The early impact of COVID-19 pandemic on mobile stroke unit care delivery: A worldwide survey.

OBJECTIVE: To report COVID -19 pandemic impact on mobile stroke units (MSUs) a world-wide survey of MSU programs. METHODS: Contact information of MSU program was obtained through the Pre-hospital Stroke Treatment Organization. Anonymous electronic questionnaire was developed and sent through the email to one representative of each program on May 15, 2020. RESULTS: Of 26 programs queried, 20 responded and completed survey based on the data or personal impression. Eighteen programs were in the regions with pandemic lockdown. Six either suspended or reduced MSU availability at some point. The reasons given for change in availability were as follows: decreased personnel availability (5 programs), risk of exposure (5 programs), and financial concerns (1 program). Staff availability was a concern among 8 programs. MSU activations were reported to be unchanged by 10 programs, but 9 programs experienced decline in activation, 1 program had more activations. Sixteen programs reported change in MSU protocol including introduction of screening questionnaire, PPE, reducing patient contact, and cleaning protocols. Nine reported that the crew was under greater stress. Only 2 respondents felt that the pandemic delayed stroke care on MSU and the remainder did not. CONCLUSION: Overall Stroke care delivery had no major disruptions despite COVID 19 pandemic posed challenges to MSU Operations.

Quantitative CTA vascular calcification, atherosclerosis burden, and stroke mechanism in patients with ischemic stroke.

BACKGROUND: Vascular calcification is recognized as the advanced stage of atherosclerosis burden. We hypothesized that vascular calcium quantification in CT angiography (CTA) would be helpful to differentiate large artery atherosclerosis (LAA) from other stroke etiology in patients with ischemic stroke. METHODS: We studied 375 acute ischemic stroke patients (200 males, mean age 69.9 years) who underwent complete CTA images of the aortic arch, neck, and head. The automatic artery and calcification segmentation method measured calcification volumes in the intracranial internal carotid artery (ICA), cervical carotid artery, and aortic arch using deep-learning U-net model and region-grow algorithms. We investigated the correlations and patterns of vascular calcification in the different vessel beds among stroke etiology by age category (young: <65 years, intermediate: 65-74 years, older ≥75 years). RESULTS: Ninety-five (25.3%) were diagnosed with LAA according to TOAST criteria. Median calcification volumes were higher by increasing the age category in each vessel bed. One-way ANOVA with Bonferroni correction showed calcification volumes in all vessel beds were significantly higher in LAA compared with other stroke subtypes in the younger subgroup. Calcification volumes were independently associated with LAA in intracranial ICA (OR; 2.89, 95% CI 1.56-5.34, P = .001), cervical carotid artery (OR; 3.40, 95% CI 1.94-5.94, P < .001) and aorta (OR; 1.69, 95%CI 1.01-2.80, P = .044) in younger subsets. By contrast, the intermediate and older subsets did not show a significant relationship between calcification volumes and stroke subtypes. CONCLUSION: Atherosclerosis calcium volumes in major vessels were significantly higher in LAA compared to non-LAA stroke in younger age.

Virtual Rounding in Stroke Care and Neurology Education During the COVID-19 Pandemic - A Residency Program Survey.

BACKGROUND AND PURPOSE: During the coronavirus disease 2019 (COVID-19) pandemic, we instituted virtual inpatient stroke rounds and acute stroke evaluations via telemedicine in the emergency department. We sought to explore trainees' and experienced providers' views on stroke care and education. METHODS: The implementation and the survey took place at a single academic comprehensive stroke center in northeast Ohio in the United States. "Virtual rounding" consisted of patient presentation and discussion in the morning in on-line virtual team format followed by in-person patient rounds in small groups. Acute stroke evaluations in the emergency department included direct in-person evaluation by neurology residents with supervision over telemedicine.The neurology residents, stroke fellows, stroke nurse practitioners, and stroke staff physicians were surveyed 2 months after implementation. Quantitative data was analyzed using descriptive statistical analysis, written responses in comment sections were analyzed using content analysis. RESULTS: Thirty-two of 42 (73%) surveys were completed. Nine (45%) residents and 5 (42%) experienced providers responded that virtual rounds did not compromise learning and education on stroke service. Fifteen (75%) residents and all experienced providers agreed that virtual rounds protected caregivers from exposure to the virus. While more than a third of residents (37%) did not feel comfortable utilizing telemedicine in ED, the majority of experienced providers (89%) were at ease with it. A total of 58% of residents and 67% of experienced providers felt that they were spending less time at the bedside, and 42% of residents and 58% of experienced providers felt less connected to patients during the pandemic. CONCLUSION: Majority of neurology residents' experience was not positive utilising telemedicine as compared to other staff providers. This is likely attributed to lack of prior exposure and unpreparedness. Incorporation of telemedicine curricula in medical school and residency training could prepare the next generation physicians to effectively use these technologies and meet the growing need for telehealth services for current and future pandemics.

Cerebrovascular Complication and Valve Surgery in Infective Endocarditis.

Infective endocarditis (IE) with neurologic complications is common in patients with active IE. The most common and feared neurological complication of left-sided IE is cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage (ICH), or an infectious intracranial aneurysm with or without rupture. In patients with cerebrovascular complications, valve replacement surgery is often delayed for concern of further neurological worsening. However, in circumstances when an indication for valve surgery to treat IE is present, the benefits of early surgical treatment may outweigh the potential neurologic deterioration. Furthermore, valve surgery has been associated with lower in-hospital mortality than medical therapy with intravenous antibiotics alone. Early valve surgery can be performed within 7 days of transient ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains challenging, and current data in the literature are conflicting about the risks and benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often recommended, balancing the risks and benefits of surgery. The range of timing of valve surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary decision between cardiothoracic surgeons, cardiologists, infectious disease experts, and vascular neurologists in an experienced referral center.

Decline in Stroke Presentations During COVID-19 Surge.

BACKGROUND AND PURPOSE: We aimed to investigate the acute stroke presentations during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: The data were obtained from a health system with 19 emergency departments in northeast Ohio in the United States. Baseline period from January 1 to March 8, 2020, was compared with the COVID period from March 9, to April 2, 2020. The variables included were total daily stroke alerts across the hospital emergency departments, thrombolysis, time to presentation, stroke severity, time from door-to-imaging, time from door-to-needle in thrombolysis, and time from door-to-puncture in thrombectomy. The 2 time periods were compared using nonparametric statistics and Poisson regression. RESULTS: Nine hundred two stroke alerts during the period across the emergency departments were analyzed. Total daily stroke alerts decreased from median, 10 (interquartile range, 8-13) during baseline period to median, 8 (interquartile range, 4-10, P=0.001) during COVID period. Time to presentation, stroke severity, and time to treatment were unchanged. COVID period was associated with decrease in stroke alerts with rate ratio of 0.70 (95% CI, 0.60-0.28). Thrombolysis also decreased with rate ratio, 0.52 (95% CI, 0.28-0.97) but thrombectomy remained unchanged rate ratio, 0.93 (95% CI, 0.52-1.62) Conclusions: We observed a significant decrease in acute stroke presentations by ≈30% across emergency departments at the time of surge of COVID-19 cases. This observation could be attributed to true decline in stroke incidence or patients not seeking medical attention for emergencies during the pandemic.