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      Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

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          Abstract

          Supplemental Digital Content is available in the text.

          Abstract

          Background and Purpose:

          The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform.

          Methods:

          Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling.

          Results:

          A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P<0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P<0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P<0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P<0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P=0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P=0.4).

          Conclusions:

          A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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          Most cited references15

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          Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

          To rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a series of case reports that offer important teaching points or novel findings. The case reports should be viewed as observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports are evaluated by in-house editors, with peer review reserved for key points as needed. We report five cases of large-vessel stroke in patients younger than 50 years of age who presented to our health system in New York City. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients. Cough, headache, and chills lasting 1 week developed in a previously healthy 33-year-old woman (Patient 1) (Table 1). She then had progressive dysarthria with both numbness and weakness in the left arm and left leg over a period of 28 hours. She delayed seeking emergency care because of fear of Covid-19. When she presented to the hospital, the score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater stroke severity), and computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus in the right carotid artery at the cervical bifurcation. Patchy ground-glass opacities in bilateral lung apices were seen on CT angiography, and testing to detect SARS-CoV-2 was positive. Antiplatelet therapy was initiated; it was subsequently switched to anticoagulation therapy. Stroke workup with echocardiography and magnetic resonance imaging of the head and neck did not reveal the source of the thrombus. Repeat CT angiography on hospital day 10 showed complete resolution of the thrombus, and the patient was discharged to a rehabilitation facility. Over a 2-week period from March 23 to April 7, 2020, a total of five patients (including the aforementioned patient) who were younger than 50 years of age presented with new-onset symptoms of large-vessel ischemic stroke. All five patients tested positive for Covid-19. By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke. On admission of the five patients, the mean NIHSS score was 17, consistent with severe large-vessel stroke. One patient had a history of stroke. Other pertinent clinical characteristics are summarized in Table 1. A retrospective study of data from the Covid-19 outbreak in Wuhan, China, showed that the incidence of stroke among hospitalized patients with Covid-19 was approximately 5%; the youngest patient in that series was 55 years of age. 1 Moreover, large-vessel stroke was reported in association with the 2004 SARS-CoV-1 outbreak in Singapore. 2 Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19. 3 The association between large-vessel stroke and Covid-19 in young patients requires further investigation. Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes. Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.
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            Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection

            New England Journal of Medicine, 372(11), 1009-1018
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              SARS2-CoV-2 and Stroke in a New York Healthcare System

              Background and Purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. Methods: We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). Results: During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. Conclusions: We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.
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                Author and article information

                Contributors
                Journal
                Stroke
                Stroke
                STR
                Stroke
                Lippincott Williams & Wilkins (Hagerstown, MD )
                0039-2499
                1524-4628
                04 March 2021
                May 2021
                04 March 2021
                : 52
                : 5
                : 1682-1690
                Affiliations
                [1 ]Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory School of Medicine, Atlanta, GA (R.G.N., D.C.H., M.H.M., M.R.F.).
                [2 ]Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo & Gates Vascular Institute at Kaleida Health, New York (J.M.D., A.H.S.).
                [3 ]Wellstar Medical Group Neurosurgery (RG) and Neurosciences (KO), Wellstar Health System, Marietta, GA (R.G., K.O.).
                [4 ]University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen (A.E.H., W.G.T.).
                [5 ]Erlanger Health System, University of Tennessee Health Sciences Center, Chattanooga, TN (T.D.).
                [6 ]Department of Neurosurgery, Mount Sinai Health System, New York (C.P.K., J.M.).
                [7 ]Department of Neurosurgery (AA) and Neurology (LE), Semmes-Murphey Clinic and University of Tennessee Health Sciences Center, Memphis (A.A., L.E.).
                [8 ]Viz.ai, Inc, Palo Alto, CA (D.B., M.N., N.M.).
                [9 ]Department of Neurology and Pediatrics, Emory University, Atlanta, GA (F.N.).
                [10 ]Cooper University Hospital, Neurological Institute and Cooper Medical School of Rowan University, Camden, NJ (T.G.J.).
                [11 ]Radiology Imaging Associates/RIA Neurovascular, Swedish Medical Center, Denver, CO (D.F.).
                Author notes
                Correspondence to: Raul G. Nogueira, MD, Grady Memorial Hospital, 80 Jesse Hill Dr SE, Room 8D108A, Atlanta, GA 30303. Email raul.g.nogueira@ 123456emory.edu
                Article
                00018
                10.1161/STROKEAHA.120.031960
                8078127
                33657851
                f7513e20-cb19-4ada-9e73-b524632e9590
                © 2021 American Heart Association, Inc.

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                : 24 July 2020
                : 8 December 2020
                : 29 January 2021
                Categories
                10178
                Original Contributions
                Clinical and Population Sciences
                Custom metadata
                T

                artificial intelligence,hospitalization,incidence,pandemic,perfusion

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