The impact of COVID-19 pandemic lockdown on emergency department visits in a tertiary hospital

Purpose: This study aimed to highlight the impact of the COVID-19 pandemic lockdown on emergency department (ED) visits of non-COVID-19 patients in a tertiary hospital and evaluate protocol development during this period. Patients and Methods: Clinical data of patients who visited the ED of Foshan Hospital of Traditional Chinese Medicine during the first-level response in Foshan, Guangdong province in 2020 (from January 23 to February 24) and the same period in 2019 and 2021 were collected. A retrospective cross-sectional analysis was performed to understand the characteristics of critically ill patients and compare the proportion of hospitalizations, deaths, and emergency ambulance calls (EACs). Results: The number of patients presenting to the ED was significantly decreased, with a 37.75% reduction in 2020 (6196) compared to the same period in 2019 (9954). A rise in patient ED presentations was observed in the same period in 2021 (10,503). This decline was mostly in the 15– 45 age group. In 2019, 2020, and 2021, critically ill patients treated by the ED totaled 568 (5.706%), 339 (5.495%), and 590 (5.617%), respectively. Compared to the same period in 2019 and 2021, the proportion of critically ill patients with respiratory system involvement, severe trauma, and poisoning decreased most significantly in 2020 (P< 0.05). In contrast, the rates of EACs, hospitalizations, and deaths increased significantly (P< 0.05). Conclusion: The number of ED visits to hospitals was decreased during the 2020 lockdown, while the rates of EACs, hospitalizations, and deaths increased significantly though there were no documented COVID-19 cases. Optimizing emergency medical resources and ensuring the safety of healthcare providers and patients were essential to provide efficient emergency diagnosis and treatment during the lockdown

Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion

The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability

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

BACKGROUND: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome. METHODS: Multicentre 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. RESULTS: A 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 \u3e60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p\u3c0.001), 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. CONCLUSION: There 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

The relevance of rich club regions for functional outcome post-stroke is enhanced in women

This study aimed to investigate the influence of stroke lesions in predefined highly interconnected (rich-club) brain regions on functional outcome post-stroke, determine their spatial specificity and explore the effects of biological sex on their relevance. We analyzed MRI data recorded at index stroke and similar to 3-months modified Rankin Scale (mRS) data from patients with acute ischemic stroke enrolled in the multisite MRI-GENIE study. Spatially normalized structural stroke lesions were parcellated into 108 atlas-defined bilateral (sub)cortical brain regions. Unfavorable outcome (mRS > 2) was modeled in a Bayesian logistic regression framework. Effects of individual brain regions were captured as two compound effects for (i) six bilateral rich club and (ii) all further non-rich club regions. In spatial specificity analyses, we randomized the split into "rich club" and "non-rich club" regions and compared the effect of the actual rich club regions to the distribution of effects from 1000 combinations of six random regions. In sex-specific analyses, we introduced an additional hierarchical level in our model structure to compare male and female-specific rich club effects. A total of 822 patients (age: 64.7[15.0], 39% women) were analyzed. Rich club regions had substantial relevance in explaining unfavorable functional outcome (mean of posterior distribution: 0.08, area under the curve: 0.8). In particular, the rich club-combination had a higher relevance than 98.4% of random constellations. Rich club regions were substantially more important in explaining long-term outcome in women than in men. All in all, lesions in rich dub regions were associated with increased odds of unfavorable outcome. These effects were spatially specific and more pronounced in women.Peer reviewe

Abstract Number ‐ 236: Pure Arterial Malformations: A Case Report

Introduction Pure arterial malformations are dilated, overlapping, and tortuous arteries forming a mass of arterial loops without a venous component. These malformations are rare, with limited cases reported in the literature. Affecting any of the intracranial arteries, they are usually found incidentally and often have a benign course. Methods We present a case of a pure arterial malformation in a young female with hyperprolactinemia. Furthermore, we review the literature and provide an updated summary of these malformations. Results A 28‐year‐old female with a history of infantile hemangiomas, polycystic ovary syndrome, and hyperprolactinemia presented with acne, mild hirsutism, and galactorrhea. Her neurological exam was normal. Magnetic Resonance Imaging (MRI) of the brain with and without contrast ruled out a prolactinoma but revealed a 3 cm vascular malformation at the margin of the left cavernous sinus extending posteriorly into the anterior left perimesencephalic cistern. Initial differentials included a pial arteriovenous malformation or less likely a dural arteriovenous fistula. She underwent a diagnostic cerebral angiogram which revealed a pure arterial malformation without arteriovenous shunting. This was composed of dysplasia of the left posterior communicating artery and anterior choroidal arteries. Stenosis of the left internal carotid artery distally with collateral support into the left anterior cerebral artery and middle cerebral artery was also noted. Lesser changes were noted in the right side with reconstitution of the right anterior cerebral artery from collaterals. Genetic testing for vascular malformation syndromes, including genes known to be associated with hereditary hemorrhagic telangiectasia, was negative. Repeat MRI/MRA done 8 months from the initial scan was stable with no abnormal large arterial venous shunting or definite saccular aneurysm formation noted. Conclusions Although rare, pure arterial malformations should be considered in the differential diagnosis for patients presenting with a cranial vascular malformation. Management of these lesions is usually conservative given their lack of arteriovenous shunting and low risk of rupture, with only a few cases undergoing surgery or endovascular treatment

Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes

Objective: This narrative review discusses posterior circulation cerebral infarcts (PCCI) and provides an update given recent randomized trials in the management of basilar artery occlusion (BAO). We examine clinical characteristics, imaging protocols, management updates, and outcomes of PCCI. Methods: The following databases were searched: MEDLINE, Scopus, Google Scholar, and Web of Science for articles on PCCI. We included randomized trials and observational studies in humans. We also reviewed relevant references from the literature identified. Results: PCCI and BAO is associated with high morbidity and mortality. Early assessment and accurate diagnosis of PCCI remains a clinical challenge. Neuroimaging advances have improved early detection, but barriers remain due to costs and availability. Recent randomized trials provide new insights for BAO patients and support the efficacy of endovascular thrombectomy. Discussion: PCCI requires specific diagnostic and management that is distinct from anterior circulation stroke. While further studies are needed in varied populations and in the subset of BAO patients presenting with milder deficits, growing randomized data support the treatment of BAO patients with endovascular thrombectomy

Serum activity of angiotensin converting enzyme 2 is decreased in patients with acute ischemic stroke

Levels of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase, are dynamically altered after stroke in preclinical models. We sought to characterize the previously unexplored changes in serum ACE2 activity of stroke patients and the mechanism of these changes. Serum samples were obtained from patients during acute ischemic stroke (n=39), conditions mimicking stroke (stroke-alert, n=23), or from control participants (n=20). Enzyme activity levels were analyzed by fluorometric assay and correlated with clinical variables by regression analyses. Serum ACE2 activity was significantly lower in acute ischemic stroke as compared to both control and stroke-alert patients, followed by an increase to control levels at three days. Serum ACE2 activity significantly correlated with the presence of ischemic stroke after controlling for other factors (P=0.01). Additional associations with ACE2 activity included a positive correlation with systolic blood pressure at presentation in stroke-alert (R(2)=0.24, P=0.03), while stroke levels showed no correlation (R(2)=0.01, P=0.50). ACE2 sheddase activity was unchanged between groups. These dynamic changes in serum ACE2 activity in stroke, which concur with preclinical studies, are not likely to be driven primarily by acute changes in blood pressure or sheddase activity. These findings provide new insight for developing therapies targeting this protective system in ischemic stroke

Abstract Number ‐ 211: Flow Diversion in Direct Carotid‐Cavernous Fistulas: Case Report and Literature Review

Introduction Direct carotid‐cavernous fistulas (dCCF) are acquired, abnormal high‐flow connections between the internal carotid artery and cavernous sinus. Interventions are often required due to the high risk of incipient morbidity and mortality if left untreated. Treatment approaches have rapidly evolved over time, and have included the use of detachable balloons, liquid embolic agents, and coil embolization through transarterial, transvenous, or combined approaches. Case series level data support an emerging role for the use of flow diversion (FD) as a stand‐alone or adjunctive treatment in dCCFs. We describe a case of FD use as an adjunctive treatment in a patient with a treatment‐resistant dCCF, and review the literature on FD use in dCCF. Methods We describe the clinical course, imaging findings, and outcomes of a 25‐year old patient who presented with a traumatic carotid‐cavernous fistula requiring multiple interventions. We also performed a literature review of Pubmed and Embase databases using combinations of MeSH and key terms to include all relevant full‐text publications of FD use in the treatment of dCCFs, up to and including February 2022. Results Our patient achieved angiographic cure and significant improvement in symptoms at 6‐month follow‐up. A total of 24 papers were identified and included, for a total number of 53 cases (23 male, 23 female, 7 unspecified). The median age of patients was 44 years (Interquartile range (IQR) 23–62). The etiology of the dCCF was traumatic (acute or as a delayed presentation) in 31 cases (58%), spontaneous in 10 cases (19%), and iatrogenic in 12 cases (23%). FD was the primary mode of treatment of the CCF in approximately half of cases (27, 51%), and was a stand‐alone treatment modality in one third of cases (18, 34%). The median number of FD devices used on initial treatment was 1 device, though retreatment was needed in 42% of cases.Angiographic resolution was achieved in 90% of cases at a median follow‐up duration of 6 months.One half of all patients had complete resolution of symptoms and a further third noted clinical improvement in at least some of their symptoms. In 10% of cases, symptoms persisted, or other complications developed that were attributed to concurrent injuries. Conclusions Treatment approaches for dCCFs have evolved over time as safer and more effective treatments become available. There is an emerging role for FD as a safe stand‐alone or adjunctive treatment option for dCCFs. Our case further supports its role in treatment‐resistant fistulas with high‐risk features. As treatment approaches continue to evolve, prospective randomized data is needed to better establish the role of flow divertors among the hierarchy of available treatment options for dCCFs