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Highlights • Neurology teams can care for patients with COVID-19 in lieu of being redeployed. • Maintaining team structures has advantages to redeployment during pandemic surges. • Streamlining neurological services increases capacity to care for COVID-19 patients., The COVID-19 pandemic dramatically affected the operations of New York City hospitals during March and April of 2020. This article describes the transformation of a neurology division at a 450-bed tertiary care hospital in a multi-ethnic community in Brooklyn during this initial wave of COVID-19. In lieu of a mass redeployment of staff to internal medicine teams, we report a novel method for a neurology division to participate in a hospital’s expansion of care for patients with COVID-19 while maintaining existing team structures and their inherent supervisory and interpersonal support mechanisms.

Background and Purpose 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). Methods 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). Results 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) Conclusion 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.

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 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.

BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) has helped many patients achieve functional independence. The effect of time-to-treatment based in specific epochs and as related to Alberta Stroke Program Early CT Score (ASPECTS) has not been established. The goal of the study was to evaluate the association between last known normal (LKN)-to-puncture time and good functional outcome. METHODS We conducted a retrospective cohort study of prospectively collected acute ischemic stroke patients undergoing MT for large vessel occlusion. We used binary logistic regression models adjusted for age, Modified Treatment in Cerebral Ischemia score, initial National Institutes of Health Stroke Scale, and noncontrast CT ASPECTS to assess the association between LKN-to-puncture time and favorable outcome defined as Modified Rankin Score 0-2 on discharge. RESULTS Among 421 patients, 328 were included in analysis. Increased LKN-to-puncture time was associated with decreased probability of good functional outcome (adjusted odds ratio [aOR] ratio per 15-minute delay = .98; 95% confidence interval [CI], .97-.99; P = .001). This was especially true when LKN-puncture time was 0-6 hours (aOR per 15-minute delay = .94; 95% CI, .89-.99; P = .05) or ASPECTS 8-10 (aOR = .98; 95% CI, .97-.99; P = .002) as opposed to when LKN-puncture time was 6-24 hours (aOR per 15-minute delay = .99; 95% CI, .97-1.00; P = .16) and ASPECTS

A 73-year-old man with hypertension presented with left hemiparesis and left hemineglect of unclear duration. CT with angiography of the head and neck showed subacute infarcts of the right frontal lobe and a right internal carotid artery thrombus, with corresponding perfusion abnormalities that would have qualified him for thrombectomy (figure).1 On closer examination, his facial hair asymmetry suggested a matured hemineglect to his left face. Based on the unenhanced imaging findings and facial hair asymmetry, we estimated his stroke onset to be more than 24 hours prior to evaluation, thereby disqualifying him for thrombectomy.

Objective: Faster time to mechanical thrombectomy (MT) is associated with better outcome in acute stroke. In patients transferred from other hospitals where a routine CT has already ruled out hemorrhage, transfer direct to angiography (DTA) suite may reduce door to groin time compared to transfer to CT angiography (CTA) first. However, this may result in unnecessary catheter angiography if many patients would have been excluded based on CTA results. We sought to determine how often CTA and repeat head CT changed the decision to proceed to MT. Methods: An internal transfer database at a comprehensive stroke center (CSC) was used to identify patients transferred from outside facilities for consideration of mechanical thrombectomy from July 2016 to May 2017. Detailed clinical and radiographic data was extracted using a standard case report form. Results: Of 187 patients transferred for MT, 171 underwent CT +/- CTA on arrival, 5 went DTA, and 11 were admitted without imaging or intervention. Among those undergoing CT +/- CTA on arrival, MT was aborted in 110 (64%) patients. Of these, 87 (79%) were aborted directly based on imaging findings, with absence of proximal large vessel occlusion (LVO) amenable to MT being the most common reason (69%), followed by rapid clinical improvement or mild deficit (7%). MT was aborted based on imaging findings in 36% of patients with NIHSS≥10 on arrival at CSC, and in 29% of patients with NIHSS≥15. In patients with outside hospital CTA demonstrating proximal LVO (n=48), MT was aborted in 48% on CSC arrival, mostly based on imaging findings (48%) or dramatic clinical improvement (31%). Use of tPA did not substantively modify any of these findings. CSC arrival to groin puncture tended to be shorter in the patients going DTA compared to CTA (median 39 v 54 min, p=0.06). Conclusions: While transfer DTA may be associated with faster door to groin puncture times, this might result in many patients undergoing unnecessary catheter angiography who would have been excluded based on CT +/- CTA findings. Even in transferred patients with severe stroke deficits on arrival, imaging excludes about 1/3 of patients from MT.

Background and purpose Faster time to mechanical thrombectomy (MT) improves outcome in stroke. In patients from other hospitals where a CT has ruled-out hemorrhage, transfer direct-to-angiography (DTA) may reduce door-to-groin time compared to transfer to CT angiography (CTA)+/−repeat CT first. However, this may result in unnecessary catheter angiography. We sought to determine how often CTA+/−CT changed the decision to proceed to MT. Methods Data on patients transferred to our comprehensive stroke center (CSC) from outside facilities for possible MT from 7/2016–5/2017 was extracted from a prospective database and supplemented with chart review. Results Of 170 patients transferred for MT undergoing CT+/−CTA on CSC arrival, MT was aborted in 108 (64%). Of these, 87 (81%) were aborted directly based on imaging findings, with absence of large vessel occlusion or occlusion too distal to be amenable to MT the most common reasons (n = 76), followed by extensive early CT changes (n = 9) and ICH post-tPA (n = 2). Even with NIHSS ≥10 on CSC arrival, MT was aborted based on imaging findings in 35% patients. Time from symptom onset dichotomized as early/late based on median onset-to-CSC arrival (253 min) was an important modifier of proceeding to MT in this group, with 71% of early presenters going to MT compared to 33% of late presenters (p = .003). Conclusions Transfer DTA may result in many patients who would have been excluded based on CT+/−CTA findings undergoing unnecessary catheter angiography. However, a target population for a DTA approach might be identifiable based on severity of deficit and time from onset.