COVID-19 is a severe infectious disease that has claimed >150,000 lives and infected millions in the United States thus far, especially the elderly population. Emerging evidence has shown the virus ...to cause hemorrhagic and immunologic responses, which impact all organs, including lungs, kidneys, and the brain, as well as extremities. SARS-CoV-2 also affects patients', families', and society's mental health at large. There is growing evidence of re-infection in some patients. The goal of this paper is to provide a comprehensive review of SARS-CoV-2-induced disease, its mechanism of infection, diagnostics, therapeutics, and treatment strategies, while also focusing on less attended aspects by previous studies, including nutritional support, psychological, and rehabilitation of the pandemic and its management. We performed a systematic review of >1,000 articles and included 425 references from online databases, including, PubMed, Google Scholar, and California Baptist University's library. COVID-19 patients go through acute respiratory distress syndrome, cytokine storm, acute hypercoagulable state, and autonomic dysfunction, which must be managed by a multidisciplinary team including nursing, nutrition, and rehabilitation. The elderly population and those who are suffering from Alzheimer's disease and dementia related illnesses seem to be at the higher risk. There are 28 vaccines under development, and new treatment strategies/protocols are being investigated. The future management for COVID-19 should include B-cell and T-cell immunotherapy in combination with emerging prophylaxis. The mental health and illness aspect of COVID-19 are among the most important side effects of this pandemic which requires a national plan for prevention, diagnosis and treatment.
The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented demand and burden on emergency health care services in New York City. We aim to describe our experience providing acute stroke ...care at a comprehensive stroke center (CSC) and the impact of the pandemic on the quality of care for patients presenting with acute ischemic stroke (AIS).
We retrospectively analyzed data from a quality improvement registry of consecutive AIS patients at New York University Langone Health's CSC between 06/01/2019-05/15/2020. During the early stages of the pandemic, the acute stroke process was modified to incorporate COVID-19 screening, testing, and other precautionary measures. We compared stroke quality metrics including treatment times and discharge outcomes of AIS patients during the pandemic (03/012020-05/152020) compared with a historical pre-pandemic group (6/1/2019-2/29/2020).
A total of 754 patients (pandemic-120; pre-pandemic-634) were admitted with a principal diagnosis of AIS; 198 (26.3%) received alteplase and/or mechanical thrombectomy. Despite longer median door to head CT times (16 vs 12 minutes; p = 0.05) and a trend towards longer door to groin puncture times (79.5 vs. 71 min, p = 0.06), the time to alteplase administration (36 vs 35 min; p = 0.83), door to reperfusion times (103 vs 97 min, p = 0.18) and defect-free care (95.2% vs 94.7%; p = 0.84) were similar in the pandemic and pre-pandemic groups. Successful recanalization rates (TICI≥2b) were also similar (82.6% vs. 86.7%, p = 0.48). After adjusting for stroke severity, age and a prior history of transient ischemic attack/stroke, pandemic patients had increased discharge mortality (adjusted OR 2.90 95% CI 1.77 – 7.17, p = 0.021)
Despite unprecedented demands on emergency healthcare services, early multidisciplinary efforts to adapt the acute stroke treatment process resulted in keeping the stroke quality time metrics close to pre-pandemic levels. Future studies will be needed with a larger cohort comparing discharge and long-term outcomes between pre-pandemic and pandemic AIS patients.
Objective:
To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis.
Background:
Most ...neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology.
Methods:
Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected.
Results:
The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59–82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis.
Conclusion:
COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.
Background
Acute ischemic stroke (AIS) in the context of COVID‐19 has received considerable attention for its propensity to affect patients of all ages. We aimed to evaluate the effect of age on ...functional outcome and mortality following an acute ischemic event.
Methods and Results
A prospectively maintained database from comprehensive stroke centers in Canada and the United States was analyzed for patients with AIS from March 14 to September 30, 2020 who tested positive for SARS‐CoV‐2. The primary outcome was Modified Rankin Scale score at discharge, and the secondary outcome was mortality. Baseline characteristics, laboratory values, imaging, and thrombectomy workflow process times were assessed. Among all 126 patients with COVID‐19 who were diagnosed with AIS, the median age was 63 years (range, 27–94). There were 35 (27.8%) patients with AIS in the aged ≤55 years group, 47 (37.3%) in the aged 56 to 70 group, and 44 (34.9%) in the aged >70 group. Intravenous tissue plasminogen activator and thrombectomy rates were comparable across these groups, (
P
=0.331 and 0.212, respectively). There was a significantly lower rate of mortality between each group favoring younger age (21.9% versus 45.0% versus 48.8%,
P
=0.047). After multivariable adjustment for possible confounders, a 1‐year increase in age was significantly associated with fewer instances of a favorable outcome of Modified Rankin Scale 0 to 2 (odds ratio OR, 0.95; 95 CI%, 0.90–0.99;
P
=0.048) and higher mortality (OR, 1.06; 95 CI%, 1.02–1.10;
P
=0.007).
Conclusions
AIS in the context of COVID‐19 affects young patients at much greater rates than pre‐pandemic controls. Nevertheless, instances of poor functional outcome and mortality are closely tied to increasing age.
To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution.
Ten patients ...diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models.
Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume.
MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.
Multiple intracranial aneurysms are common. While sequential clipping of multiple aneurysms during a single open surgical procedure has been reported, the same is not true for endovascular coiling. ...We present our experience describing the safe coiling of multiple aneurysms in the same setting.
Retrospective review of our coiling log between 2006 and 2009 showed six cases in which multiple aneurysms were coiled in the same session.
All patients were coiled using the same microcatheter. Distal aneurysms were coiled first. Good occlusion rates were achieved in all cases. There were no thromboembolic events or procedure-related rupture or mortality.
In addition to safety and efficacy, cost savings are expected when coiling multiple aneurysms in the same procedure.
This case report describes a novel endovascular method for treating chronically occluded internal carotid artery (COICA). The patient is a 55-year-old male with vascular risk factors who presented to ...an outside institution with right-sided weakness and dysarthria, was diagnosed as having a stroke, and discharged with medical management. The patient's symptoms failed to improve throughout the week prompting him to visit another outside institution, where computed tomography (CT) angiography showed bilateral occlusion of the ICAs at their origins extending intracranially. The patient was then transferred to our hospital, where head CT revealed bilateral acute infarcts predominantly in the left centrum ovale/corona radiata and left temporoparietal region. CT perfusion showed a large area of hypoperfusion in the entire left hemisphere as well as part of the right hemisphere (mismatch volume of 438-526 mL). The patient had significant neurological deficits despite sustained high perfusion pressure, so the following morning, the patient was taken for angiography showing complete occlusion of the left ICA with support mostly from the left external carotid artery (ECA)/ophthalmic collateralization. The microcatheter was able to be advanced to the level of the ophthalmic segment of the left ICA, so the decision was made to proceed with stenting from the left ophthalmic ICA to the cervical ICA. Seven consecutive coronary-carotid stents were placed to essentially reconstruct the left ICA. Post-stenting, the patient was treated with an Integrilin drip and transitioned to Aspirin and Brilinta the following morning. The patient's symptoms markedly improved after the procedure. CT perfusion, as well as diffusion magnetic resonance imaging (MRI), revealed recovery of the patient's penumbra and stability of the existing infarcts despite the delayed nature of revascularization respectively. This is a rarely reported study in literature describing the successful deployment of multiple stents in recreating the ICA from its extracranial to intracranial portion.
Abstract only
Introduction:
Thrombectomy for acute ischemic stroke with large vessel occlusion is a highly effective therapy. However, meta-analyses of seminal trials show as many as 54% of ...thrombectomy patients do not achieve functional independence at 90 days (Goyal et al, Lancet 2016) and 72% of patients do not get discharged to home (Jahan et al, NEJM 2019). Here we investigate technical factors associated with maximizing the likelihood of good discharge outcome. Specifically, we evaluated how thrombectomy technique (clot suction alone, stentretriever alone, or combination therapy with both) and reperfusion grade (partial TICI 2b or complete TICI 3) affected the likelihood of good outcome defined as discharge to home or acute rehab.
Methods:
Retrospective data from 15 hospitals were used including patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was discharge to home or inpatient rehabilitation (IRF) versus other discharge dispositions, including death. Multivariate logistic regression was used to determine if TICI 3 versus TICI 2b and/or procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) were associated with better outcome of discharge to home/IRF, adjusting for age, race, medical history, and NIHSS at admission. Main effects and interaction between technique and TICI were included in the model.
Results:
The analysis included 787 patients, 55.3% (n=435) were discharged home/IRF and 44.7% (n=352) were discharged elsewhere or expired. Patients with TICI 3 grade were more likely to be discharged to home/IRF compared to those with TICI 2b (Adjusted Odds Ratio (AOR)=1.35, p=.018). Those who received distal aspiration only (AOR=1.87. p<.001) and combination approach (AOR=1.64, p=.047) were also more likely to have favorable discharge status compared to stent retriever only. The interaction effect of TICI score and procedure technique was not significant (p=.873).
Conclusion:
Our analysis suggested that both TICI grade 3 and distal aspiration or combination approach techniques independently predicted more favorable disposition outcome.
Abstract only
Introduction:
Prior randomized trials have defined substantial reperfusion for stroke thrombectomy as TICI 2b or TICI 3. However, recent data suggest that complete TICI 3 reperfusion ...results in more favorable patient outcomes than partial reperfusion with TICI 2b. We have multiple effective techniques for thrombectomy, but it is not clear which are most likely to achieve TICI 3 rather than TICI 2b reperfuson.
Methods:
Retrospective data from 15 hospitals were used for patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was TICI grade 3, defined as complete reperfusion, versus TICI 2b. Multivariate logistic regression was conducted to determine if procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) was associated with achieving TICI 3 versus 2b adjusting for sex, age ≥70 vs ≤69, race/ethnicity, history of chronic renal insufficiency or diabetes, history or newly diagnosed atrial fibrillation or flutter, previous anticoagulation medication. Interaction effects between technique and clinical variables were also tested.
Results:
The analysis included 787 patients, 67.9% (n=534) TICI 3 and 32.1% (n=253) TICI 2b. While, main effect of procedure technique was not a significant predictor of achieving TICI 3 (p=.451), interaction effects showed superiority of the combination approach in several patient populations. Specifically, the combined approach increased the likelihood of TICI 3 compared to stent retrieval alone for older patients (Adjusted Odds Ratio (AOR) =1.79, p=.007), those with a history of diabetes (AOR=1.56, p=.045) and Asian patients (AOR=4.41, p=.010). Among AFIB/flutter patients, the combined approach also increased the odds of complete reperfusion compared to stent retriever alone (AOR=1.76, p=.005) or distal aspiration alone (AOR=1.38, p=.034).
Conclusion:
The combined approach of retrievable stent and distal aspiration was a significant predictor of achieving TICI 3 in certain patient subgroups including patients who were older, Asian, had a history of diabetes or history of or current AFIB/flutter.
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