Abstract
In the 18 months since the outbreak of the COVID-19 pandemic, numerous studies have documented its devastating impact on stroke worldwide. Early reports highlighted a marked reduction in stroke admissions,1,2 although subsequent population-based analyses suggested that there was not a true reduction in stroke incidence, but a failure of acute stroke cases to be admitted to hospital with excess mortality particularly in nursing homes. 3 If anything there was an overall increase in stroke cases, likely due to the known association between COVID-19 itself and stroke.3,4 A particular concern over this period has been access to acute reperfusion therapies, and whether the pandemic, and the many precautions associated with it, might reduce the proportion of patients receiving such therapies.
A comprehensive metanalysis in this month’s IJS from Romoli et al. provides some modestly reassuring data. 5 They performed a systematic review and metanalysis on stroke admissions and the rate and timing of reperfusion treatments during the first wave of the COVID-19 pandemic versus the pre-pandemic timeframe; 29 studies including 212,960 patients were included. Not unexpectedly, the COVID-19 period was associated with a 31% reduction in stroke admission rates, with a relatively higher presentation of large artery occlusion, perhaps reflecting selective admission of more serious cases and/or the increased large artery occlusive stroke seen in COVID-19 patients. Reassuringly, there was no reduction in the proportion of patients receiving endovascular therapy. Their overall message is that, despite a marked contraction in admissions, stroke networks were able to deliver similar rates of treatments to those provided in the pre-pandemic period. Both drip and ship and mothership models performed reasonably, although the mothership model was more likely to preserve the rate of treatment during the COVID-19 period as opposed to drip and ship. They suggest that in any further pandemics, it is vital that acute stroke services are maintained, and their results demonstrate that reperfusion therapies can still be successfully delivered despite restrictions caused by COVID-19. A recent WSO paper has emphasized the importance of preserving and adapting stroke services over the coming years. 6
Recent global stroke statistics show significant sex disparities in stroke. 7 Men have a consistently higher incidence of acute ischemic stroke, but stroke mortality appears to be greater in women. Wang et al. in this month’s issue present an analysis from eight national and regional stroke registries which contributed individual patient data from China, Japan, Philippines, Singapore, South Korea, and Taiwan over the period 2005–2018. 8 They used these data from 4453 patients to compare prognosis in women compared with men after thrombolysis. Women were more likely than men to have an unfavorable shift in the modified Rankin scale with an adjusted odds ratio of 1.14 (95% CI 1.02–1.28). This disparity was particularly marked in women over age 70. The authors point that out that the International Stroke Trial showed no major sex differences in functional outcome after intravenous tissue plasminogen activator, but in contrast, data from a large European register of nearly 10,000 patients also reported consistent findings that women had poorer functional outcome compared with men at three months. With the difference being more marked in the elderly, they suggest a number of factors that may account for these differences which include women suffering more severe strokes and a higher prevalence of atrial fibrillation and cardioembolic stroke in women which are themselves associated with a poor prognosis in thrombolysed patients.
Whether general or local anesthesia is preferable for patients undergoing thrombectomy remains a hotly debated topic. Most data are available from anterior circulation stroke, and there is much less data on posterior circulation stroke. Terceno et al. from the Catalan Stroke Code and Reperfusion Consortium address this issue in an analysis of their registry, in 298 patients who underwent endovascular treatment for posterior circulation large vessel occlusion. 9 After controlling for confounders in multivariable regression, general anesthesia was associated with a poor outcome with an adjusted odds ratio of 3.11 (95% CI 1.32–7.2). Their results suggest that local anesthesia may be safer in patients with posterior circulation stroke, who tend often to have high NIHSS at baseline and the potential of brainstem complications, although due to the retrospective nature of the study, it is impossible to exclude selection bias.