Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry

© 2020 World Stroke Organization.[Background]: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. [Aim]: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. [Methods]: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). [Results]: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p ¼ 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p ¼ 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. [Conclusions]: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes

Complete Bilateral Ophthalmoplegia in the Setting of Elevated Intracranial Pressure that Improved with Transverse Venous Sinus Stenting (.pdf)

Elevated ICP is known to cause vision loss, abducens nerve palsy, and rarely oculomotor and trochlear nerve palsies. Severe dysmotility of both eyes in all gazes has not been reported. Venous sinus stenosis has been postulated as a possible pathophysiologic mechanism underlying elevated ICP in the setting of idiopathic intracranial hypertension, and stenting of the transverse sinus has been therapeutic 3,4. The current report describes resolution of complete ophthalmoplegia in the setting of secondary elevated ICP treated with transverse venous sinus stenting

Vitamin D deficiency and post-stroke depression: A systematic review and meta-analysis

Objective: Low vitamin D levels have often been associated with depression as well as worsen stroke outcomes. With post-stroke depression (PSD) being an important factor contributing to poor recovery and rehabilitation and thereby poor functional outcomes, this study was undertaken to explore the role of vitamin D deficiency in PSD and their correlation with stroke prognosis and outcomes. Methods: A systematic search of eligible studies from PubMed, MEDLINE, Cochrane CENTRAL, and Google Scholar were identified. Selected studies were those that met the inclusion criteria. Statistical analysis was conducted using Review Manager 5.4.1. A random-effects model was used to pool the data when heterogeneity was seen and so, results were reported in the standard mean differences within their corresponding 95 % confidence interval. Results: Our analysis showed statistically significant clinical depression in the Vitamin D deficient group on the BDI-II (SMD = 6.90 [3.32, 10.48]; p = 0.0002) and PHQ-9 (SMD = 3.20 [1.84, 4.56]; p < 0.00001) scales. Of the seven studies, four showed significantly poorer prognosis in PSD patients with respect to NIHSS (SMD = 1.54; [0.34, 2.74]; p < 0.0001) and MMSE (SMD = -2.53 [3.79, 1.27]; p < 0.0001). Conclusion: This study shows a significant association between serum Vitamin D levels and PSD. Further studies are needed to explore causal relationships and the effect of vitamin supplementation on stroke prognosis and outcomes in relation to PS

Delays in thrombolysis during COVID-19 are associated with worse neurological outcomes: the Society of Vascular and Interventional Neurology Multicenter Collaboration

Introduction: We have demonstrated in a multicenter cohort that the COVID-19 pandemic has led to a delay in intravenous thrombolysis (IVT) among stroke patients. Whether this delay contributes to meaningful short-term outcome differences in these patients warranted further exploration. Methods: We conducted a nested observational cohort study of adult acute ischemic stroke patients receiving IVT from 9 comprehensive stroke centers across 7 U.S states. Patients admitted prior to the COVID-19 pandemic (1/1/2019-02/29/2020) were compared to patients admitted during the early pandemic (3/1/2020-7/31/2020). Multivariable logistic regression was used to estimate the effect of IVT delay on discharge to hospice or death, with treatment delay on admission during COVID-19 included as an interaction term. Results: Of the 676 thrombolysed patients, the median age was 70 (IQR 58-81) years, 313 were female (46.3%), and the median NIHSS was 8 (IQR 4-16). Longer treatment delays were observed during COVID-19 (median 46 vs 38 min, p = 0.01) and were associated with higher in-hospital death/hospice discharge irrespective of admission period (OR per hour 1.08, 95% CI 1.01-1.17, p = 0.03). This effect was strengthened after multivariable adjustment (aOR 1.15, 95% CI 1.07-1.24, p \u3c 0.001). There was no interaction of treatment delay on admission during COVID-19 (pinteraction = 0.65). Every one-hour delay in IVT was also associated with 7% lower odds of being discharged to home or acute inpatient rehabilitation facility (aOR 0.93, 95% CI 0.89-0.97, p \u3c 0.001). Conclusion: Treatment delays observed during the COVID-19 pandemic led to greater early mortality and hospice care, with a lower probability of discharge to home/rehabilitation facility. There was no effect modification of treatment delay on admission during the pandemic, indicating that treatment delay at any time contributes similarly to these short-term outcomes

Interaction of Ethnicity and Arrival Method on Thrombectomy Delay: The Society of Vascular and Interventional Neurology Collaboration

Background Compared with non‐Hispanic White patients, non‐Hispanic Black (NHB) and Hispanic populations are less likely to receive acute treatment for ischemic stroke, and when they do, it can be delayed. We evaluated the interaction between arrival method and race or ethnicity on door‐to‐arterial puncture (DTAP) time in thrombectomy. Methods We conducted a retrospective observational cohort study of consecutive adults who underwent endovascular thrombectomy from 14 US Comprehensive Stroke Centers (January 1, 2019–July 31, 2020). DTAP was assessed in a linear mixed model including an interaction term for race or ethnicity and arrival method. Results Of the 1908 included patients, 356 of whom were Hispanic, Hispanic and NHB patients experienced significant delays in DTAP compared with non‐Hispanic White patients (adjusted βHisp=0.32, 95% CI, 0.08–0.55; βNHB=0.23; 95% CI, 0.04–0.41). More severe deficits were associated with shorter DTAP (βNIHSS per point −0.03; 95% CI −0.04 to −0.03), and arrival via emergency medical services or private vehicle versus transfer were associated with longer delays (βEMS=0.57; 95% CI, 0.41–0.74; βPV=1.27; 95% CI, 0.85–1.70). There was a significant interaction between Hispanic ethnicity and emergency medical services (P=0.03) or private vehicle arrival (P=0.04) in a direction favoring shorter treatment delays. Sites that treated a minority population of Hispanic patients (<50% being Hispanic) experienced a significant delay in DTAP among Hispanic and NHB versus non‐Hispanic White (median 72 minutes [interquartile range (IQR), 49–104] versus 83 minutes [IQR, 50–119] versus 58 minutes [IQR, 27–95], P<0.01), whereas sites treating a Hispanic majority showed no difference in DTAP (P=0.39). Conclusions Endovascular therapy is delayed in Hispanic and NHB patients when compared with non‐Hispanic White patients. Although arrival by emergency medical services or private vehicle also contributed to treatment delays, Hispanic ethnicity modified this effect such that there was less delay in DTAP. This may be related to communication barriers between caregivers and health care providers when a Hispanic patient is suddenly disabled from stroke

Short‐Term Outcomes of Acute Stroke During COVID‐19 by Race and Ethnicity in the United States: The Society of Vascular and Interventional Neurology Multicenter Collaboration

Background The COVID‐19 pandemic has disproportionately affected Black and Hispanic communities, whose stroke care has been previously shown to experience existing disparities. We sought to evaluate how these disparities in stroke care and in‐hospital mortality have been affected by the COVID‐19 pandemic. Methods In this retrospective observational cohort study, we evaluated stroke hospitalizations in the Society of Vascular and Interventional Neurology COVID‐19 registry. We compared stroke characteristics between non‐Hispanic White, non‐Hispanic Black, and Hispanic patients pre–COVID‐19 and post–COVID‐19 (March–July 2019 versus March–July 2020) and evaluated whether racial and ethnic differences present before the pandemic were exacerbated during the pandemic. Our primary outcome was in‐hospital mortality/discharge to hospice, and secondary outcomes were acute treatment use. Results Of the 4908 included patients, numerically fewer non‐Hispanic White and Hispanic patients were evaluated during COVID‐19. Non‐Hispanic White and non‐Hispanic Black patients with large‐vessel occlusion were more likely to undergo thrombectomy (P<0.01 for both) when compared with the pre–COVID‐19 epoch. In‐hospital mortality/hospice rates were higher during COVID‐19 (12.8% versus 9.9%; P<0.01), with higher rates observed across all race and ethnic groups, although the odds of death/hospice during the pandemic period became nonsignificant after multivariable adjustment (adjusted odds ratio, 1.23 [95% CI, 0.95–1.62]; P=0.12). Conclusions There was an increase in mortality/hospice discharges among all races during the COVID‐19 period. There were no noted racial or ethnic differences in rates of thrombolytic use, thrombectomy, or mortality within racial groups prepandemic compared with during the pandemic. Although other studies have demonstrated deepening disparities in these outcomes during COVID‐19, our data suggest that declines in stroke presentations and use of acute stroke therapies were not a uniform phenomenon. Disparities in stroke care were differentially affected in thrombolytic versus endovascular therapies and among non‐Hispanic Black and Hispanic patients

Cerebrovascular events and outcomes in hospitalized patients with COVID-19 : The SVIN COVID-19 Multinational Registry

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020-16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130-280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes

Abstract 248: Structural Analysis of Aspiration Catheters and Procedural Outcomes: An Analysis of the SVIN Registry

Introduction Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN Registry) treated with stand‐alone contact aspiration for the first pass in the MCA M1 or intracranial ICA occlusions from 2012‐2021. Catheters were stratified based on construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first pass effect (FPE ‐ first‐pass eTICI2c‐3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first pass technique. FPE was observed in 34% and associated with age (OR:1.016;95%CI:1.006‐1.027), cardioembolic stroke etiology (OR:1.685;95%CI:1.77 ‐2.41), MCA M1(OR:2.737;95%CI:1.091 ‐1.867), non‐general anesthesia (OR:0.546;95%CI:0.389 ‐0.767), as well as with 0.070” (OR:2.038;95%CI:1.099 ‐3.779) and 0.088” (OR:3.899;95%CI:1.582 ‐9.606) distal catheter inner diameter in the adjusted analysis. Median time from arterial access to clot contact was 17 minutes with faster times observed in younger patients (OR:0.986;95%CI:0.975 ‐0.996) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18‐30cm) on multivariable regression (OR:0.303; 95%CI:0.113‐0.816). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of FPE. Aspiration catheters with reduced distal tip hydrophilic coating were associated with faster arterial access to clot contact time

Acute ischaemic stroke associated with SARS-CoV-2 infection in North America.

BackgroundTo analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome.MethodsMulticentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications.ResultsA total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age &gt;60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p&lt;0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome.ConclusionThere is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality