There is accumulating data suggesting that the ischemic stroke may be increased in patients with corona virus disease 2019 (COVID-19) due to hyper coagulopathy. An increase in acute ischemic stroke patients who require mechanical thrombectomy is to be expected particularly in regions with high rates of COVID-19

French, Brandi R.

Gomez, Camilo R.

Hassan, Ameer E.

Jani, Vishal

Qureshi, Adnan

Siddiq, Farhan

Suri, M.Fareed K.

English

Scholarworks@UTRGV Univ. of Texas RioGrande Valley

University of Texas Rio Grande Valley ScholarWorks @ UTRGV School of Medicine Publications and Presentations School of Medicine 10-2020 Effect of COVID-19 Pandemic on Mechanical Thrombectomy for Acute Ischemic Stroke Treatment in United States Adnan Qureshi University of Missouri Farhan Siddiq Brandi R. French Camilo R. Gomez Vishal Jani See next page for additional authors Follow this and additional works at: https://scholarworks.utrgv.edu/som_pub  Part of the Medicine and Health Sciences Commons Recommended Citation Qureshi, Adnan I., Farhan Siddiq, Brandi R. French, Camilo R. Gomez, Vishal Jani, Ameer E. Hassan, and M. Fareed K. Suri. “Effect of COVID-19 Pandemic on Mechanical Thrombectomy for Acute Ischemic Stroke Treatment in United States.” Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association 29, no. 10 (October 2020): 105140. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105140. This Article is brought to you for free and open access by the School of Medicine at ScholarWorks @ UTRGV. It has been accepted for inclusion in School of Medicine Publications and Presentations by an authorized administrator of ScholarWorks @ UTRGV. For more information, please contact justin.white@utrgv.edu, william.flores01@utrgv.edu. Authors Adnan Qureshi, Farhan Siddiq, Brandi R. French, Camilo R. Gomez, Vishal Jani, Ameer E. Hassan, and M.Fareed K. Suri This article is available at ScholarWorks @ UTRGV: https://scholarworks.utrgv.edu/som_pub/136 Effect of COVID-19 Pandemic on Mechanical Thrombectomyfor Acute Ischemic Stroke Treatment in United StatesAdnan I. Qureshi, MD,* Farhan Siddiq, MD,* Brandi R. French, MD,*Camilo R. Gomez, MD,* Vishal Jani, MD,† Ameer E. Hassan, DO,‡ andM. Fareed K. Suri, MD§Keywords: Stroke—Ischemic stroke—COVID-19—Mechenical thrombectomy© 2020 Published by Elsevier Inc.There is accumulating data suggesting that the ischemicstroke may be increased in patients with corona virus dis-ease 2019 (COVID-19) due to hyper coagulopathy.1,2 Anincrease in acute ischemic stroke patients who requiremechanical thrombectomy is to be expected particularlyin regions with high rates of COVID-19.1We used national utilization data of a specific stentretriever (TrevoTM. Stryker Neurovascular, Inc. Fremont,California, United States), as a surrogate for mechanicalthrombectomy procedures, per month and for each statesince January 1 2019 to April 30, 2020. Although StrykerNeurovascular, Inc kindly provided access to the nationaldevice utilization information, they did not have any rolein the analysis of the data, or the writing of the presentcommunication. We calculated the median number ofmechanical thrombectomy performed per month basedon data from pre-COVID 12-month period (March 1, 2019to February 29, 2020). We excluded 25 states wheremedian mechanical thrombectomy performed per monthin the pre-COVID 12-month period was 10 or less fromthe primary analysis. As the monthly mechanical throm-bectomy volume was not normally distributed, we usedone-sample two-tailed Wilcoxin signed rank test withalpha = 0.05 to compare the number of mechanical throm-bectomy performed in March and April 2020 withmonthly median value for pre-COVID 12-month periodfor each of the respective 24 states. Compared with themedian value per month for pre-COVID 12-month period,number of mechanical thrombectomy performed inMarch 2020 was significantly lower in 7 states and higherin 6 states, and not significantly different in 11 states. InApril 2020, the number of mechanical thrombectomycompared with the median value per month for pre-COVID 12-month period was significantly lower in 11states, higher in 3 states, and not significantly different inremaining 10 states. Interestingly the number of mechani-cal thrombectomy performed in New York state, whichwas most affected from COVID-19 was significantlyreduced in March 2020 (47 procedures), but not in April2020 (52 procedures) compared to the median monthlyvalue of 58.5 procedures in pre-COVID 12-month period.We identified the total number of COVID-19 cases (permillion) in each state at April 30th, 2020. The bar graph(Fig. 1) demonstrates the change in number of mechanicalthrombectomy performed per state according to totalnumber of COVID-19 cases within respective state. Therewas no relationship visualized between the total numberof COVID-19 cases in a state and change in number ofmechanical thrombectomy performed. In an Ad Hocexploratory analysis, the results were similar for 25 stateswith an average of 10 or less procedures per month. InMarch 2020, 5 states had reduction in number of mechani-cal thrombectomy performed, 8 had an increase, and nochange was observed in 12 states. Whereas in April 2020,11 states had had reduction in number of mechanicalthrombectomy performed, 2 states had an increase and nochange was observed in 12 states.In general, we observed no change in March but an over-all reduction in April 2020 in number of mechanical throm-bectomy performed for acute ischemic stroke. There was avariation between states in regards to change in number ofmechanical thrombectomy performed with most statesexperiencing no change, an increasing proportion experienc-ing a decrease, and a minority actually experiencing anincrease in mechanical thrombectomy performed. ThisFrom the *Zeenat Qureshi Stroke Institute and Department ofNeurology, University of Missouri, Columbia, MO; †Departmentof Neurology, Creighton University School of Medicine, Omaha,NE; ‡Department of Neurology, University of Texas Rio GrandeValley, Department of Neuroscience, Valley Baptist Hospital, Har-lingen, TX; and §St. Cloud Hospital, St. Cloud, MN.Received June 25, 2020; revision received July 5, 2020; accepted July7, 2020.Corresponding author. E-mail: vbjani@yahoo.com.1052-3057/$ - see front matter© 2020 Published by Elsevier Inc.https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105140Journal of Stroke and Cerebrovascular Diseases, Vol. 29, No. 00 (), 2020: 105140 1Fig. 1. Box plot representing median, interquartile range, minimum and maximum values of mechanical thrombectomy performed in each state presented accord-ing to COVID-19 cases within respective state (in ascending order from top to bottom). The red and green bars represent mechanical thrombectomy performed inMarch and April, 2020, respectively. The diamond represents the mean value; Red bars with * if p < 0.05 for difference between March 2020 and median valueper month of pre-COVID 12-month period; Green bars with * if p < 0.05 between April 2020 and median value per month of pre-COVID 12-month period.2 A.I.<.T.N.C.A.I.Q.M. QURESHI ET AL.change in number of mechanical thrombectomy performedwas not explained by differences in occurrence of COVID-19 between states. We understand that TrevoTM stentretriever is not the only device for use in mechanical throm-bectomy but it is unlikely that practitioners will changedevice preference due to COVID-19 pandemic and there-fore, the observed changes are likely due to actual change innumbers of mechanical thrombectomy performed. Plausiblereasons for the apparent reduction in performance ofmechanical thrombectomy during April 2020 include: a)Delays in accessing specialized care, resulting in patientspresenting outside of the therapeutic window3, b) Reluc-tance of acute ischemic stroke patients to present at emer-gency departments4, and c) Reduction in stroke occurrenceduring the COVID-19 pandemic as a result of mandatedsocial distancing. In regards to reluctance of patients to pres-ent at emergency department, acute ischemic stroke patientswho require thrombectomy typically have severe neurologicdeficits and are unlikely to avoid hospitalization unlikethose with transient ischemic attack or minor deficits.3 Con-cerning the possibility of an effect by mandated social dis-tancing, this could reflect the reduction that such a practicemay have on exposure to a larger number of other respira-tory tract infections that independently increase the risk ofischemic stroke.4,5 Our data is reflective of early part of theCOVID-19 pandemic and additional changes may be seenas the pandemic continues to evolve.Disclosure: NoneReferences1. Qureshi AI, Abd-Allah F, Alsenani F, et al. Manage-ment of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel. Int JStroke 2020 Jun 22. https://doi.org/10.1177/1747493020923234. 1747493020935396.2. Oxley TJ, Mocco J, Majidi S, et al. Large-vessel stroke as apresenting feature of COVID-19 in the young. N Engl JMed 2020;382:e60.3. Bersano A, Kraemer M, Touze E, et al. Stroke care duringthe COVID-19 pandemic: experience from three largeEuropean countries. Eur J Neurol 2020. https://doi.org/10.1111/ene.1437510.1111/ene.14375. Jun 3.4. Castillo-Torres SA, Gongora-Rivera F. Where are thestroke patients? The apparent decrease amid the COVID-19 pandemic. J Vasc Intervent Neurol 2020. cdn.website-editor.net. in press (accessed July 28, 2020).5. Smeeth L, Thomas SL, Hall AJ, Hubbard R, FarringtonP, Vallance P. Risk of myocardial infarction and strokeafter acute infection or vaccination. N Engl J Med2004;351:2611-2618.COVID-19 ANDMECHANICAL THROMBECTOMY IN USA 3

Effect of COVID-19 Pandemic on Mechanical Thrombectomy for Acute Ischemic Stroke Treatment in United States

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Effect of COVID-19 Pandemic on Mechanical Thrombectomy for Acute Ischemic Stroke Treatment in United States

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