Global Impact of the COVID-19 Pandemic on Cerebral Venous Thrombosis and Mortality

Background and purpose: Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. Methods: We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). Results: There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths. Conclusions: During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT

Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

Background Current stroke guidelines recommend advanced imaging (computed tomography [CT] perfusion or magnetic resonance imaging) prior to endovascular therapy (EVT) in patients with late presentation of large vessel occlusion. Adherence to guidelines may be constrained by resources or timely access to imaging. We sought to understand the factors which influence late window imaging selection for EVT candidates with large vessel occlusion. Methods We conducted an international survey from January to May 2022. The questions aimed to identify advanced imaging and treatment decisions based on access to imaging, time delays, and simulated patient scenarios. Results There were 3000 invited participants and 1506 respondents, the majority (89.6%) from comprehensive stroke centers in high‐income countries. Neurointerventionalists comprised 31.8% and noninterventionalists 68.2% of respondents. Overall, 70.7% reported routine use of advanced imaging for late EVT selection, and 63.6% reported its usage in every case. There was greater availability of advanced imaging in comprehensive stroke centers versus primary stroke centers (67.0% versus 33.7%; P<0.0001), and high‐ versus low‐middle income countries (70.5% versus 44.5%; P<0.0001). When presented with a late window patient, 41.6% would complete CT perfusion or magnetic resonance imaging prior to EVT, 25.4% would perform CT perfusion or magnetic resonance imaging prior to IVT and EVT, and 25.8% would refer to EVT without advanced imaging. If advanced imaging was not readily available, 70.1% would refer a patient to EVT based on CT in the late window. Additional time delay within 20 minutes to obtain advanced imaging was considered acceptable in 77.7% of respondents. Conclusion Current guidelines for imaging late window EVT candidates are inconsistent with imaging decisions by physicians. Most respondents consider an imaging delay of greater than 20 minutes unacceptable. Access to advanced imaging was greater in comprehensive stroke centers and high‐income countries. In the case of limited access most respondents would consider EVT based on CT only

Global Impact of the COVID-19 Pandemic on Cerebral Venous Thrombosis and Mortality.

BACKGROUND AND PURPOSE: Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. METHODS: We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). RESULTS: There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths. CONCLUSIONS: During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT

Detección de Mycobacterium tuberculosis por observación microscópica y susceptibilidad a las drogas para el diagnóstico rápido de la tuberculosis

This research compares the microscopic observation of drug susceptibility tests with traditional methods for identifying Mycobacterium Tuberculosis . Methods: This study analyzed 100 sputum samples from two patient groups: one group was categorized as having been exposed to tuberculosis and the other group was categorized as having a high risk of TB. This study performed Sputum-smears, Löwenstein-Jensen cultures, as well as the MODS method, and the proportion method. Results: Out of 100 samples studied, 22 cases were sputum-smear positive. 22 cases were found positive to Löwenstein-Jensen, and 23 positive cases were found to MODS. Both sensitivity and specificity for MODS were 100% (P < 0.05). Löwenstein-Jensen had a sensitivity of 100% and a specificity of 98.7% (P <0.05). The average time for positive results using MODS was 7.04 days, while LJ took 34.18 days (P < 0.05). Of the 22 Sputum samples taken in order to determine the pattern of resistance, MODS and the proportion method matched in 96% for INH and 100% for Rifampin. For both methods, there were 5 MDR and one case resistant to Isoniazide (P < 0.05). Conclusions: The MODS liquid method proved to be faster, more sensitive, and more cost effective compared to the reference methods used to detect Mycobacterium Tuberculosis.En esta investigación se identifica a Mycobacterium tuberculosis y su sensibilidad a drogas por el método de susceptibilidad directa a fármacos mediante observación microscópica comparándose con los métodos tradicionales. Métodos: Se analizaron 100 muestras de esputo procedentes de dos grupos de pacientes: pacientes sintomáticos respiratorios y pacientes de alto riesgo con sospecha de tuberculosis. Se realizó baciloscopía, cultivo en medio Löwenstein- Jensen, método MODS, y susceptibilidad antimicrobiana por método de las proporciones. Resultados: De un total de 100 muestras procesadas, 22% resultaron positivos a la baciloscopía. 22 casos fueron positivos a Löwenstein-Jensen, y 23 casos positivos a MODS. La sensibilidad utilizando MODS fue del 100% y para el cultivo en Löwenstein-Jensen fue del 100%. La especificidad de MODS fue del 100% y LJ fue del 98.7%, (P < 0.05). El tiempo promedio o average para obtener resultados positivos con MODS y LJ fue de 7 y 34.17 días respectivamente (P <0.05). De los 22 aislamientos determinados para hallar el patrón de resistencia, la concordancia entre MODS y el método de las proporciones fue del 96% para INH y 100% para Rifampicina. Para ambos métodos resultaron 5 MDR y un caso monoresistente a isoniazida(P < 0.05). Conclusiones: El método MODS demuestra ser más rápido, más sensible y más costo-efectivo que los métodos de referencia utilizados para detectar Mycobacterium tuberculosis

Serum magnesium levels and outcomes in patients with acute spontaneous intracerebral hemorrhage

Background-—Magnesium (Mg) has potential hemostatic properties. We sought to investigate the potential association of serum Mg levels (at baseline and at 48 hours) with outcomes in patients with acute spontaneous intracerebral hemorrhage (ICH). Methods and Results-—We reviewed data on all patients with spontaneous ICH with available Mg levels at baseline, over a 5-year period. Clinical and radiological outcome measures included initial hematoma volume, admission National Institutes of Health Stroke Scale and ICH scores, in-hospital mortality, favorable functional outcome (modified Rankin Scale scores, 0–1), and functional independence (modified Rankin Scale scores, 0–2) at discharge. Our study population consisted of 299 patients with ICH (mean age, 61±13 years; mean admission serum Mg, 1.8±0.3 mg/dL). Increasing admission Mg levels strongly correlated with lower admission National Institutes of Health Stroke Scale score (Spearman’s r, 0.141; P=0.015), lower ICH score (Spearman’s r, 0.153; P=0.009), and lower initial hematoma volume (Spearman’s r, 0.153; P=0.012). Higher admission Mg levels were documented in patients with favorable functional outcome (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.025) and functional independence (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.022) at discharge. No association between serum Mg levels at 48 hours and any of the outcome variables was detected. In multiple linear regression analyses, a 0.1-mg/dL increase in admission serum Mg was independently and negatively associated with the cubed root of hematoma volume at admission (regression coefficient, 0.020; 95% confidence interval, 0.040 to 0.000; P=0.049) and admission ICH score (regression coefficient, 0.053; 95% confidence interval, 0.102 to 0.005; P=0.032). Conclusions-—Higher admission Mg levels were independently related to lower admission hematoma volume and lower admission ICH score in patients with acute spontaneous ICH. © 2018 The Authors

Impact of pretreatment with intravenous thrombolysis on reperfusion status in acute strokes treated with mechanical thrombectomy

Introduction We sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center. Methods Consecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented. Results A total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0-2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33-70) vs 70 (IQR 44-98) min; p&lt;0.001). Among patients who achieved SR (n=292), the median number of required device passes was lower in the IVT+MT subgroup (1 (IQR 1-1) vs 2 (IQR 1-2); p&lt;0.001), while the rate of patients requiring ≤2 device passes was higher (98% vs 77%; p&lt;0.001). IVT+MT was independently related to higher odds of SR (OR 1.64; 95% CI 1.03 to 2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient -20.39; 95% CI -27.56 to -13.22; p&lt;0.001) on multivariable analyses adjusting for potential confounders. Among patients with SR, IVT+MT was independently associated with a higher likelihood of ≤2 device passes (OR 14.63; 95% CI 4.46 to 48.00; p&lt;0.001). Conclusions IVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT. © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

Introduction One uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)). Objective To evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT. Methods Consecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated. Results A total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11-20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p&lt;0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005). Conclusions IVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT. © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ

Predictors of Decompressive Hemicraniectomy in Successfully Recanalized Patients With Anterior Circulation Emergency Large‐Vessel Occlusion

Background Mechanical thrombectomy (MT) has been shown to improve functional outcome in patients with anterior circulation strokes and emergent large‐vessel occlusion (ELVO). Despite successful recanalization, some of these patients require decompressive hemicraniectomy (DHC). We aimed to study the predictors of DHC in successfully recanalized anterior circulation ELVO patients. Methods Consecutive patients with anterior circulation ELVO treated with MT during a 6‐year period were evaluated. Only successfully recanalized patients (modified Thrombolysis in Cerebral Infarction grades 2b, 2c, or 3) after MT were included in the analysis. Baseline demographic, clinical, and procedural variables were compared between patients requiring DHC after successful recanalization versus those who did not. Results Of 453 successfully recanalized patients with ELVO, 47 who underwent DHC had higher admission blood glucose levels (170±88 versus 142±66 mg/dL; P=0.008), lower median Alberta Stroke Program Early CT Scores (9 [interquartile range, 8–10] versus 10 [interquartile range, 9–10]; P=0.002), higher prevalence of poor collaterals on pretreatment computed tomography angiogram (75% versus 26%; P<0.001), and required more passes during MT (median, 3 [interquartile range, 3–4] versus 2 [interquartile range, 1–2]; P=0.001) compared with those who did not undergo DHC. In a multivariable model after adjusting for multiple confounders, higher admission blood glucose levels (P=0.031), poor collaterals on computed tomography angiography (P<0.001), and higher number of passes during MT (P<0.001) emerged as independent predictors of DHC in successfully recanalized patients with ELVO. Conclusions Higher admission blood glucose levels, poor collateral pattern on computed tomography angiography, and higher number of passes during MT were independently associated with DHC in patients with anterior circulation ELVO achieving successful recanalization following MT