Impact of COVID-19 on stroke admissions, treatments, and outcomes at a comprehensive stroke centre in the United Kingdom.

INTRODUCTION: The coronavirus disease (COVID-19) pandemic has changed routine clinical practice worldwide with major impacts on the provision of care and treatment for stroke patients. METHODS: This retrospective observational study included all patients admitted to the Royal Stoke University Hospital in Stoke-on-Trent, UK, with a stroke or transient ischaemic attack between March 15th and April 14th, 2020 (COVID). Patient demographics, characteristics of the stroke, treatment details and logistics were compared with patients admitted in the corresponding weeks in the year before (2019). RESULTS: There was a 39.5% (n = 101 vs n = 167) reduction in admissions in the COVID cohort compared with 2019 with more severe strokes (median National Institutes of Health Stroke Scale (NIHSS) 7 vs 4, p = 0.02), and fewer strokes with no visible acute pathology (21.8 vs 37.1%, p = 0.01) on computed tomography. There was no statistically significant difference in the rates of thrombolysis (10.9 vs 13.2%, p = 0.72) and/or thrombectomy (5.9 vs 4.8%, p = 0.90) and no statistically significant difference in time from stroke onset to arrival at hospital (734 vs 576 min, p = 0.34), door-to-needle time for thrombolysis (54 vs 64 min, p = 0.43) and door-to-thrombectomy time (181 vs 445 min, p = 0.72). Thirty-day mortality was not significantly higher in the COVID year (10.9 vs 8.9%, p = 0.77). None of the 7 stroke patients infected with COVID-19 died. CONCLUSIONS: During the COVID-19 pandemic, the number of stroke admissions fell, and stroke severity increased. There was no statistically significant change in the delivery of thrombolysis and mechanical thrombectomy and no increase in mortality.

Mechanical thrombectomy: can it be safely delivered out of hours in the UK?

BACKGROUND: Mechanical thrombectomy was approved by NICE as a treatment for stroke in 2016. However, most of the evidence is from studies conducted during working hours. Only few centres in the UK perform thrombectomies out-of-hours. The Royal Stoke University Hospital (RSUH) has offered thrombectomies over 24 h (24/7) since 2010. The aim of this service review is to compare the outcomes for patients treated in regular working hours to those treated outside normal working hours within this unit. METHODS: This retrospective service analysis includes all patients treated with mechanical thrombectomy at RSUH since the start of the service in January 2010 to June 2019. Data on key demographics, timings, procedural complications, and long-term outcomes including death and disability at 90 days were collected. In-hours was defined as the time between 8:00-17:00 h, Monday to Friday; out-of-hours was defined as any time outside this period. RESULTS: In total, 516 mechanical thrombectomies were performed in this time period; data were available on 501 of these. Successful recanalization (TICI 2b/3) was achieved in 86% of patients. By 90 days 96 (19%) had died and 234 (47%) were functionally independent (modified Rankin Scale score ≤ 2). 211 (42%) of the procedures were performed in-hours and 290 (58%) out-of-hours. Door-to-CT and door-to-groin times were significantly longer out-of-hours than in-hours, but thrombectomy duration was significantly shorter. There were no significant differences in complications and short- and long-term outcomes. CONCLUSION: Mechanical thrombectomy was delivered safely and effectively 24/7 in this UK hospital, with no difference in clinical outcomes.

Maternal Mental Health During and Before the COVID-19 Pandemic: A Comparative Analysis in the Kingdom of Bahrain.

Introduction The coronavirus disease 2019 (COVID-19) pandemic created a crisis in health care systems worldwide. The maternity services were restricted due to the pandemic regulations. The psychological burden on the pregnant women was to various extents. Individuals and organizations implemented support schemes to understand and support their mental health. In our study, the psychological impact of pregnant women who contracted COVID-19 during pregnancy was compared with pregnancy of the same population before the pandemic as it could be a précised and helpful method to counsel pregnant women effectually. Study design This retrospective study included 111 women and was conducted at Bahrain Defense Force Hospital from January 2021 until December 2021. The researchers distributed a Hospital Anxiety and Depression Scale (HADS) questionnaire to women who delivered babies during the pandemic. The researchers then analyzed these scores and compared them with the scores of a control group of women who completed their pregnancies before the pandemic. The data were analyzed using SPSS Version 25.0 (IBM Corp., Armonk, NY). P-values of less than 0.05 were considered statistically significant. Results The HADS questionnaire results demonstrated that women's anxiety and depression during their pregnancy during the COVID-19 pandemic were significantly higher than that during their pregnancy before the pandemic, with a mean score of 14.97 (95% CI: 14.5 to 15.4) and 9.4 (95% CI: 8.8 to 9.9), respectively, and a p-value of <0.001. Additionally, during the COVID-19 pandemic, 100% of participants were "abnormal" in the anxiety category, and 86.5% were "abnormal" in the depression category, whereas before the pandemic, 0.9% of the studied population were abnormal, 3.6% were borderline abnormal, and 95.5% were normal in the depression category. The comparison of these scores highlighted that the pandemic had a significant negative psychological effect on the mothers during pregnancy, thus increasing their anxiety and depression. The correlated personal, social, and clinical factors were fear of delivery, fear of disease transmission, loss of family support, social isolation, uncertainty of life, and economic crises. Depression scores were significantly correlated to factors such as fear of disease transmission to the baby (p=0.027), fear of delivery (p=0.008), and loss of family support (p=0.001). Contributing factors and anxiety scores yielded significant correlations with fear of delivery (rs =0.258), fear of transmission (rs=0.198), and uncertainty of disease life (rs=0.247). As for depression, it was significantly correlated to one factor: loss of family support (rs=-0.335). Conclusion The mental health, in terms of anxiety and depression, of pregnant women was significantly affected during the COVID-19 pandemic.

Is intraprocedural intravenous aspirin safe for patients who require emergent extracranial stenting during mechanical thrombectomy?

BACKGROUND: Intraoperative antiplatelet therapy is recommended for emergent stenting during mechanical thrombectomy (MT). Most patients undergoing MT are also given thrombolysis. Antiplatelet agents are contraindicated within 24 hours of thrombolysis. We evaluated outcomes and complications of patients stented with and without intravenous aspirin during MT. METHODS: All patients who underwent emergent extracranial stenting during MT at the Royal Stoke University Hospital, UK between 2010 and 2020, were included. Patients were thrombolysed before MT, unless contraindicated. Aspirin 500 mg intravenously was given intraoperatively at the discretion of the operator. Symptomatic intracranial haemorrhage (sICH) and the National Institutes for Health Stroke Scale score (NIHSS) were recorded at 7 days, and mortality and functional recovery (modified Rankin Scale: mRS ≤2) at 90 days. RESULTS: Out of 565 patients treated by MT 102 patients (median age 67 IQR 57-72 years, baseline median NIHSS 18 IQR 13-23, 76 (75%) thrombolysed) had a stent placed. Of these 49 (48%) were given aspirin and 53 (52%) were not. Patients treated with aspirin had greater NIHSS improvement (median 8 IQR 1-16 vs median 3 IQR -9-8 points, p=0.003), but there were no significant differences in sICH (2/49 (4%) vs 9/53 (17%)), mRS ≤2 (25/49 (51%) vs 19/53 (36%)) and mortality (10/49 (20%) vs 12/53 (23%)) with and without aspirin. NIHSS improvement (median 12 IQR 4-18 vs median 7 IQR -7-10, p=0.01) was greater, and mortality was lower (4/33 (12%) vs 6/15 (40%), p=0.05) when aspirin was combined with thrombolysis, than for aspirin alone, with no increase in bleeding. CONCLUSION: Our findings based on registry data derived from routine clinical care suggest that intraprocedural intravenous aspirin in patients undergoing emergent stenting during MT does not increase sICH and is associated with good clinical outcomes, even when combined with intravenous thrombolysis.

The use of hypnotherapy as treatment for functional stroke: A case series from a single center in the UK.

BACKGROUND: Functional neurological disorder is defined by symptoms not explained by the current model of disease and its pathophysiology. It is found in 8.4% of patients presenting as acute stroke. Treatment is difficult and recurrence rates are high. We introduced hypnotherapy as a therapeutic option in addition to standard stroke unit care. METHODS: This is an observational study of successive patients with functional neurological disorder presenting as acute stroke treated with hypnotherapy between 1 April 2014 and 1 February 2018. The diagnosis of functional neurological disorder was confirmed by clinical examination and computed tomography/magnetic resonance imaging. Hypnosis was delivered by a hypnotherapy trained stroke physician using imagery for induction. A positive response was defined as a National Institutes of Health Stroke score reduction to 0 or by ≥4 points posthypnotherapy. Costs were calculated as therapist time and benefits as reduction in disability/bed days. RESULTS: Sixty-eight patients (mean age 36.4 years, 52 (76%) females, mean baseline National Institutes of Health Stroke 5.0 (range 1-9)) were included. Two patients (3%) could not be hypnotized. Fifty-eight 58 (85%) responded, 47 (81%) required one treatment session, while 19% needed up to three sessions for symptomatic improvement. No adverse events were observed. Disability (modified Rankin Scale) reduced from a mean of 2.3 to 0.5 resulting in an average cost saving of £1,658 per patient. Most (n = 50, 86%) remained well without recurrence at six-month follow-up. CONCLUSIONS: In this case series, hypnotherapy was associated with rapid and sustained recovery of symptoms. A prospective randomized controlled study is required to confirm the findings and establish generalizability of the results.

The cost of providing mechanical thrombectomy in the UK NHS: a micro-costing study.

INTRODUCTION: The clinical efficacy and cost-effectiveness of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke is well established, but uncertainty remains around the true cost of delivering this treatment within the NHS. The aim of this study was to establish the cost of providing MT within the hyperacute phase of care and to explore differences in resources used and costs across different neuroscience centres in the UK. METHOD: This was a multicentre retrospective study using micro-costing methods to enable a precise assessment of the costs of MT from an NHS perspective. Data on resources used and their costs were collected from five UK neuroscience centres between 2015 and 2018. RESULTS: Data were collected on 310 patients with acute ischaemic stroke treated with MT. The mean total cost of providing MT and inpatient care within 24 hours was £10,846 (95% confidence interval (CI) 10,527-11,165) per patient. The main driver of cost was MT procedure costs, accounting for 73% (£7,943; 95% CI 7,649-8,237) of the total 24-hour cost. Costs were higher for patients treated under general anaesthesia (£11,048; standard deviation (SD) 2,654) than for local anaesthesia (£9,978; SD 2,654), mean difference £1,070 (95% CI 381-1,759; p=0.003); admission to an intensive care unit (ICU; £12,212; SD 3,028) against for admission elsewhere (£10,179; SD 2,415), mean difference £2,032 (95% CI 1,345-2,719; p<0001).The mean cost within 72 hours was £12,440 (95% CI 10,628-14,252). The total costs for the duration of inpatient care before discharge from a thrombectomy centre was £14,362 (95% CI 13,603-15,122). CONCLUSIONS: Major factors contributing to costs of MT for stroke include consumables and staff for intervention, use of general anaesthesia and ICU admissions. These findings can inform the reimbursement, provision and strategic planning of stroke services and aid future economic evaluations.

Rare and challenging case of stroke as a manifestation of non bacterial thrombotic endocarditis in an underlying ovarian clear cell carcinoma.

Non bacterial thrombotic endocarditis presenting as a stroke is a rare presentation as a result of an underlying occult ovarian clear cell adenocarcinoma. Embolic events secondary to non bacterial thrombotic endocarditis are potentially a life-threatening condition if not diagnosed and treated promptly. High clinical suspicion for an underlying neoplasm is one of the key elements to be considered in the management of non bacterial thrombotic endocarditis. Systemic anticoagulation will treat as well as prevent further thromboembolic events.

The National Service Framework for Older People: England's approach to ending age discrimination in services and therapeutics.

In 1997, the new Labour Government in the UK embarked on an ambitious programme of reform. One of the key changes has been the publication of a series of National Service Frameworks. The National Service Framework for Older People (NSFOP) sets out a 10-year programme that has as its principal standard rooting out age discrimination. Together with its companion documents, a series of robust milestones and standards are set out that have to be met. Although generally welcomed by the profession, the NSFOP has been criticised by some because it mandates the initiation of new 'intermediate care' services that may be seen as denying older people the opportunity for admission to mainstream hospital care. Monitoring tools covering both procedures and prescribing have been developed. The government-produced frameworks mirror guidelines produced by the profession and include a number of prescribing recommendations, e.g. the use of antihypertensives and aspirin (acetylsalicylic acid) in the prevention of stroke, and the use of calcium, vitamin D and bisphosphonates in the treatment of osteoporosis. In tackling age discrimination, both direct and indirect barriers to effective prescribing need to be considered. The evidence base on the effectiveness of medication in older people is more limited due to the previous systematic exclusion of older people from clinical trials. The consequent lack of evidence of efficacy, coupled with perhaps a natural reluctance to prescribe potentially toxic medication, may lead to underprescribing. Other indirect causes of age discrimination may include difficulties for older people attending hospitals for drug monitoring, and the difficulties of translating the results of trials into meaningful endpoints that older patients can understand and thus make valid decisions about whether they wish to take the particular drug or not. At the same time as the NSFOP argues against age discrimination, other government policies may operate in a contradictory manner. Examples include the trend to make drugs available over the counter in pharmacies and for which the patient has to pay rather than receive them free, the restriction of some prescription-only drugs from the health service, and the need for referral to specialist services for some drugs, e.g. sildefanil, which older people may be reluctant to access. Successfully combating age discrimination is likely to require a regulatory framework, continued monitoring, tackling indirect forms of discrimination, as well as embedding antidiscrimination policies in all facets of health education.

Mechanical thrombectomy for ischaemic stroke: the first UK case series.

BACKGROUND AND PURPOSE: Endovascular treatments have the potential to accelerate reperfusion in acute ischaemic stroke with large vessel occlusion. In the UK only a few stroke centres offer this interventional option. The University Hospital of North Staffordshire (UHNS) has treated the largest number of cases in the UK. Results of the first 106 endovascular treatments (EVT) are presented here. METHODS: All patients treated with EVT (intra-arterial thrombolysis (IAT), mechanical thrombectomy (MT) or both, or an attempt at intervention) for acute stroke at UHNS, Stoke-on-Trent, UK, were entered into a prospective register. Baseline demographic and clinical data, the National Institutes for Health Stroke Scale (NIHSS), imaging results including Thrombolysis in Cerebral Infarction (TICI) score, and complications were recorded. Mortality, and modified Rankin score (mRS) were assessed at 90 days. RESULTS: From December 2009 to January 2013 106 patients (mean age 64 years, median baseline NIHSS 18) were treated with EVT (thrombectomy ± IAT 83%, IAT alone 13%, neither 4%). Seventy-eight per cent of occlusions were in the anterior circulation. Intravenous bridging thrombolysis was performed in 81%. Revascularization was successful (TICI 2b/3) in 84%. The median time from stroke onset to the end of the procedure was 6 h 03 min. A good outcome (mRS ≤ 2) at 90 days was achieved in 48% with a mortality of 15%. Fatal or nonfatal symptomatic intracranial haemorrhage (sICH) within 10 days occurred in 9%. The median length of stay was 14 days (31% discharged home ≤ 7 days). CONCLUSIONS: EVT led to good clinical outcomes in almost 50% of patients with severe strokes.

Mechanical thrombectomy in acute ischaemic stroke: a review of the literature, clinical effectiveness and future use.

The only effective treatment licensed for acute ischaemic stroke is intravenous thrombolysis within 4.5 hours from stroke onset. An alternative method of restoring blood flow is mechanical thrombectomy (MT). Although this is highly effective at recanalization, it remains unclear whether it is more effective than thrombolysis in improving clinical outcomes. This review examines key clinical outcomes from published studies and reviews ongoing studies to identify devices, patient population, and stated outcomes of MT. We discuss the issues when comparing clinical outcomes from different trials and suggest measures to help standardize reporting. We used routine review methodology to search relevant databases for stroke and MT published between 1999 - 2012 and active trials between August 2011 - May 2012. The studies in this review had an overall patient population of 8354. The most widely used primary outcome (94% of studies) was successful recanalization. The mean mortality across the studies was 17% (range 7 - 44), 64% of studies reported neurological improvement and 97% reported functional outcome with 42% (range 15 - 54)] achieving independence in activities of daily living. Mean symptomatic intracerebral haemorrhage was 11% (range 0 - 45%). There were significant differences in outcome reporting between studies. Evidence from published studies shows a strong relationship between recanalization and good outcomes although non-standardization makes comparisons difficult. There is a trend towards higher recanalization, lower mortality, and better functional outcome in more recent studies. To examine effectiveness of MT vs thrombolysis, randomized controlled trials are needed. Several are currently in progress but it remains to be seen if procedures and outcomes are reported in a standardized manner.