Number Of Stroke Admissions Research Articles

Trends of frequency, mortality and risk factors among patients admitted with stroke from 2017 to 2019 to the medical ward at Kilimanjaro Christian Medical Centre hospital: a retrospective observational study

ObjectiveThe burden of stroke has increased in recent years worldwide, particularly in low-income and middle-income countries. In this study we aim to determine the number of stroke admissions, and associated...

Hospital size, remoteness and stroke outcome.

Previous studies have shown an association between number of stroke admissions and outcomes. Small hospitals often support more remote areas and we studied national data to determine if an association exists between hospital remoteness and stroke care. Data from the Irish National Audit of Stroke (INAS) on average stroke admissions, adjusted mortality for ischaemic stroke, thrombolysis rate and proportion with door to needle (DTN) ≤45 min were analysed. Hospital remoteness was quantified by distance to the next hospital, nearest neurointerventional centre and location within 10 km of the national motorway network. Data for 23 of 24 stroke services were evaluated. Median number of strokes admitted per year was 186 (range 84-497). Nine hospitals (39%) admitted ≥200 stroke patients per year (mean 332). Average adjusted mortality (7.0 vs. 7.3, P = 0.67 t-test), mean thrombolysis rate (12.1% vs. 9.2%, P = 0.09) and mean proportion of patients treated ≤45 min (40.4% vs. 31.3%, P = 0.2) did not differ significantly between higher and lower volume hospitals.Hospitals close to the motorway network (n = 15) had a higher mean thrombolysis rate (11.9% vs. 7.5%, P = 0.01 t-test) and proportion DTN ≤45 min (43.7-18.4%, P < 0.001).Number of stroke admissions did not correlate with mortality (r = 0.06, P = 0.78), DTN (r = 0.12, P = 0.95) or thrombolysis rate (r = 0.35, P = 0.20). Distance to next hospital correlated strongly negatively with DTN (r = -0.47, P = 0.02) and thrombolysis rate (-0.43, P = 0.04). Remoteness of hospitals is associated with worse measures of stroke outcome and management.

Non-Modifiable Factors Associated with Medication-Adherence among Stroke Survivors in Lagos State, Nigeria

Stroke is the world's second most common cause of mortality and the third most common cause of morbidity and disability. Recurrent strokes make up a significant number of stroke admissions to the emergency room. This condition is largely preventable by identifying and addressing the risk factors involved. Hence, this study examined the non-modifiable risk factors associated with medication adherence among stroke survivors in Lagos state, Nigeria. A descriptive cross-sectional survey was conducted using a multistage sampling technique, including 386 stroke survivors from 10 stroke rehabilitation facilities in Lagos state. A validated structured interviewer-administered questionnaire was used for data collection. Data were analyzed using descriptive statistics, Chi-square and Binary logistic regression at a significance level of 5%. The participants' mean age was 52.42 ± 12.143. Results showed that participants aged 51-60years were more likely to adhere to their medication than other age groups. The result also showed no association existed between the age of stroke survivors and medication adherence (OR = 1.119, CI = 0.941-1.332, p = 0.549), ethnicity and medication adherence (OR = 1.176, CI 0.89-1.55, p = 0.211), and the gender (OR = 1.147, CI = 0.748-1.761, p = 0.665). However, there is a significant association between number of stroke and medication adherence (OR = 0.699, CI = 0.499-0.980, p = 0.038). This study's findings highlight important gaps in the factors that influence and are associated with medication adherence. Therefore, other non-modifiable factors asides from the ones assessed in this study should be researched.

Impact of the COVID-19 Pandemic in the Acute Stroke Admissions and Outcomes in a Philippine Tertiary Hospital

Background and Purpose: The COVID-19 pandemic has been continuing its global spread ever since its onset, and efforts to curb the infection in multiple reports have contrasting effects on stroke severity, admissions, and outcomes. In the Philippines, where the COVID-19 pandemic shows no signs of slowing down and has been in the world’s longest lockdown, we investigated the effect of the pandemic in the stroke admissions and outcomes in one of the largest tertiary hospitals in the Philippines. Methods: This is a retrospective, comparative study of all adult stroke patients admitted between pre-COVID-19 (February 2019–January 2020) and COVID-19 periods (February 2020–January 2021). The differences of stroke types, severity, classification, and discharge outcomes between pre-COVID-19 and during COVID-19 were analyzed in the study. Results: There is a decrease in total number of stroke admissions from 597 in the pre-COVID-19 period to 487 during the pandemic. Stroke patients take significantly longer time to seek hospital consultation from the onset of stroke symptoms, and significantly higher proportion of patients have moderate and severe stroke. The discharge outcome showed significantly higher proportions of dependency upon discharge (13%) and higher proportion of death in stroke patients from 7% pre-CO­VID-19 pandemic to 13% during the pandemic. Conclusions: There was reduction in total stroke admissions, mild and transient stroke during the pandemic. There were a significantly higher proportion of stroke patients having moderate and severe stroke. The discharge outcome of stroke patients is functionally poorer during the pandemic, and more stroke patients have died compared before the COVID-19 pandemic.

The Change in Acute Ischemic Stroke Numbers in the Emergency Service During Early Phase of COVID -19 Pandemic

Objective: Although the actual relationship between COVID -19 and the incidence of stroke has not yet been clearly defined, various potential mechanisms such as hypercoagulation or viral infecton burden have been reported as risk factors that can increase the risk of stroke. However, various anecdotal reports have emphasized the falling rate of new ischemic stroke diagnoses during period of COVID-19. This study was conducted to estimate the change in the number of new stroke diagnoses and evaluate the approximate causes of such situations during the early period of the COVID-19 outbreak.Methods: In this retrospective observational descriptive study, the patients were divided into two groups as January-February 2020 (Pre-COVID−19) and March-April 2020 (COVID-19 Period), based on when the first COVID-19 case was reported in Turkey in March 2020. Patients who were admitted to the emergency department (ED) between 01 January 2019 and 30 April 2019 and diagnosed with ischemic cerebrovascular disease were included as the control group to estimate the number of cases predicted for 2020. The data of the groups were retrospectively analyzed in terms of the number of stroke admissions and demographic features.Results: Among the 274 patients diagnosed with acute ischemic stroke during the 4-month study period, 112 (40.9%) were detected during the COVID-19 period. Considering the linear relationship between the number of patients diagnosed with ischemic stroke in January-February 2019 and March-April 2019 in the control group of the study, this number was expected to be 163 in March-April 2020, since the number of patients with ischemic stroke diagnosed in January-February 2020 was 162. While it was determined that a 25.35% decrease had occurred in January-February 2020 compared to the January-February 2019, it was determined that a 48.9% decrease had occurred in March-April 2020 compared to the same period of the previous year.Conclusion: This study showed that the number of patients admitted to the hospital with a diagnosis of ischemic stroke in the March-April 2020 decreased statistically significantly compared to the pre-pandemic period of the same year.

Impact of COVID-19 pandemic on haemorrhagic stroke admissions: a systematic review and meta-analysis

Background and purposeCOVID-19 pandemic, a global health crisis, is disrupting the present medical environment. This systematic review and meta-analysis aimed to evaluate the impact of the COVID-19 pandemic on stroke...

Short-Term Association of Air Pollutant Levels and Hospital Admissions for Stroke and Effect Modification by Apparent Temperature: Evidence From Shanghai, China.

The epidemiological evidence on relationships between air pollution, temperature, and stroke remains inconclusive. Limited evidence is available for the effect modification by apparent temperature, an indicator reflecting reactions to the thermal environment, on short-term associations between air pollution and hospital admissions for stroke. We used a generalized additive model with Poisson regression to estimate the relative risk (RR) of stroke admissions in Shanghai, China, between 2014 and 2016 associated with air pollutants, with subgroup analyses by age, sex, apparent temperature, and season. During the study period, changes in the daily number of stroke admissions per 10 μg/m3 increase in nitrogen dioxide (at lags 0, 1, 0–1, and 0–2) ranged from 1.05 (95% CI: 0.82%, 2.88%) to 2.24% (95% CI: 0.84%, 3.65%). For each 10 μg/m3 increase in sulfur dioxide concentrations at lags 1, 2, 0–1, and 0–2, the RR of daily stroke admissions increased by 3.34 (95% CI: 0.955%, 5.79%), 0.32 (95% CI: −1.97%, 2.67%), 3.33 (95% CI: 0.38%, 6.37%), and 2.86% (95% CI: −0.45%, 6.28%), respectively. The associations of same-day exposure to nitrogen dioxide with stroke admissions remained significant after adjustment for ozone levels. These associations were not modified by sex, age, apparent temperature, or season. More research is warranted to determine whether apparent temperature modifies the associations between air pollution and stroke admissions.

Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study.

Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate (p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

A comparative time matched hospital based study of first ever stroke patients admitted to stroke unit during pre-COVID 19 vs COVID 19 pandemic era

To study effects of COVID 19 pandemic era on demographics, type and severity of strokes, morbidity &amp; mortality among patients having first ever stroke who were admitted to stroke unit during similar months(April &amp; May) in year 2019 &amp; 2020. To study the effects of COVID 19 pandemic era on diagnosis of minor strokes and utilization of imaging modalities(MRI/NCCT). Retrospective Study. The study was conducted at GMC Kota, a tertiary care hospital in Rajasthan. All patients having their first ever stroke and admitted to our stroke unit during the pre-COVID 19 period (April 2019-May 2019) and the COVID 19 period (April 2020-May 2020) were considered. The characteristics of stroke, the severity, the number of admissions per day, and demographic characteristics as well as the short-term outcomes were studied. Biostatistician was consulted for statistical analysis. Descriptive statistics, Shapiro-Wilk test, means with standard deviation, Chi-square test, Fisher’s exact test, Linear and logistic regression were used as per data characteristics and requirement. P-value of &amp;#60;.05 was considered significant. Of the 108 patients included, 44 (40.7%) presented during the COVID-19 period. There was a 36% reduction in first-ever stroke diagnoses from (1.05/day) to (0.72/day) (p&amp;#60;.0001). The admitted patients were five years older and in much worse health than in the pre-COVID 19 era (p&amp;#60;.0001). There was a statistically significant reduction in MRI use by 27% (p=0.055). The observation suggests an overall reduced number of stroke admissions per day. Patients admitted were older and more severely ill. In COVID 19 era patients, mortality and mRS at admission and discharge were higher, along with a longer hospital stay. An overall reduction in the utilization of MRI was observed due to COVID protocol.

Exploring the Relationship Between Air Quality and Ischemic Stroke Admissions During the COVID-19 Pandemic

ObjectivesAmongst all the global catastrophe due to Coronavirus disease 2019, a significant bright spot is a reduction in air pollution as countries undergo lockdowns to limit the spread of infection. Another reduction that has been reported is in the number of strokes presenting to hospitals, despite the virus implicated in causing a hypercoagulable state. Acute exposure to air pollution has been linked to increase in stroke incidence and the improvement in air quality may be responsible for the decrease in stroke presentations. Materials and MethodsTo explore this hypothesis, we compared the air quality index (AQI) of Karachi, the largest cosmopolitan city of Pakistan, during the lockdown period in 2020 to the same period in the previous year. ResultsWe found a significant drop in AQI depicting an improvement in air quality. Simultaneously, we identified a drop in number of stroke admissions to less than half from 2019 to 2020 at one of the largest tertiary care hospitals of the city, during this period of interest. Conclusion: We hypothesize that one important reason for this drop in stroke admissions, may be an actual reduction in stroke incidence brought about by an improvement in air quality.

Stroke Care During the COVID-19 Pandemic: Asian Stroke Advisory Panel Consensus Statement

The COVID-19 pandemic has impacted the health system worldwide. Stroke is one of the leading causes of death and disability in the world. Asia has a diverse health system and more than two-thirds of strokes occur in this region. The Asian Stroke Advisory Panel (ASAP) conducted a survey among the member countries to explore the impact of COVID-19 on stroke care. The stroke admission numbers have fallen, as have the number of patients who received thrombolysis and mechanical thrombectomy. The stroke unit and rehabilitation beds have been reallocated for COVID-19 care. ASAP recommends emergency department screening of stroke patients for COVID-19 and protected stroke code to be activated for COVID-19 suspect stroke patients. Noncontrast computed tomography (CT), CT angiography, and CT chest are the imaging modalities of choice. All health care professionals involved in triaging, imaging, and stroke care should wear appropriate personal protective equipment. All eligible stroke patients (COVID suspect/positive/non-COVID) should receive intravenous thrombolysis/mechanical thrombectomy. Mobile stroke units and robots can be used wherever available for evaluation and triaging. All stroke patients should receive standard stroke unit care. Limited rehabilitation should be offered to patients and training of caregivers if needed. Telemedicine/telestroke should be used for rehabilitation and follow-up. The ASAP consensus statement can be adapted to suit local and national health care systems.

Exploring the Collateral Damage of the COVID-19 Pandemic on Stroke Care: A Statewide Analysis.

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Abstract P846: The Collateral Damage of COVID-19 Pandemic on Stroke Care: Data From a State Stroke Registry

Introduction: During the Coronavirus Disease-2019 (COVID-19) pandemic the “stay-home” public campaign implemented to contain the spread of the virus and the reorganization of hospitals to manage the overwhelming volume of affected patients, may have had unintended consequences. Prior studies reported a decrease in the number of stroke and TIAs admissions. Most reports have been from single hospitals, there is no data available on the impact on a statewide level. Methods: A retrospective analysis of stroke quality improvement data reported to the State of Maryland. These data are from Primary, Thrombectomy-Capable, and Comprehensive Stroke Centers. The number of admissions for stroke overall and by stroke subtype are reported and compared for March-June 2020 vs. March-June 2019. Last known well (LKW) to hospital arrival, intravenous tPA (IV tPA) and thrombectomy rates were analyzed. Results: The overall number of stroke admissions from March-June 2020 compared to March-June 2019 was 1,001 vs. 1,203 in March, 809 vs. 1,112 in April, 950 vs. 1206 in May, and 937 vs. 1,261 in June. There was an average 21% decrease for the 4-month period in 2020 compared to 2019. For ischemic stroke, there was a decrease in hospital admission for each month in 2020 vs. 2019: 740 vs. 922 in March, 606 vs. 866 in April, 721 vs. 906 in May, and 698 vs. 880 in June. TIAs admission rates were similarly decreased in 2020 vs. 2019: 116 vs. 136, 74 vs. 97, 111 vs. 137, and 107 vs. 111. The number of ICH admissions in 2020 vs. 2019 was 100 vs. 107 in March, 90 vs. 112 in April, 96 vs. 116 in May, and 103 vs. 121 in June. Median LKW well to hospital arrival was 292 vs. 254 min in March, 383 vs. 293 min in April, 291.5 vs. 247 min in May, and 320 vs. 292 min in June. There was about 1% decrease in thrombectomy rates in the 4-month period in 2020 compared to 2019. Conclusions: During the COVID-19 pandemic in the State of Maryland there was a consistent decrease in the volume of stroke admissions. Median LKW to hospital arrival was also increased, supporting evidence for of a delay in stroke care. While reasons for these changes need to be further explored, our findings suggest that public health campaigns for the pandemic should take into account and not adversely affect the acute care of unrelated medical emergencies.

Impact of National Lockdown on the Hyperacute Stroke Care and Rapid Transient Ischaemic Attack Outpatient Service in a Comprehensive Tertiary Stroke Centre During the COVID-19 Pandemic.

Background: The COVID-19 pandemic is having major implications for stroke services worldwide. We aimed to study the impact of the national lockdown period during the COVID-19 outbreak on stroke and transient ischemic attack (TIA) care in London, UK.Methods: We retrospectively analyzed data from a quality improvement registry of consecutive patients presenting with acute ischemic stroke and TIA to the Stroke Department, Imperial College Health Care Trust London during the national lockdown period (between March 23rd and 30th June 2020). As controls, we evaluated the clinical reports and stroke quality metrics of patients presenting with stroke or TIA in the same period of 2019.Results: Between March 23rd and 30th June 2020, we documented a fall in the number of stroke admissions by 31.33% and of TIA outpatient referrals by 24.44% compared to the same period in 2019. During the lockdown, we observed a significant increase in symptom onset-to-door time in patients presenting with stroke (median = 240 vs. 160 min, p = 0.020) and TIA (median = 3 vs. 0 days, p = 0.002) and a significant reduction in the total number of patients thrombolysed [27 (11.49%) vs. 46 (16.25%, p = 0.030)]. Patients in the 2020 cohort presented with a lower median pre-stroke mRS (p = 0.015), but an increased NIHSS (p = 0.002). We registered a marked decrease in mimic diagnoses compared to the same period of 2019. Statistically significant differences were found between the COVID and pre-COVID cohorts in the time from onset to door (median 99 vs. 88 min, p = 0.026) and from onset to needle (median 148 vs. 126 min, p = 0.036) for thrombolysis whilst we did not observe any significant delay to reperfusion therapies (door-to-needle and door-to-groin puncture time).Conclusions: National lockdown in the UK due to the COVID-19 pandemic was associated with a significant decrease in acute stroke admission and TIA evaluations at our stroke center. Moreover, a lower proportion of acute stroke patients in the pandemic cohort benefited from reperfusion therapy. Further research is needed to evaluate the long-term effects of the pandemic on stroke care.

Acute Stroke Care in the With-COVID-19 Era: Experience at a Comprehensive Stroke Center in Japan.

Introduction: The pandemic of coronavirus disease 2019 (COVID-19) has had a significant impact on stroke healthcare, including the prehospital care system and in-hospital workflow. Japan experienced the outbreak of COVID-19, and the State of Emergency was declared during April 2020 and May 2020. The aim of the present study was to clarify the effect of the COVID-19 pandemic on a comprehensive stroke center in Japan.Methods: We retrospectively reviewed consecutive patients with acute ischemic stroke admitted in our institute between December 2019 and July 2020. The patients who underwent reperfusion therapy (intravenous thrombolysis and/or mechanical thrombectomy) were divided into the pre-COVID-19 period (December 2019 to March 2020) and the With-COVID-19 period (April 2020 to July 2020). Study outcomes were the number of stroke admissions in our institute, workflow time metrics, the frequency of modified Rankin Scale score 0–2 at discharge, and brain imaging modalities before reperfusion therapy in patients who underwent reperfusion therapy.Results: In our institute, the number of stroke admissions decreased during the State of Emergency and then increased after the lifting of the State of Emergency. Among patients who underwent reperfusion therapy (median age, 77 years; female 27%; median baseline National Institutes of Health Stroke Scale score, 10), times from hospital arrival to imaging [25 (21–33) min vs. 30 (25–38) min, P = 0.03] and to thrombolysis [38 (31–52) min vs. 51 (37–64) min, P = 0.03] were prolonged compared with the pre-COVID-19 period. There was no significant difference in the frequency of modified Rankin Scale score 0–2 at discharge between the two periods (32 vs. 45%, P = 0.21). The proportion of computed tomography vs. magnetic resonance imaging as an emergency brain imaging tool before reperfusion therapy changed, with computed tomography having become predominant in the With-COVID-19 period.Conclusions: In our institute, the number of stroke admissions, workflow time metrics, and imaging modalities for reperfusion therapy were affected by the COVID-19 pandemic.

Stroke Admissions, Stroke Severity, and Treatment Rates in Urban and Rural Areas During the COVID-19 Pandemic.

Background: Many regions worldwide reported a decline of stroke admissions during the early phase of the coronavirus disease 2019 (COVID-19) pandemic. It remains unclear whether urban and rural regions experienced similar declines and whether deviations from historical admission numbers were more pronounced among specific age, stroke severity or treatment groups.Methods: We used registry datasets from (a) nine acute stroke hospitals in Berlin, and (b) nine hospitals from a rural TeleNeurology network in Northeastern Germany for primary analysis of 3-week-rolling average of stroke/TIA admissions before and during the COVID-19 pandemic. We compared course of stroke admission numbers with regional cumulative severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) infections. In secondary analyses, we used emergency department logs of the Berlin Charité University hospital to investigate changes in age, stroke severity, and thrombolysis/thrombectomy frequencies during the early regional Sars-CoV-2 spread (March and April 2020) and compared them with preceding years.Results: Compared to past years, stroke admissions decreased by 20% in urban and 20-25% in rural hospitals. Deviations from historical averages were observable starting in early March and peaked when numbers of regional Sars-CoV-2 infections were still low. At the same time, average admission stroke severity and proportions of moderate/severe strokes (NIHSS >5) were 20 and 20–40% higher, respectively. There were no relevant deviations observed in proportions of younger patients (<65 years), proportions of patients with thrombolysis, or number of thrombectomy procedures. Stroke admissions at Charité subsequently rebounded and reached near-normal levels after 4 weeks when the number of new Sars-CoV-2 infections started to decrease.Conclusions: During the early pandemic, deviations of stroke-related admissions from historical averages were observed in both urban and rural regions of Northeastern Germany and appear to have been mainly driven by avoidance of admissions of mildly affected stroke patients.

Impact of COVID-19 pandemic on stroke admissions in Qatar

IntroductionThe COVID-19 pandemic has resulted in a dramatic unexplained decline in hospital admissions due to acute coronary syndromes and stroke. Several theories have emerged aiming to explain this decline, mostly...

Impact of COVID-19 Pandemic on a Regional Stroke Thrombectomy Service in the United Kingdom

Introduction: We examined the impact of the coronavirus disease 2019 (COVID-19) pandemic on our regional stroke thrombectomy service in the UK. Methods: This was a single-center health service evaluation. We began testing for COVID-19 on 3 March and introduced a modified “COVID Stroke Thrombectomy Pathway” on 18 March. We analyzed the clinical, procedural and outcome data for 61 consecutive stroke thrombectomy patients between 1 January and 30 April. We compared the data for January and February (“pre-COVID,” n = 33) versus March and April (“during COVID,” n = 28). Results: Patient demographics were similar between the 2 groups (mean age 71 ± 12.8 years, 39% female). During the COVID-19 pandemic, (a) total stroke admissions fell by 17% but the thrombectomy rate was maintained at 20% of ischemic strokes; (b) successful recanalization rate was maintained at 81%; (c) early neurological outcomes (neurological improvement following thrombectomy and inpatient mortality) were not significantly different; (d) use of general anesthesia fell significantly from 85 to 32% as intended; and (e) time intervals from onset to arrival, groin puncture, and recanalization were not significantly different, whereas internal delays for external referrals significantly improved for door-to-groin puncture (48 [interquartile range (IQR) 39–57] vs. 33 [IQR 27–44] minutes, p = 0.013) and door-to-recanalization (82.5 [IQR 61–110] vs. 60 [IQR 55–70] minutes, p = 0.018). Conclusion: The COVID-19 pandemic has had a negative impact on the stroke admission numbers but not stroke thrombectomy rate, successful recanalization rate, or early neurological outcome. Internal delays actually improved during the COVID-19 pandemic. Further studies should examine the effects of the COVID-19 pandemic on longer term outcome.

Letter by Agarwal et al Regarding Article, “Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era”

HomeStrokeVol. 51, No. 11Letter by Agarwal et al Regarding Article, “Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Agarwal et al Regarding Article, “Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era” Ayush Agarwal, DM, Venugopalan Y. Vishnu, DM and M.V. Padma Srivastava, DM Ayush AgarwalAyush Agarwal Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. Search for more papers by this author , Venugopalan Y. VishnuVenugopalan Y. Vishnu https://orcid.org/0000-0002-3654-8137 Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. Search for more papers by this author and M.V. Padma SrivastavaM.V. Padma Srivastava https://orcid.org/0000-0001-7615-9411 Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. Search for more papers by this author Originally published26 Oct 2020https://doi.org/10.1161/STROKEAHA.120.031678Stroke. 2020;51:e342To the Editor:We read with great interest the article by Diegoli et al1 on the impact of coronavirus 2019 (COVID-19) on admissions of ischemic stroke in Brazil. We studied the same in a tertiary care hospital in India and compared stroke admissions between March 2019 and May 2019 to the same time period in 2020. We found an ≈25% decrease in stroke admissions this year and 7 of our patients with stroke were COVID-19 positive (ischemic-2, hemorrhagic-5). One hundred forty-five patients with stroke were admitted last year compared with one hundred eleven this year. The baseline characteristics like mean age and sex were the same in both years, but our patients were younger with a mean age of 54 years (compared with 67 years) with a male preponderance of 70%.The percentage of patients with hemorrhagic stroke increased during this pandemic, accounting for 39.6% (44/111) admissions compared with 24.8% (36/145) last year. Diegoli et al1 had found similar rates of hemorrhagic stroke in both study periods. Our finding therefore may either be because they tend to be sicker and seek admission presently or because of some yet to be delineated causality associated with COVID-19.2Among patients with ischemic stroke, the number undergoing thrombolysis remained ≈10% in study periods (7/67 in 2020 compared with 10/109 in 2019), but the number undergoing endovascular thrombectomy decreased from ≈10% (10/109) to 6% (4/67). This could be because of delay in vessel imaging due to COVID-19 testing before the same (dictates the protective gear needed to be worn during endovascular thrombectomy) or reluctance in undergoing interventions.There are no conclusive data suggesting that patients with stroke are more susceptible to COVID-19. However, reluctance to seek medical care, delayed recognition of symptoms, and delayed presentations during this COVID-19 pandemic has reduced the number of stroke admissions by a quarter with increased prevalence of hemorrhagic strokes in our institute.AcknowledgmentsThis study acknowledges all faculty members and residents of the Department of Neurology, All India Institute of Medical Sciences, New Delhi.DisclosuresNone.FootnotesFor Disclosures, see page e342.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

High Prevalence of Moyamoya Syndrome in Appalachia

Introduction: Moyamoya is a chronic cerebrovascular condition of unclear etiology characterized by progressive occlusion of 1 or both internal carotid arteries with neovascular collateral formation. With both an idiopathic form (moya­moya disease) and congenital condition-associated form (moyamoya syndrome), it can cause ischemic and hemorrhagic stroke. Recent findings in Kentucky have challenged traditional estimates of its incidence in US populations. Using the Kentucky Appalachian Stroke Registry (KApSR), our aim was to further characterize its incidence as a cause of stroke and to understand the patient population in Appalachia. Methods: A retrospective review of moyamoya patients was performed using the KApSR database. Data collected included demographics, county location, risk factors, comorbidities, and health-care encounters from January 1, 2012, to December 31, 2016. Results: Sixty-seven patients were identified; 36 (53.7%) resided in Appalachian counties. The cohort accounted for 125 of 6,305 stroke admissions, representing an incidence of 1,983 per 100,000 stroke admissions. Patients presented with ischemic strokes rather than hemorrhagic strokes (odds ratio 5.50, 95% CI: 2.74–11.04, p < 0.01). Eleven patients (16.4%) exhibited autoimmune disorders. Compared to the general population with autoimmune disorder prevalence of 4.5%, the presence of autoimmunity within the cohort was significantly higher (p < 0.01). Compared to non-Appalachian patients, Appalachian patients tended to present with lower frequencies of tobacco use (p = 0.08), diabetes mellitus (p = 0.13), and hypertension (p = 0.16). Conclusions: Moyamoya accounts for a substantial number of stroke admissions in Kentucky; these patients were more likely to develop an ischemic stroke rather than a hemorrhagic stroke. Autoimmune disorders were more prevalent in moyamoya patients than in the general population. The reduced frequency of traditional stroke risk factors within the Appalachian group suggests an etiology distinct to the population.