Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic.

BACKGROUND: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic. METHODS: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic. RESULTS: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 (P=0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city (P<0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale. CONCLUSIONS: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.

Stroke severity and outcomes for octogenarians receiving statins.

Pre-exposure to 3-hydroxy-3-methylgutaryl-coenzyne A reductase inhibitors (statins) appears to improve outcomes in patients with acute ischemic stroke (AIS). Whether this extends to patients over 80 is not known. Patients ≥80 years of age with AIS were retrospectively reviewed from the stroke registry of a tertiary stroke center. Pre-admission statin use, demographics, vascular risk factors, and comorbid conditions were assessed. Primary outcomes were admission National Institutes of Health Stroke Scale (NIHSS) scores and in-hospital mortality/discharge to hospice, and secondary outcomes included subsequent intracerebral hemorrhage (ICH) and modified Barthel index (mBI) at 3 months. Multivariable logistic regression was used to evaluate the association between pre-admission statin use and outcomes among elderly patients. Among 804 patients ≥80, those taking statins prior to AIS admission were overall younger, were more likely to have hypertension, coronary artery disease, diabetes, hyperlipidemia, and were more likely to be on an antiplatelet, but less likely to receive treatment with IV tissue plasminogen activator (tPA). Patients on statin had lower stroke severity (NIHSS>16: 21.9% vs. 27.6%) and in-hospital mortality/discharge to hospice (22.8% vs. 27.6%), but neither was significant. There was no difference in ICH (1.2% vs. 1.9%), and patients on statins had a non-significant trend toward less disability on mBI (27.5% vs. 35.7%). Pre-admission statin use did not show a statistical difference in either outcome, but it did show a trend toward lower stroke severity and improved short-term outcomes. In addition, our study suggests that statins may be safe in elderly stroke patients and may not increase the risk of ICH.

Loss of vascular early response gene reduces edema formation after experimental stroke.

Vascular Early Response Gene (Verge) is an immediate early gene (IEG) that is up-regulated in endothelial cells in response to a number of stressors, including ischemic stroke. Endothelial cell lines that stably express Verge show enhanced permeability. Increased Verge expression has also been associated with blood brain barrier breakdown. In this study we investigated the role of Verge in ischemic injury induced by middle cerebral artery occlusion (MCAO) in both Verge knockout (KO) and wild type (WT) mice. Verge KO mice had significantly less cerebral edema formation after MCAO compared to WT mice. However, stroke outcome (infarct size and neurological deficit scores) evaluated at either 24 or 72 hours after stroke showed no differences between the two genotypes. Verge deletion leads to decreased edema formation after ischemia; however acute stroke outcomes were unchanged.

Mismatch: when the imaging studies conflict with the neurologic exam.

As neurologists, we increasingly rely on imaging studies to help us diagnose acute stroke. This unusual case is a reminder that even sophisticated imaging techniques can have false negatives and emphasizes the importance of the clinical exam.

The blood-brain barrier: geriatric relevance of a critical brain-body interface.

The blood-brain barrier (BBB) represents the interface between the brain and other body tissues. Its ability to protect the brain from harmful compounds has attracted the attention of clinicians and investigators, but far from being a simple physical barrier, the BBB is a complex, heterogeneous, and dynamic tissue. The integrated function of the cerebral microvasculature, tight junction proteins, brain microvascular endothelial cells (BMECs), cellular transport pathways, and enzymatic machinery jointly contribute to normal BBB integrity. Aging, systemic diseases, and ischemic injury can disrupt these processes, resulting in a decline in overall BBB function and integrity. Based on the published literature, this study proposes that age- and disease-related BBB alterations play a key role in diminishing the ability of older patients to recover from acute ischemic stroke. Evidence linking deficits in the cerebral microvasculature and BBB integrity to dementia, medication-related cognitive decline, white matter disease (WMD or leukoaraiosis), and related geriatric syndromes including delirium, gait disorders, and urinary incontinence is also reviewed. Priority areas for a future research agenda include strategies to improve clinicians' ability to diagnose, prevent, and manage BBB abnormalities. In future years, in vivo measures such as functional and contrast-enhanced neuroimaging will be used to evaluate BBB integrity in older adults while also assessing the effectiveness of interventions, some targeting inflammatory pathways known to disrupt the BBB, for their ability to prevent or slow the progression of these complex multifactorial geriatric syndromes.

Localization of brain white matter hyperintensities and urinary incontinence in community-dwelling older adults.

BACKGROUND: Because white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) may be linked to geriatric syndromes involving mobility, cognition, and affect, we postulated that involvement of areas critical to bladder control could influence urinary incontinence (UI). METHODS: One hundred community-dwelling individuals (75-89 years) were recruited into three groups stratified by age and gender reflecting normal and mildly and moderately impaired mobility. Baseline incontinence status and related symptoms were evaluated in 97 individuals using validated instruments (3IQ, Urinary Incontinence Severity Index, Urogenital Distress Inventory, Incontinence Impact Questionnaire). Regional WMH was measured using an MRI brain imaging segmentation pipeline and WM tract-based parcellation atlas. RESULTS: Sixty-two (64%) of the participants were incontinent, mostly with urgency (37; 60%) and moderate-severe symptoms (36; 58%). Incontinent individuals were more likely to be women with worse scores for depression and mobility. WMH located in right inferior frontal regions predicted UI severity, with no significant relationship with incontinence, incontinence type, bother, or functional impact. As regards WM tracts, WMH within regions normally occupied by the anterior corona radiata predicted severity and degree of bother, cingulate gyrus predicted incontinence and severity, whereas cingulate (hippocampal portion) and superior fronto-occipital fasciculus predicted severity. CONCLUSIONS: Presence of WMH in right inferior frontal regions and selected WM tracts predicts incontinence, incontinence severity, and degree of bother. Our observations support the findings of recent functional MRI studies indicating a critical role for the cingulum in bladder control, while also suggesting potential involvement of other nearby WM tracts such as anterior corona radiata and superior fronto-occipital fasciculus.

Neuroimaging of bilateral caudate infarction manifesting as Parkinsonian gait disorder.

Neurobehavioral changes characterize the clinical presentation of bilateral caudate infarction. We describe an 82-year-old man who presented with a Parkinsonian gait disorder in the absence of behavioral abnormality whose diffusion-weighted imaging demonstrated infarction of the caudate nuclei.

Acute stroke management in the elderly.

BACKGROUND AND PURPOSE: Though the proportion of elderly stroke patients is increasing, patients >80 years are often excluded from clinical stroke trials. We reviewed the management of older patients presenting with acute ischemic stroke (AIS) and assessed the safety and efficacy of recombinant tissue plasminogen activator (rtPA) administration in a community-based setting. METHODS: A retrospective review of patients >80 years (n = 341) admitted to a community stroke center with AIS were compared to their younger counterparts (n = 690) using the stroke center database from April 2003 to December 2005. Parameters that were measured included admission and discharge NIH Stroke Scale (NIHSS), rate of thrombolytic treatment, the frequency and etiology of thrombolytic exclusion criteria and complications from rtPA for the different aged populations. Additional data were collected for Barthel Index at 12 months. RESULTS: A total of 166 patients underwent thrombolysis. Older patients were not delayed in reaching the hospital within 3 h of stroke onset (182/690, 26%, in the <80 cohort vs. 98/341, 29%, in the > or = 80 cohort). Although the overall rates of tPA use were similar in both the young and aged cohort, older patients were less likely to be treated with rtPA because of reasons not listed as exclusion criteria (17% in the <80 cohort vs. 32% in the > or = 80 cohort). The older group did not have an excess risk of intracranial hemorrhage following rtPA infusion despite equivalent NIHSS on admission (13.5 in the <80 cohort vs. 12.4 in the > or = 80 cohort). Both groups showed improvement in NIHSS following thrombolytic treatment with a drop of 7.7 points in the younger age group and 5.6 points in the older group. Elderly patients treated with rtPA had a comparable 12-month modified Barthel Index score to younger cohorts. CONCLUSIONS: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age.