: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions. CONCLUSION: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study's objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Early angiographic occlusion of ruptured blister aneurysms of the internal carotid artery using the Pipeline Embolization Device as a primary treatment option.

BACKGROUND: Data on the timing, durability and occlusion rate of treating ruptured blister cerebral aneurysms using the Pipeline Embolization Device (PED) are limited. CLINICAL PRESENTATION: Three patients who presented with subarachnoid hemorrhages from ruptured blister aneurysms of the internal carotid arteries were treated with the PED. RESULTS: Aneurysmal occlusion with reconstruction of the parent vessels occurred angiographically using the PED as a primary treatment modality. All three patients were treated successfully without immediate or delayed complications and remained neurologically intact during the 6-month follow-up period. CONCLUSIONS: Complete occlusion of a ruptured blister aneurysm can occur immediately after PED placement. In ruptured blister aneurysms with contrast stagnation after PED treatment, early angiographic occlusion was confirmed as early as 6 weeks and continued with medium-term durability.

Confusion and slurred speech in a 34-year-old woman from India.

A 34-year-old woman from India, presented with episodes of confusion and progressive speech deterioration. She also had a painless neck "lump", which persisted despite antibiotics. She was diagnosed to have a space occupying lesion in the left parietal lobe, which was subsequently biopsied.

Memory loss, behavioral changes, and slurred speech in a 49-year-old man.

A 49-year-old man presented with slurred speech, memory loss, and behavioral changes. His clinical course was marked by decline in functional status and cognition. He had poorly controlled hypertension and hyperlipidemia. Neuroimaging was remarkable for multiple subcortical white matter lesions. We discuss the diagnostic and therapeutic approach of rapidly progressing cognitive decline in the given clinical setting.

Rheumatoid meningitis.

An 80-year-old woman with rheumatoid arthritis had gait difficulties and frequent falls. MRI of the brain showed an extra-axial enhancing lesion overlying the right frontal-parietal cortex, that progressively extended to the contralateral side. This was accompanied by further decline in her functional status. We discuss the diagnostic and therapeutic approach of a pachy-leptomeningeal process in a rheumatoid patient.