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Inpatient Stroke Case Studies

Inpatient e/m case studies.

Case study of a stroke patient at varying visit levels to better understand code selection for inpatient encounters under the revised guidelines for 2024.

67-year-old Female with Stroke

Total time* for Inpatient E/M in 2023

Refer to the following tables for correct code selection when billing based on time for inpatient E/M Services:

*Total time includes non face-to-face time on the date of service

Day 1: Critical Care (99291)

A 67-year-old woman with hypertension and diabetes presents to the emergency department with abrupt onset of left hemiparesis 45 minutes ago.

Pre-evaluation : Discussed presentation and vital signs with ED provider (3 mins).

Face-to-face evaluation : Performed medically appropriate history and exam. She has a dense left hemiparesis and an NIH Stroke Scale score of 8. Thrombolysis safety criteria reviewed (7 mins).

Post-evaluation : Non-contrast head CT, CTA of head and neck, and lab results reviewed in the ED. Case discussed with ED provider and thrombolysis recommended. Consultation documented in the ED (25 mins).

Total time : 35 minutes.

Critical Care Coding

According to the 2024 CPT code set, a provider may bill for critical care when the following requirements are met:

• A critical condition: one that acutely impairs a vital organ system with a high probability of imminent or life-threatening deterioration. This includes, for example, central nervous system failure.
• Direct delivery of critical care: high complexity decision-making to assess, manipulate, and support vital systems to treat organ system failure or prevent further life-threatening deterioration.
• At least 30 minutes of time spent solely in the care of the patient. It does not need to be continuous, and it includes both time at the bedside and time spent on the same floor or unit engaged in work directly related to the patient’s care (e.g., documenting critical care, reviewing test results, discussing care with other providers, obtaining history, or discussing treatments or treatment limitations with surrogates when the patient lacks the capacity to do so).

Specific critical care credentials are not required to bill critical care. Critical care is usually provided in a critical care area such as an intensive care unit or emergency department, but this is not always the case (for example, critical care provided to a deteriorating patient in a non-critical care unit).

Other examples of critical care might include:

• Evaluating a patient with status epilepticus and prescribing anti-epileptic drugs or sedative infusions,
• Evaluating a patient with acute respiratory failure from neuromuscular disease and prescribing plasmapheresis,
• Evaluating a patient with coma after cardiac arrest and discussing prognosis, treatment, and goals of care with surrogates (documenting the patient’s lack of capacity to participate)

Critical care, 30-74 minutes CPT 99291 is justified based on the above documentation, although E&M codes (e.g., 99223) associated with fewer wRVUs and lower reimbursement could be used as well.

Day 2: Subsequent Hospital Inpatient Care

Pre-rounds : Reviewed vitals, labs, and studies (LDL, Hemoglobin A1c, EKG, TTE). Review and document independent interpretation of MRI (8 mins).

On Rounds : Performed medically appropriate history and exam. The patient’s symptoms and findings improved somewhat overnight. Patient counseled about stroke evaluation and secondary prevention (10 mins).

Post-rounds : Order atorvastatin, order diabetes consult for management of diabetes. Document discussion with case management possible need for acute inpatient rehabilitation. Documentation completed (10 mins).

Total time : 28 minutes

In this situation, billing according to MDM would be associated with higher reimbursement.

Day 3: Discharge Day Management (By Primary Service)

Pre-rounds : Reviewed vitals, daily CBC and BMP, nursing notes and PT/OT notes (5 mins).

On Rounds : Performed medically appropriate history and exam. The patient reports continued slight improvement in symptoms and requests counseling on how complementary and alternative medicine might help manage her chronic conditions (15 mins).

Post-rounds : Prescribe antiplatelet agent, antidiabetic medications, and antihypertensives. Prepare discharge paperwork and document discharge summary (15 mins).

Total time : 35 minutes

Discharge Day Management Coding (Inpatient or Observation)

Discharge CPTs are selected based on total (face-to-face and non-face-to-face) time, not MDM:

• 99238: 30 minutes or less
• 99239: 31 minutes or more

Discharge CPTs would be used by the primary attending service (e.g., a Neurohospitalist service). Consulting services would continue to choose Subsequent Day codes based on time or MDM.

Discharge Day Management, 31 minutes or more   CPT 99239  

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Interactive Training of the Emergency Medical Services Improved Prehospital Stroke Recognition and Transport Time

Lukas sveikata.

1 J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States

2 Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

Kazimieras Melaika

3 Faculty of Medicine, Vilnius University, Vilnius, Lithuania

Adam Wiśniewski

4 Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland

Aleksandras Vilionskis

5 Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania

6 Stroke Center, Republican Vilnius University Hospital, Vilnius, Lithuania

Kȩstutis Petrikonis

7 Department of Neurology, Lithuanian University of Health Sciences, Kaunas, Lithuania

Edgaras Stankevičius

Kristaps jurjans.

8 Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia

9 Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia

Aleksandra Ekkert

10 Center of Neurology, Vilnius University, Vilnius, Lithuania

Dalius Jatužis

Rytis masiliūnas, associated data.

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

Background and Purpose

Acute stroke treatment outcomes are predicated on reperfusion timeliness which can be improved by better prehospital stroke identification. We aimed to assess the effect of interactive emergency medical services (EMS) training on stroke recognition and prehospital care performance in a very high-risk cardiovascular risk population in Lithuania.

We conducted a single-center interrupted time-series study between March 1, 2019 and March 15, 2020. Two-hour small-group interactive stroke training sessions were organized for 166 paramedics serving our stroke network. We evaluated positive predictive value (PPV) and sensitivity for stroke including transient ischemic attack identification, onset-to-door time, and hospital-based outcomes during 6-months prior and 3.5 months after the training. The study outcomes were compared between EMS providers in urban and suburban areas.

In total, 677 suspected stroke cases and 239 stroke chameleons (median age 75 years, 54.8% women) were transported by EMS. After the training, we observed improved PPV for stroke recognition (79.8% vs . 71.8%, p = 0.017) and a trend of decreased in-hospital mortality (7.8% vs . 12.3, p = 0.070). Multivariable logistic regression models adjusted for age, gender, EMS location, and stroke subtype showed an association between EMS stroke training and improved odds of stroke identification (adjusted odds ratio [aOR] 1.6 [1.1–2.3]) and onset-to-door ≤ 90 min (aOR 1.6 [1.1–2.5]). The improvement of PPV was observed in urban EMS (84.9% vs . 71.2%, p = 0.003), but not in the suburban group (75.0% vs . 72.6%, p = 0.621).

Conclusions

The interactive EMS training was associated with a robust improvement of stroke recognition, onset to hospital transport time, and a trend of decreased in-hospital mortality. Adapted training strategies may be needed for EMS providers in suburban areas. Future studies should evaluate the long-term effects of the EMS training and identify optimal retraining intervals.

Introduction

Stroke is a life-threatening condition in which prompt and accurate diagnosis is essential for successfully implementing reperfusion therapies ( 1 ). Emergency medical services (EMS) play a crucial role in early recognition of stroke, as they are the first-line providers in about two-thirds of cases ( 2 ). Although EMS use by stroke patients is associated with earlier emergency department (ED) arrival, quicker evaluation, and more rapid treatment, how healthcare providers respond to stroke remains an essential factor in explaining prehospital delays ( 1 ). The process of clinically identifying a stroke is still the most significant challenge for EMS, as a percentage of stroke mimics reaches up to 50% ( 3 , 4 ). Consequently, stroke mimics utilize the limited resources of acute stroke care pathways that might otherwise be directed toward the actual stroke patients who may benefit from acute time-sensitive revascularization therapies the most ( 5 ). Of concern, stroke mimic number in stroke care systems is expected to rise due to demographic changes in the coming decades ( 6 ). Therefore, it is crucial to improve the EMS performance in early stroke recognition. Fast and correct stroke diagnosis facilitates an early transfer to stroke-ready hospitals, reduces the volume of stroke mimics, and improves outcomes of acute stroke.

Intensive efforts are made to improve the quality of early stroke care. Training programs for EMS staff in simulated neurological environments increase knowledge on stroke recognition and awareness of time-sensitive medical emergencies ( 1 , 7 – 12 ). The hospital prenotification has improved in-hospital timeliness metrics and increased intravenous thrombolysis (IVT) rates ( 13 ). In addition, prehospital stroke scales and screening methods for EMS staff have been introduced to allow for a more objective stroke identification (e.g., Face Arm Speech Time test, Los Angeles Motor Scale, Cincinnati Prehospital Stroke Scale) ( 14 , 15 ). Moreover, specific scales for large vessel occlusion stroke were developed to facilitate the identification of candidates for endovascular therapy (EVT) ( 16 ). Given the changing landscape of prehospital stroke identification, a continuous educational effort is required to ensure optimal implementation of prehospital stroke protocols.

Stroke education interventions in prehospital care provided mixed results. A large multicenter randomized control trial in the United Kingdom did not show any benefit on the IVT rate. Surprisingly, the onsite care duration was prolonged in the EMS group that applied an enhanced stroke assessment protocol ( 17 ). On the other hand, several interventions increased the accuracy of stroke identification, the number of patients who underwent reperfusion therapy, and significantly reduced the time from the symptom onset to hospital arrival ( 7 – 9 , 11 , 18 ). Furthermore, the duration of the training effects remains unknown ( 19 ). Finally, the paucity of studies in very high cardiovascular risk populations, such as the Baltic countries, urged us to investigate prehospital stroke care intervention in Lithuania ( 20 ). Following the European ( 21 ) and North American guidelines ( 13 ), it is crucial to systematically assess the effectiveness of specific stroke education interventions and maintain the continuity of EMS education.

This study aimed to prospectively evaluate the effect of interactive EMS training on stroke recognition accuracy and the continuum of stroke care metrics. Second, we hypothesize that the EMS training effect might differ in the communities served and compare the training effect in urban and suburban locations.

Study Design

We used an interrupted time-series design ( 22 ) to examine the impact of interactive EMS stroke training on EMS and hospital-based performance measures. We evaluated the positive predictive value (PPV) and sensitivity for identifying stroke patients, onset-to-door (OTD) ≤ 90 min rate, and hospital-based outcomes, including door-to-CT ≤ 30 min rate, reperfusion therapy, door-to-needle ≤ 30 min rate, and in-hospital mortality. We compared these variables between two periods−6 months before and 3.5 months after the interactive EMS training. The EMS personnel were blinded to the assessment.

The study was approved by the Vilnius Regional Biomedical Research Ethics Committee and conducted following the Declaration of Helsinki. The manuscript complies with STROBE guidelines for observational research.

This single-center study was conducted in Vilnius University Hospital (VUH) from 1 March 2019 to 16 March 2020, terminated earlier due to an unanticipated state-wide COVID-19 lockdown ( 23 ). VUH is one of the two comprehensive stroke centers (CSC) in Eastern Lithuania with a catchment population of 945,000 1 , served by one EMS agency in urban and seven in suburban municipalities ( 24 ). The EMS response team consisted of a two-person team—paramedic and driver-paramedic. The EMS agencies were staffed by 331 specialists (217 in urban and 114 in suburban locations) and transported ≈20,400 patients. 2 The paramedics had prior training in nursing (307, 92.7%) or medicine (24, 7.3%).

The post-training period coincided with the change in national stroke triage guidelines, implemented on January 1, 2020. The new regulations affected the workflow of suburban EMS as it required direct transport of all suspected stroke cases to the stroke-ready hospitals with IVT or EVT capability, bypassing regional hospitals irrespective of the time from symptom onset. 3

Study Population

We collected data of suspected stroke or transient ischemic attack (TIA) patients referred by the EMS to the VUH ED. Secondary transfers from other hospitals and in-hospital strokes were not included. We also collected data on false negatives, that is, stroke cases that were not identified by the EMS. EMS used the Face Arm Speech Time test (FAST) for the identification of suspected strokes ( 25 ). Overall, 15,086 patients were referred to the ED by the EMS, of whom 916 patients with EMS suspected or hospital confirmed strokes were included in the analysis ( Figure 1 ). Stroke case ascertainment was done after arrival at the hospital by an attending neurologist after a complete stroke work-up. We did not include cases admitted during the 3-month training period.

Flowchart of the study population. Patients were referred to the emergency department (ED) of Vilnius University Hospital by emergency medical services (EMS) between March 1, 2019 and March 15, 2020.

Interactive EMS Training

Twelve 2-h interactive prehospital stroke recognition training sessions were held in the Neurology Department of VUH over 3 months (from September to November 2019). Interactive training sessions were given by stroke neurologists from the Lithuanian Stroke Association. Each training session was limited to 20 EMS staff members. In total, 166 out of 331 (50.2%) paramedics working in our stroke network participated in the training. The training curriculum was based on the publicly available ANGELS initiative's e-learning course for stroke education for emergency medical teams 4 adapted for local needs and in-person delivery (available online 5 ). The EMS stroke training covered stroke epidemiology, pathophysiology, acute stroke treatment, and outcomes, emphasizing the time-sensitive aspects of acute stroke care. The EMS staff was trained to recognize stroke with the FAST test and identify the major stroke syndromes and stroke mimics. Additionally, participants received an update on prehospital acute stroke management. The presentation emphasized the importance of last known well (LKW) documentation, glucose check, minimizing the on-scene time, and hospital prenotification, followed by an interactive discussion.

Data Collection

Demographic and clinical characteristics such as age, gender, stroke type, daily stroke volume, type of reperfusion therapy, acute stroke care timeliness metrics (onset-to-door, door-to-needle, door-to-groin), and the National Institutes of Health Stroke Scale (NIHSS) scores at admission and discharge were collected for all confirmed strokes and stroke alerts referred by EMS. True positives were defined as EMS-suspected strokes followed by in-hospital confirmation of stroke (ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage) or TIA after a complete neurologic evaluation, including neuroimaging by CT or MRI. False positives, or stroke mimics, were defined as stroke alerts given an alternative diagnosis after a full assessment. Furthermore, we collected information on false negative cases, termed stroke chameleons. The NIHSS score was documented only for patients who were considered for reperfusion therapy.

Statistical Analysis

We compared categorical variables using the χ 2 test and Fisher's exact test, as appropriate. Based on their Gaussian distribution, the quantitative variables were compared using the Student's t -test or Mann–Whitney U test. Baseline characteristics and outcome measures were compared before and after the training and based on EMS location strata (urban vs . suburban). The 95% confidence intervals (CI) were calculated, where applicable.

Before the training, baseline trends in monthly EMS performance and hospital-based outcomes were assessed using univariate linear regression and the χ 2 test for trend. We performed multivariable logistic regression models to assess the association between the training and EMS performance and in-hospital outcome measures. To account for potential confounding effects of age, gender, EMS location, and stroke subtype where appropriate, we used the hybrid backward/forward stepwise selection using the Akaike information criterion ( 26 ), removing variables with a nonsignificant ( p > 0.05) association. Age was forced into all models as an a priori confounder. P < 0.05 (two-sided) was considered statistically significant. IBM SPSS Statistics 23.0 software (IBM Corp., Armonk, NY, United States) and R version 3.6.2 were used for statistical analyses.

We enrolled 916 patients with a median age of 75 (interquartile range: 66–82) years, of which 502 (54.8%) were female. In total, 677 suspected strokes (73.9%) were admitted to the ED, comprising 509 true positives (55.6%) and 168 false positives (18.3%). In contrast, EMS did not recognize 239 (26.1%) strokes, labeled false negatives or stroke chameleons. The study groups before and after the training were balanced in terms of demographics, stroke subtype, and baseline NIHSS ( Table 1 ). Urban EMS providers transported 500 patients (54.6%), whereas suburban EMS transported 416 (45.4%).

Baseline characteristics and outcomes of emergency medical services suspected stroke admissions.

IQR, interquartile range; ICH, intracerebral hemorrhage; SAH, subarachnoid hemorrhage; IVT, intravenous thrombolysis; EVT, endovascular treatment; NIHSS, National Institutes of Health Stroke Scale.

† Only patients with established onset of symptoms are included (n = 433).

‡ Baseline (n = 343) and discharge NIHSS (n = 172) are reported only for ischemic stroke patients who were considered for reperfusion therapy .

Demographic and Clinical Characteristics Before and After the Training

More daily stroke alerts (3 [2–4] vs . 2 [1–3], p = 0.002) and confirmed strokes (3 [2–4] vs . 2 [1–3], p <0.001) were observed in the post-training period. However, proportionally fewer patients were eligible for reperfusion therapy (28.8% post-training vs . 37.2% pre-training, p = 0.031) due to a decreased rate of endovascular therapy compared to the pre-training period (9.0% vs . 18.3%, p = 0.001). No significant differences in IVT and combined treatment groups were observed.

The median onset-to-door time (110 [74–196] min vs . 119 [78–205] min, p = 0.606) improved numerically after the training but did not reach statistical significance. The door-to-needle, door-to-groin times, and discharge NIHSS did not differ significantly before and after the stroke training.

We did not identify any trends in EMS performance or prehospital care metrics during the 6 months before the EMS training ( Table 2 ); thus, next, we assessed the impact of EMS training on these metrics.

Trends in emergency medical services performance and hospital-based outcomes during the 6 months before the training.

PPV, positive predictive value; CT, computed tomography; IVT, intravenous thrombolysis.

† Linear regression coefficient for the proportion of cases with each outcome during 1-month intervals.

‡ χ 2 or Fisher's Exact Test for trend, as appropriate .

EMS Training Effect

In the pairwise comparison, the PPV for the identification of acute stroke patients was significantly higher in the post-training period (79.8% [75.1–84.4] vs . 71.8% [67.3–76.3], p = 0.017). Notably, however, the proportion of false negatives and the EMS recognized stroke patients (sensitivity) did not differ before and after the intervention ( Table 3 ). Although there was a weak trend for improvement in door-to-needle times and in-hospital mortality, there was no statistically significant difference in other hospital-based outcomes before and after the EMS training.

Emergency medical services performance and hospital-based outcomes among 916 suspected or confirmed strokes before and after the training.

CI, confidence interval; PPV, positive predictive value; CT, computed tomography; IVT, intravenous thrombolysis.

† Included stroke patients, who underwent reperfusion treatment (n = 203).

‡ Only ischemic stroke patients (n = 606).

§ Only hospitalized stroke patients (n = 636) .

Multivariable logistic regression showed improved odds of stroke identification (PPV) ( Table 4 ), which remained significant after adjusting for age, gender, and EMS location (adjusted odds ratio (aOR) 1.6 [1.1–2.4]). Furthermore, we observed improved odds of patient arrival within 90 min of stroke onset (aOR 1.6 [1.1–2.5]), driven by an improvement in OTD ≤ 90 min time in urban EMS (56.8% [46.4–66.7] post-training vs . 41.1% [33.5–49.0] pre-, p = 0.019).

Logistic regression models showing the association between emergency medical services training and acute stroke care performance measure and hospital-based outcomes.

OR, odds ratio; CI, confidence interval; PPV, positive predictive value; CT, computed tomography; IVT, intravenous thrombolysis.

† Adjusted for age, gender, and EMS location (urban vs. suburban).

‡ Adjusted for age, gender, EMS location, and stroke type.

*P <0.05 .

Urban vs. Suburban EMS

EMS-referred patients from urban and suburban areas did not differ in demographic characteristics, acute stroke types, baseline and discharge stroke severity, and eligibility for reperfusion therapy ( Table 1 ). Although there were more overall daily confirmed strokes referred by urban EMS (1 [1–2] vs . 1 [0–2], p = 0.005), there was no difference in the proportion of suspected strokes vs . total patients transported by urban and suburban EMS; thus, indicating similar suspected stroke prevalence in both groups.

There was no significant baseline difference in PPV values between urban and suburban EMS ( Figure 2 ). However, after the training, the PPV improved in the urban EMS group (84.9% [78.9–90.8] vs . 71.2% [65.1–77.2], p = 0.003), but not in the suburban EMS (75.0% [68.0–82.0] vs . 72.6% [66.0–79.2], p = 0.621). Marginally more stroke chameleons were referred by urban than suburban EMS (35.0% [30.6–39.7] vs . 28.1% [23.5–33.2], p = 0.044), indicating lower sensitivity in the urban EMS group. However, there was no significant difference in sensitivity before and after the training within each EMS group.

Emergency medical services (EMS) performance before and after the EMS training. (A) Positive predictive value (PPV) for identification of stroke patients. (B) Onset-to-door time ≤ 90 min rate stratified by EMS location.

Shorter overall median onset-to-door time was observed in patients referred by urban EMS (93 [67–159] min vs . 137 [89–269] min, p < 0.001), and more urban patients reached the CSC within 90 min (46.9% [40.6–53.2] 25.3% [19.7–31.8], p < 0.001) compared to the suburban EMS. After the training, there was a weak trend for improvement of the absolute onset-to-door time (84.5 min vs . 108.0 min, p = 0.074) and a significant improvement in onset-to-door ≤ 90 min rate in the urban EMS (70.5% [60.2–79.0] vs . 41.1% [33.5–49.0], p = 0.019), but not in the suburban EMS group (28.0% [19.9–37.8] vs . 22.8% [15.7–31.9], p = 0.406) ( Figure 2 ).

We have several main findings from this prospective interrupted time-series study evaluating the effect of interactive EMS training on prehospital stroke care. First, we found a sustained improvement of prehospital stroke recognition during at least four consecutive months after the training. Second, we found an improved rate of timely transfers of suspected strokes to the hospital, demonstrating the overall benefit of EMS training on the continuum of prehospital care. Third, we found a trend of decreased in-hospital mortality that could be related to more timely stroke patient transport to the hospital. Finally, the training effect was more pronounced in the urban EMS group and, thus, we discuss the possible reasons and implications.

We found fewer stroke mimics in the post-training period without an increase in the false negative rate. Thus, increasing the PPV did not result in suboptimal triage of strokes, nor did it deprive stroke patients of time-sensitive revascularization treatment. The improvement of PPV was driven by a reduced rate of stroke mimics in the urban EMS group. One of the reasons for significantly improved PPV in the urban but not the suburban EMS group could be the implementation of new national regulation of prehospital stroke triage on January 1, 2020, that partially overlapped with the post-training period. According to the new law, suspected stroke patients were transferred directly to stroke-ready hubs bypassing primary evaluation in the regional hospitals irrespective of their LKW time. The new guidelines were designed to improve access to reperfusion therapy for stroke patients in the suburban regions. However, the stroke triage pathway change may have increased the false positive rate in the suburban EMS group as they transported more suspected stroke cases directly to the CSC instead of the regional hospitals. Thus, we speculate that the weak trend of PPV improvement in the suburban EMS group reflects the effect of EMS training offsetting the expected dip of PPV in the suburban EMS group. Another possible explanation could be differences in stroke knowledge between urban and suburban paramedics before the training or other variables, such as differing socioeconomic status, comorbidities, or secular trends, not evaluated in this study.

The increase in PPV after the training is clinically relevant because it can help reduce the false positive cases overflowing the acute stroke care pathways. Optimal utilization of the frontline stroke care and neuroimaging resources is particularly relevant during peak hours of stroke incidence, such as the morning hours ( 27 ) or public health emergencies, as was the case during the COVID-19 pandemic ( 23 ). Therefore, continuous efforts are crucial to ensure optimal prehospital stroke identification.

Previous studies have shown that a brief educational EMS intervention could substantially improve EMS knowledge of prehospital stroke scales, prenotification compliance, and field triage protocols ( 10 , 28 ). Moreover, a recent prospective study by Oostema et al. assessed the real-world impact of EMS training on prehospital stroke recognition and found that an online EMS education module coupled with performance feedback was associated with improved stroke recognition sensitivity, increased hospital prenotification, and faster tPA delivery ( 9 ). In addition to these findings, our study demonstrates that in-person interactive EMS training improves prehospital stroke identification and timely transfer to the ED. We also note that the sensitivity in our study did not change after the training, which might be explained by a relatively high baseline performance. The baseline stroke recognition sensitivity in our study (68.0%) was comparable to the post-training sensitivity in the Oostema et al. study (69.5%), suggesting a ceiling effect of stroke sensitivity improvement. Consequently, the improvement in PPV did not result in a false negative rate (type II error) increase and, thus, did not deprive stroke patients of time-sensitive treatment. Similarly, our intervention did not affect the reperfusion therapy rate. Nevertheless, our baseline IVT rate was at least two times higher (15.9%) than in 10 out of 13 studies reported in a recent meta-analysis ( 19 ). Therefore, this suggests interventions had less effect in populations with high baseline performance.

A recent attempt to enhance prehospital stroke care was undertaken in the Paramedic Acute Stroke Treatment Assessment (PASTA), a multicenter randomized clinical trial in the UK. Surprisingly, the intervention resulted in 8.5 min longer onsite care time and did not show any tPA rate improvement ( 17 ). Arguably, sophisticated prehospital assessment protocols did not facilitate IVT decision-making. On the other hand, we find conflicting results from non-randomized intervention studies showing that prehospital intervention improved reperfusion therapy rates ( 11 , 19 ) and in-hospital treatment times ( 9 , 11 ). In addition to the previous studies, our study shows that interactive EMS training can improve stroke recognition and prehospital transfer times and, thus, improve the overall timeliness of acute stroke care. In contrast, we did not observe changes in hospital-based metrics. However, our study was not designed to evaluate the in-hospital performance since we did not collect data on hospital prenotification rate, and the EMS staff was not involved in the clinical care after the ED admission. Other in-hospital variables, such as imaging capacity, availability of rapid image interpretation, and ED workload influence the stroke care but are not accounted for in our study.

The training effect on timely prehospital transportation was more robust in the urban compared to the suburban EMS group. Since transport time from suburban regions is longer due to greater distances between the patient and the CSC, fewer patients could arrive within 90 min of symptom onset. Furthermore, due to the national regulatory changes during the study, all suspected stroke cases were to be transported to stroke-ready hospitals, irrespective of the time of symptom onset. Thus, the number of stroke alerts outside the acute treatment window increased in the suburban but not the urban EMS group. Hence, the actual training effect in the suburban EMS group was confounded by these regulatory changes.

The recent stroke triage changes in Lithuania were aimed to increase EVT access to patients in suburban areas by transporting suspected stroke cases directly to stroke-ready centers. However, the choice between drip and ship or mothership model is context-specific ( 29 ) and poses thorny clinical dilemmas ( 30 ). EVT has a remarkable treatment effect with the number needed to treat of 2.6 to reduce disability in the early hours after stroke onset ( 31 ). If large vessel occlusion (LVO) is suspected, direct transfer to a CSC with EVT capacity might be privileged, as a shorter time to reperfusion would improve the treatment effect ( 32 ). On the other hand, bypassing primary stroke centers with IVT capacity might cause unnecessary delays to IVT and an increase in false positive large vessel occlusion transfers due to suboptimal triage. To address these questions, the RACECAT study was conceived in Catalonia, Spain, a first randomized clinical trial in the field ( ClinicalTrials.gov , identifier: {"type":"clinical-trial","attrs":{"text":"NCT02795962","term_id":"NCT02795962"}} NCT02795962 ). After randomizing 1,401 patients, the preliminary study results showed no difference in ischemic stroke outcomes between drip-and-ship and mothership models in a highly coordinated stroke network ( 33 ). Similarly, in our study, we did not observe any change in IVT rate, whereas surprisingly there was a decrease in EVT rate. However, the comparison of IVT and EVT rates before and after the training should be made with caution. The post-training period coincides with the increased transfer rate of suspected suburban stroke cases with elongated LKW, resulting in a higher number of strokes arriving at the CSC beyond the EVT window. Another explanation could be a cyclical variation in EVT eligible cases. Nevertheless, since all stroke alerts were analyzed, the regulation change was not expected to confound the comparison of EMS stroke recognition. Future studies should evaluate the impact of the triage regulation change on reperfusion therapy accessibility and stroke outcomes that was out of scope of the current study.

Although the direct transfer to the CSC could be most beneficial for LVO patients, the FAST scale used in our study was not explicitly designed to detect LVO. In this context, a prospective study comparing eight prehospital scales for LVO identification showed that an adapted version of Gaze-Face-Arm-Speech-Time (G-FAST) had high LVO recognition accuracy similar or higher to other LVO scores ( 34 ). Moreover, improving the PPV of the stroke screening tools can increase the area where the mothership model provides the best stroke treatment outcome ( 29 ). More studies will be needed to explore the optimal LVO prediction methods to triage patients for different transfer pathways.

The main strength of our study is a prospective design and relatively large sample size. The blinding of EMS staff to the assessment allowed us to evaluate the training effect and avoid the apprehension bias, also known as the Hawthorne effect, when participants modify their behavior in response to their awareness of being observed ( 35 ). The main limitation of our study was the absence of a control group to fully evaluate the actual effect of the intervention. However, since there were no significant differences in demographic and clinical characteristics of suspected stroke cases before and after the training, the confounding by unmeasured factors was limited. Also, the overlap between the first month before and the last month after the training allowed us to compare similar calendar periods. Second, due to optional attendance, just over half of the EMS staff underwent the training. However, this rather introduces a bias toward the null, and we expect a stronger training effect with higher participation. Third, we found increased daily stroke rates in the post-training period, influenced by the change in the stroke triage regulations in suburban regions. However, the marginal increase in stroke prevalence during the post-training period could not fully explain the PPV improvement. We observed improved PPV with non-overlapping CI in the urban EMS and a weak trend in the suburban group favoring a consistent effect of EMS training across both groups. Fourth, our intervention did not target the dispatcher stroke recognition or hospital prenotification rate; thus, the inclusion of additional actors in the intervention might further improve the prehospital stroke care. Fifth, due to the emerging COVID-19 pandemic, we terminated our analysis before the national lockdown which significantly limited access to urgent and non-urgent healthcare ( 23 ). Had the study been continued and more cases were included in the post-training period, we could have expected a more significant effect on the in-hospital mortality. Also, we could not conclude on the long-term effects of the training beyond four months. Finally, our study was conducted in a very high cardiovascular risk population ( 20 ). These findings are generalizable to currently underrepresented populations with similar healthcare systems and EMS staffing patterns, including but not limited to Baltic states and Eastern European countries. Therefore, this study could inform prehospital clinical care and study design to improve prehospital stroke workflow using publicly available e-learning stroke education resources.

Interactive EMS training improved the prehospital stroke recognition that was maintained during at least four consecutive months. Consequently, we found a measurable improvement in prehospital stroke transfer metrics and a trend toward decreased in-hospital mortality providing evidence for EMS training's positive effect on overall acute stroke care. The EMS training effect was more robust in the urban than the suburban EMS group. Thus, context-tailored training programs should be considered for EMS providers in different locations. Future studies should evaluate the long-term effects of the EMS training on prehospital stroke care, hospital-related outcomes, and aim to determine optimal retraining intervals.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Vilnius Regional Bioethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

LS, KM, DJ, AV, and RM: conception and design of the research. KM and RM: acquisition of the data. LS, KM, and RM: analysis and interpretation of the data and drafting the manuscript. LS, KM, AW, AV, KP, ES, KJ, AE, DJ, and RM: critical revision of the manuscript. All authors approved the final version to be published.

Boehringer Ingelheim GmbH & Co KG Lithuania covered the relevant training expenses.

Conflict of Interest

This study received funding from Boehringer Ingelheim GmbH & Co KG Lithuania. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit for publication. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We greatly acknowledge the EMS staff for taking part in the training. LS was supported by the Swiss National Science Foundation postdoctoral scholarship (P2GEP3_191584). This article/publication is based on work from the IRENE COST Action—Implementation Research Network in Stroke Care Quality (CA18118), supported by COST (European Cooperation in Science and Technology; www.cost.eu ).

1 Lithuanian Department of Statistics. (2020). Statistics Lithuania. Available at: https://www.stat.gov.lt/home [Accessed December 12, 2020].

2 Institute of Hygiene, Ministry of Health of The Republic of Lithuania. (2019). Health and Healthcare Institutions in Lithuania. https://hi.lt/uploads/pdf/leidiniai/Statistikos/LT_gyv_sveikata/leid2019.pdf [Accessed June 21, 2021].

3 Ministry of Health of The Republic of Lithuania. (2019). The Statement on Acute Stroke Work-up and Management Guideline Change. https://e-seimas.lrs.lt/portal/legalAct/lt/TAD/24591240ff0411e993cb8c8daaf8ff8a [Accessed June 21, 2021].

4 Angels Initiative. (2020). The Advanced Stroke Life Support e-Learning. https://www.angels-initiative.com/academy/emergency-services/advanced-stroke-life-support [Accessed June 21, 2021].

5 Lietuvos insulto asociacija. (2020). Informacija gydytojams. Available at: http://www.insultoasociacija.lt/index.php/profesionalams/gydytojams [Accessed June 15, 2021].

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• Volume 13, Issue 8
• Clinical course of a 66-year-old man with an acute ischaemic stroke in the setting of a COVID-19 infection
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• http://orcid.org/0000-0002-7441-6952 Saajan Basi 1 , 2 ,
• Mohammad Hamdan 1 and
• Shuja Punekar 1
• 1 Department of Stroke and Acute Medicine , King's Mill Hospital , Sutton-in-Ashfield , UK
• 2 Department of Acute Medicine , University Hospitals of Derby and Burton , Derby , UK
• Correspondence to Dr Saajan Basi; saajan.basi{at}nhs.net

A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater oxygen requirement, alongside reduced levels of consciousness. A positive COVID-19 throat swab, in addition to bilateral pneumonia on chest X-ray and lymphopaenia in his blood tests, confirmed a diagnosis of COVID-19 pneumonia. A proactive decision was made involving the patients’ family, ward and intensive care healthcare staff, to not escalate care above a ward-based ceiling of care. The patient died 5 days following admission under the palliative care provided by the medical team.

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• infectious diseases
• global health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bcr-2020-235920

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SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is a new strain of coronavirus that is thought to have originated in December 2019 in Wuhan, China. In a matter of months, it has erupted from non-existence to perhaps the greatest challenge to healthcare in modern times, grinding most societies globally to a sudden halt. Consequently, the study and research into SARS-CoV-2 is invaluable. Although coronaviruses are common, SARS-CoV-2 appears to be considerably more contagious. The WHO figures into the 2003 SARS-CoV-1 outbreak, from November 2002 to July 2003, indicate a total of 8439 confirmed cases globally. 1 In comparison, during a period of 4 months from December 2019 to July 2020, the number of global cases of COVID-19 reached 10 357 662, increasing exponentially, illustrating how much more contagious SARS-CoV-2 has been. 2

Previous literature has indicated infections, and influenza-like illness have been associated with an overall increase in the odds of stroke development. 3 There appears to be a growing correlation between COVID-19 positive patients presenting to hospital with ischaemic stroke; however, studies investigating this are in progress, with new data emerging daily. This patient report comments on and further characterises the link between COVID-19 pneumonia and the development of ischaemic stroke. At the time of this patients’ admission, there were 95 positive cases from 604 COVID-19 tests conducted in the local community, with a predicted population of 108 000. 4 Only 4 days later, when this patient died, the figure increased to 172 positive cases (81% increase), illustrating the rapid escalation towards the peak of the pandemic, and widespread transmission within the local community ( figure 1 ). As more cases of ischaemic stroke in COVID-19 pneumonia patients arise, the recognition and understanding of its presentation and aetiology can be deciphered. Considering the virulence of SARS-CoV-2 it is crucial as a global healthcare community, we develop this understanding, in order to intervene and reduce significant morbidity and mortality in stroke patients.

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A graph showing the number of patients with COVID-19 in the hospital and in the community over time.

Case presentation

A 66-year-old man presented to the hospital with signs of left-sided weakness. The patient had a background of chronic obstructive pulmonary disease (COPD), atrial fibrillation and had one previous ischaemic stroke, producing left-sided haemiparesis, which had completely resolved. He was a non-smoker and lived in a house. The patient was found slumped over on the sofa at home on 1 April 2020, by a relative at approximately 01:00, having been seen to have no acute medical illness at 22:00. The patients’ relative initially described disorientation and agitation with weakness noted in the left upper limb and dysarthria. At the time of presentation, neither the patient nor his relative identified any history of fever, cough, shortness of breath, loss of taste, smell or any other symptoms; however, the patient did have a prior admission 9 days earlier with shortness of breath.

The vague nature of symptoms, entwined with considerable concern over approaching the hospital, due to the risk of contracting COVID-19, created a delay in the patients’ attendance to the accident and emergency department. His primary survey conducted at 09:20 on 1 April 2020 demonstrated a patent airway, with spontaneous breathing and good perfusion. His Glasgow Coma Scale (GCS) score was 15 (a score of 15 is the highest level of consciousness), his blood glucose was 7.2, and he did not exhibit any signs of trauma. His abbreviated mental test score was 7 out of 10, indicating a degree of altered cognition. An ECG demonstrated atrial fibrillation with a normal heart rate. His admission weight measured 107 kg. At 09:57 the patient required 2 L of nasal cannula oxygen to maintain his oxygen saturations between 88% and 92%. He started to develop agitation associated with an increased respiratory rate at 36 breaths per minute. On auscultation of his chest, he demonstrated widespread coarse crepitation and bilateral wheeze. Throughout he was haemodynamically stable, with a systolic blood pressure between 143 mm Hg and 144 mm Hg and heart rate between 86 beats/min and 95 beats/min. From a neurological standpoint, he had a mild left facial droop, 2/5 power in both lower limbs, 2/5 power in his left upper limb and 5/5 power in his right upper limb. Tone in his left upper limb had increased. This patient was suspected of having COVID-19 pneumonia alongside an ischaemic stroke.

Investigations

A CT of his brain conducted at 11:38 on 1 April 2020 ( figure 2 ) illustrated an ill-defined hypodensity in the right frontal lobe medially, with sulcal effacement and loss of grey-white matter. This was highly likely to represent acute anterior cerebral artery territory infarction. Furthermore an oval low-density area in the right cerebellar hemisphere, that was also suspicious of an acute infarction. These vascular territories did not entirely correlate with his clinical picture, as limb weakness is not as prominent in anterior cerebral artery territory ischaemia. Therefore this left-sided weakness may have been an amalgamation of residual weakness from his previous stroke, in addition to his acute cerebral infarction. An erect AP chest X-ray with portable equipment ( figure 3 ) conducted on the same day demonstrated patchy peripheral consolidation bilaterally, with no evidence of significant pleural effusion. The pattern of lung involvement raised suspicion of COVID-19 infection, which at this stage was thought to have provoked the acute cerebral infarct. Clinically significant blood results from 1 April 2020 demonstrated a raised C-reactive protein (CRP) at 215 mg/L (normal 0–5 mg/L) and lymphopaenia at 0.5×10 9 (normal 1×10 9 to 3×10 9 ). Other routine blood results are provided in table 1 .

CT imaging of this patients’ brain demonstrating a wedge-shaped infarction of the anterior cerebral artery territory.

Chest X-ray demonstrating the bilateral COVID-19 pneumonia of this patient on admission.

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Clinical biochemistry and haematology blood results of the patient

Interestingly the patient, in this case, was clinically assessed in the accident and emergency department on 23 March 2020, 9 days prior to admission, with symptoms of shortness of breath. His blood results from this day showed a CRP of 22 mg/L and a greater lymphopaenia at 0.3×10 9 . He had a chest X-ray ( figure 4 ), which indicated mild radiopacification in the left mid zone. He was initially treated with intravenous co-amoxiclav and ciprofloxacin. The following day he had minimal symptoms (CURB 65 score 1 for being over 65 years). Given improving blood results (declining CRP), he was discharged home with a course of oral amoxicillin and clarithromycin. As national governmental restrictions due to COVID-19 had not been formally announced until 23 March 2020, and inconsistencies regarding personal protective equipment training and usage existed during the earlier stages of this rapidly evolving pandemic, it is possible that this patient contracted COVID-19 within the local community, or during his prior hospital admission. It could be argued that the patient had early COVID-19 signs and symptoms, having presented with shortness of breath, lymphopaenia, and having had subtle infective chest X-ray changes. The patient explained he developed a stagnant productive cough, which began 5 days prior to his attendance to hospital on 23 March 2020. He responded to antibiotics, making a full recovery following 7 days of treatment. This information does not assimilate with the typical features of a COVID-19 infection. A diagnosis of community-acquired pneumonia or infective exacerbation of COPD seem more likely. However, given the high incidence of COVID-19 infections during this patients’ illness, an exposure and early COVID-19 illness, prior to the 23 March 2020, cannot be completely ruled out.

Chest X-ray conducted on prior admission illustrating mild radiopacification in the left mid zone.

On the current admission, this patient was managed with nasal cannula oxygen at 2 L. By the end of the day, this had progressed to a venturi mask, requiring 8 L of oxygen to maintain oxygen saturation. He had also become increasingly drowsy and confused, his GCS declined from 15 to 12. However, the patient was still haemodynamically stable, as he had been in the morning. An arterial blood gas demonstrated a respiratory alkalosis (pH 7.55, pCO 2 3.1, pO 2 6.7 and HCO 3 24.9, lactate 1.8, base excess 0.5). He was commenced on intravenous co-amoxiclav and ciprofloxacin, to treat a potential exacerbation of COPD. This patient had a COVID-19 throat swab on 1 April 2020. Before the result of this swab, an early discussion was held with the intensive care unit staff, who decided at 17:00 on 1 April 2020 that given the patients presentation, rapid deterioration, comorbidities and likely COVID-19 diagnosis he would not be for escalation to the intensive care unit, and if he were to deteriorate further the end of life pathway would be most appropriate. The discussion was reiterated to the patients’ family, who were in agreement with this. Although he had evidence of an ischaemic stroke on CT of his brain, it was agreed by all clinicians that intervention for this was not as much of a priority as providing optimal palliative care, therefore, a minimally invasive method of treatment was advocated by the stroke team. The patient was given 300 mg of aspirin and was not a candidate for fibrinolysis.

Outcome and follow-up

The following day, before the throat swab result, had appeared the patient deteriorated further, requiring 15 L of oxygen through a non-rebreather face mask at 60% FiO 2 to maintain his oxygen saturation, at a maximum of 88% overnight. At this point, he was unresponsive to voice, with a GCS of 5. Although, he was still haemodynamically stable, with a blood pressure of 126/74 mm Hg and a heart rate of 98 beats/min. His respiratory rate was 30 breaths/min. His worsening respiratory condition, combined with his declining level of consciousness made it impossible to clinically assess progression of the neurological deficit generated by his cerebral infarction. Moreover, the patient was declining sharply while receiving the maximal ward-based treatment available. The senior respiratory physician overseeing the patients’ care decided that a palliative approach was in this his best interest, which was agreed on by all parties. The respiratory team completed the ‘recognising dying’ documentation, which signified that priorities of care had shifted from curative treatment to palliative care. Although the palliative team was not formally involved in the care of the patient, the patient received comfort measures without further attempts at supporting oxygenation, or conduction of regular clinical observations. The COVID-19 throat swab confirmed a positive result on 2 April 2020. The patient was treated by the medical team under jurisdiction of the hospital palliative care team. This included the prescribing of anticipatory medications and a syringe driver, which was established on 3 April 2020. His antibiotic treatment, non-essential medication and intravenous fluid treatment were discontinued. His comatose condition persisted throughout the admission. Once the patients’ GCS was 5, it did not improve. The patient was pronounced dead by doctors at 08:40 on 5 April 2020.

SARS-CoV-2 is a type of coronavirus that was first reported to have caused pneumonia-like infection in humans on 3 December 2019. 5 As a group, coronaviruses are a common cause of upper and lower respiratory tract infections (especially in children) and have been researched extensively since they were first characterised in the 1960s. 6 To date, there are seven coronaviruses that are known to cause infection in humans, including SARS-CoV-1, the first known zoonotic coronavirus outbreak in November 2002. 7 Coronavirus infections pass through communities during the winter months, causing small outbreaks in local communities, that do not cause significant mortality or morbidity.

SARS-CoV-2 strain of coronavirus is classed as a zoonotic coronavirus, meaning the virus pathogen is transmitted from non-humans to cause disease in humans. However the rapid spread of SARS-CoV-2 indicates human to human transmission is present. From previous research on the transmission of coronaviruses and that of SARS-CoV-2 it can be inferred that SARS-CoV-2 spreads via respiratory droplets, either from direct inhalation, or indirectly touching surfaces with the virus and exposing the eyes, nose or mouth. 8 Common signs and symptoms of the COVID-19 infection identified in patients include high fevers, severe fatigue, dry cough, acute breathing difficulties, bilateral pneumonia on radiological imaging and lymphopaenia. 9 Most of these features were identified in this case study. The significance of COVID-19 is illustrated by the speed of its global spread and the potential to cause severe clinical presentations, which as of April 2020 can only be treated symptomatically. In Italy, as of mid-March 2020, it was reported that 12% of the entire COVID-19 positive population and 16% of all hospitalised patients had an admission to the intensive care unit. 10

The patient, in this case, illustrates the clinical relevance of understanding COVID-19, as he presented with an ischaemic stroke underlined by minimal respiratory symptoms, which progressed expeditiously, resulting in acute respiratory distress syndrome and subsequent death.

Our case is an example of a new and ever-evolving clinical correlation, between patients who present with a radiological confirmed ischaemic stroke and severe COVID-19 pneumonia. As of April 2020, no comprehensive data of the relationship between ischaemic stroke and COVID-19 has been published, however early retrospective case series from three hospitals in Wuhan, China have indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke. 11 These studies have not yet undergone peer review, but they tell us a great deal about the relationship between COVID-19 and ischaemic stroke, and have been used to influence the American Heart Associations ‘Temporary Emergency Guidance to US Stroke Centres During the COVID-19 Pandemic’. 12

The relationship between similar coronaviruses and other viruses, such as influenza in the development of ischaemic stroke has previously been researched and provide a basis for further investigation, into the prominence of COVID-19 and its relation to ischaemic stroke. 3 Studies of SARS-CoV-2 indicate its receptor-binding region for entry into the host cell is the same as ACE2, which is present on endothelial cells throughout the body. It may be the case that SARS-CoV-2 alters the conventional ability of ACE2 to protect endothelial function in blood vessels, promoting atherosclerotic plaque displacement by producing an inflammatory response, thus increasing the risk of ischaemic stroke development. 13

Other hypothesised reasons for stroke development in COVID-19 patients are the development of hypercoagulability, as a result of critical illness or new onset of arrhythmias, caused by severe infection. Some case studies in Wuhan described immense inflammatory responses to COVID-19, including elevated acute phase reactants, such as CRP and D-dimer. Raised D-dimers are a non-specific marker of a prothrombotic state and have been associated with greater morbidity and mortality relating to stroke and other neurological features. 14

Arrhythmias such as atrial fibrillation had been identified in 17% of 138 COVID-19 patients, in a study conducted in Wuhan, China. 15 In this report, the patient was known to have atrial fibrillation and was treated with rivaroxaban. The acute inflammatory state COVID-19 is known to produce had the potential to create a prothrombotic environment, culminating in an ischaemic stroke.

Some early case studies produced in Wuhan describe patients in the sixth decade of life that had not been previously noted to have antiphospholipid antibodies, contain the antibodies in blood results. They are antibodies signify antiphospholipid syndrome; a prothrombotic condition. 16 This raises the hypothesis concerning the ability of COVID-19 to evoke the creation of these antibodies and potentiate thrombotic events, such as ischaemic stroke.

No peer-reviewed studies on the effects of COVID-19 and mechanism of stroke are published as of April 2020; therefore, it is difficult to evidence a specific reason as to why COVID-19 patients are developing neurological signs. It is suspected that a mixture of the factors mentioned above influence the development of ischaemic stroke.

If we delve further into this patients’ comorbid state exclusive to COVID-19 infection, it can be argued that this patient was already at a relatively higher risk of stroke development compared with the general population. The fact this patient had previously had an ischaemic stroke illustrates a prior susceptibility. This patient had a known background of hypertension and atrial fibrillation, which as mentioned previously, can influence blood clot or plaque propagation in the development of an acute ischaemic event. 15 Although the patient was prescribed rivaroxaban as an anticoagulant, true consistent compliance to rivaroxaban or other medications such as amlodipine, clopidogrel, candesartan and atorvastatin cannot be confirmed; all of which can contribute to the reduction of influential factors in the development of ischaemic stroke. Furthermore, the fear of contracting COVID-19, in addition to his vague symptoms, unlike his prior ischaemic stroke, which demonstrated dense left-sided haemiparesis, led to a delay in presentation to hospital. This made treatment options like fibrinolysis unachievable, although it can be argued that if he was already infected with COVID-19, he would have still developed life-threatening COVID-19 pneumonia, regardless of whether he underwent fibrinolysis. It is therefore important to consider that if this patient did not contract COVID-19 pneumonia, he still had many risk factors that made him prone to ischaemic stroke formation. Thus, we must consider whether similar patients would suffer from ischaemic stroke, regardless of COVID-19 infection and whether COVID-19 impacts on the severity of the stroke as an entity.

Having said this, the management of these patients is dependent on the likelihood of a positive outcome from the COVID-19 infection. Establishing the ceiling of care is crucial, as it prevents incredibly unwell or unfit patients’ from going through futile treatments, ensuring respect and dignity in death, if this is the likely outcome. It also allows for the provision of limited or intensive resources, such as intensive care beds or endotracheal intubation during the COVID-19 pandemic, to those who are assessed by the multidisciplinary team to benefit the most from their use. The way to establish this ceiling of care is through an early multidisciplinary discussion. In this case, the patient did not convey his wishes regarding his care to the medical team or his family; therefore it was decided among intensive care specialists, respiratory physicians, stroke physicians and the patients’ relatives. The patient was discussed with the intensive care team, who decided that as the patient sustained two acute life-threatening illnesses simultaneously and had rapidly deteriorated, ward-based care with a view to palliate if the further deterioration was in the patients’ best interests. These decisions were not easy to make, especially as it was on the first day of presentation. This decision was made in the context of the patients’ comorbidities, including COPD, the patients’ age, and the availability of intensive care beds during the steep rise in intensive care admissions, in the midst of the COVID-19 pandemic ( figure 1 ). Furthermore, the patients’ rapid and permanent decline in GCS, entwined with the severe stroke on CT imaging of the brain made it more unlikely that significant and permanent recovery could be achieved from mechanical intubation, especially as the damage caused by the stroke could not be significantly reversed. As hospitals manage patients with COVID-19 in many parts of the world, there may be tension between the need to provide higher levels of care for an individual patient and the need to preserve finite resources to maximise the benefits for most patients. This patient presented during a steep rise in intensive care admissions, which may have influenced the early decision not to treat the patient in an intensive care setting. Retrospective studies from Wuhan investigating mortality in patients with multiple organ failure, in the setting of COVID-19, requiring intubation have demonstrated mortality can be up to 61.5%. 17 The mortality risk is even higher in those over 65 years of age with respiratory comorbidities, indicating why this patient was unlikely to survive an admission to the intensive care unit. 18

Regularly updating the patients’ family ensured cooperation, empathy and sympathy. The patients’ stroke was not seen as a priority given the severity of his COVID-19 pneumonia, therefore the least invasive, but most appropriate treatment was provided for his stroke. The British Association of Stroke Physicians advocate this approach and also request the notification to their organisation of COVID-19-related stroke cases, in the UK. 19

Learning points

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is one of seven known coronaviruses that commonly cause upper and lower respiratory tract infections. It is the cause of the 2019–2020 global coronavirus pandemic.

The significance of COVID-19 is illustrated by the rapid speed of its spread globally and the potential to cause severe clinical presentations, such as ischaemic stroke.

Early retrospective data has indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke.

Potential mechanisms behind stroke in COVID-19 patients include a plethora of hypercoagulability secondary to critical illness and systemic inflammation, the development of arrhythmia, alteration to the vascular endothelium resulting in atherosclerotic plaque displacement and dehydration.

It is vital that effective, open communication between the multidisciplinary team, patient and patients relatives is conducted early in order to firmly establish the most appropriate ceiling of care for the patient.

• Cannine M , et al
• Wunderink RG
• van Doremalen N ,
• Bushmaker T ,
• Morris DH , et al
• Wang X-G , et al
• Grasselli G ,
• Pesenti A ,
• Wang M , et al
• American Stroke Assocation, 2020
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• Zhang Y-huan ,
• Dong X-F , et al
• Li X , et al
• Hu C , et al
• Zhang S , et al
• Jiang B , et al
• Xu J , et al
• British Association of Stroke Physicians

Contributors SB was involved in the collecting of information for the case, the initial written draft of the case and researching existing data on acute stroke and COVID-19. He also edited drafts of the report. MH was involved in reviewing and editing drafts of the report and contributing new data. SP oversaw the conduction of the project and contributed addition research papers.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Next of kin consent obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

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Redefining stroke alerts: The case for a CT alert

Reframe your thinking to get patients with atypical neurologic emergency symptoms immediate care.

Photo/Getty Images

By Patrick D. Horan Jr

In the time it takes you to read this article, at least one person will have died from a stroke. Strokes are the second leading cause of death in the U.S..

We have taken great strides to educate healthcare professionals, prehospital providers and lay persons to recognize the signs and symptoms of a stroke. If someone presents to a stroke center either by way of EMS or by self presentation with a positive Cincinnati, NIH or some other stroke scale, they are then typically classified as a stroke alert case and receive (rightfully so) preferential treatment including a rapid CT.

The cogs are ever turning when it comes to stroke care. Providers surround the patient and perform a wave of testing including a point-of-care glucose, neurological assessment, and pull a series of lab values.

A CT scan of a suspected stroke patient is paramount in determining the best treatments for these patients. Do we administer Tenecteplase, initiate thrombectomy or simply monitor the patient? Is the patient even having a stroke? It all begins with one of my favorite diagnostic instruments, the “donut of truth,” AKA the CT scanner.

But I believe we have pigeonholed ourselves with the nomenclature that is the “stroke alert.” While I cannot speak for every hospital system in the United States, I will say that typically, patients require a positive stroke assessment to initiate a stroke alert. I believe we are doing a disservice to our patients. There are a myriad of patients having neurological emergencies, including strokes, that present atypically (including a normal stroke assessment). These patients are clearly in desperate need of emergent neurological care and a CT scan, but alas, without that positive scale, they do not qualify for an alert.

Case study: Atypical symptoms

Let’s consider the following case.

David is a 33-year-old male with a fairly unremarkable medical history. David works as a healthcare provider, is overweight and works swing shift. He takes no medications and only complains about seasonal allergies. David woke up one morning and noticed that his vision in his right eye was exceptionally fuzzy. The night before, he attributed fuzziness in both eyes to allergies. This morning, his vision was getting worse but he needed to proctor a BLS exam so he proceeded to leave and teach the course. Over the next 4 hours, the vision would go from fuzzy to complete darkness, isolated to the right eye. Now, David is no slouch – he knew the common signs and symptoms of a stroke and even several atypical symptoms, but something impacting the right eye? Is that possible? His significant other (also a healthcare provider) evaluated the eye and immediately noticed something concerning. David had anisocoria and relative afferent pupillary defect to the right eye and the right eye only. Ultimately, David agreed to be evaluated in the emergency department. It’s important to note even at this point, David refused to believe that this was some life-altering emergency, thinking his symptoms were perhaps allergies a detached retina. As David approached the hospital, reality began to set in.

Looking at the case study above you can see, probably better than David, that he is clearly experiencing a neurological emergency. The concern for many of you rightfully should be the question – is this a stroke? Or, more aptly, did the blood flow to the right eye get disrupted? If David was your patient, would you call a stroke alert?

Could you call a stroke alert in this circumstance? Often, protocols are written to require a positive stroke exam to trigger an alert. The included table shows David’s score for various stroke tests used in the U.S. You may notice that he was negative for almost every test with a score of 2 for NIH.

Limiting delays to care

I think we can also agree that David may have been having a disruption of blood flow through the ophthalmic artery and warranted further investigation. David could also have been suffering from a retinal detachment, ocular trauma, glaucoma, cataracts, retinopathy from diabetes, cancer and so much more. But one thing is for certain, with many of those conditions being time-sensitive, life-altering conditions, David needed a thorough physical exam and a trip to CT.

So, I ask again, would you consult with medical control and advocate for the stroke alert? Better yet, can we as a collective change the way we view neurological emergencies and our approach to patient care by making the stroke alert a CT alert? A high-performance stroke team will have a flow designed to minimize time before getting a scan and limiting delays to care. Why do we reserve this for only the most obvious of strokes?

Changing the name of the alert serves more than just crossing out the name and replacing it with a CT alert. We need to change the way we approach neurological emergencies and give these patients the priority access to CT they need.

David did not trigger a classic stroke, alert. Once he arrived at the hospital, he was registered, and sat in the waiting room for an hour before he was evaluated by an advanced practice provider. The triage nurse and the APP discussed their concerns and ultimately requested an attending physician to weigh in on the matter. Providers became increasingly concerned, finally agreeing that they needed to get David to CT and they needed to do so quickly. Each one of those providers were deeply concerned about their assessment findings and believed David was having a major neurological emergency, but they were faced with the atypical and had to navigate policy and procedure to make the right care happen.

The most efficient way to get David to CT was to call a stroke alert to activate the appropriate protocols.

Once again, I ask that you, as a healthcare professional, change your thought process. Change the way you think about neurological emergencies. By requiring strict criteria to call a stroke alert, we stand to miss more emergencies than we catch. Advocate for your patient and advocate that they get the care they need.

David received his CT and experienced some world class stroke care. Ultimately, it was determined David had a demyelinating disease that resulted in the right eye blindness. He has since regained some vision and returned to work. It all started with recognizing the neurological emergency and even more importantly, recognizing that we needed to rule out the most time-sensitive, life-altering emergencies first, which starts with the patient getting a CT alert.

When a Stroke is Not a Stroke: A Case Study

Stroke Mimics

There are patients, though, that present with stroke-like signs and symptoms that are unrelated to a stroke. This is called a stroke mimic. Mimics account for 20-25% of suspected stroke presentations, occurring frequently in patients under 50 years old. 6,7 Many studies acknowledge that a decreased level of consciousness, a loss of intellectual function such as concentration, thinking, remembering, or reasoning, and normal eye movements are predictors of a stroke mimic .4 One particular study explained patients that present with a stroke mimic are younger and, more likely, female. None of these patients had a history of stroke risk factors, such as atrial fibrillation, hypertension, hyperlipidemia, obesity, renal failure, had smoked, or a poor diet. 5, 8    

There are many conditions that can mimic a stroke: sepsis, syncope, intracranial tumor, conversion, and factitious disorder, Bell’s palsy, or previous facial trauma. An acronym that addresses the most common mimics is HEMI.

H:  Hypoglycemia/Hyperglycemia

E:   Epilepsy (seizure)

M: Multiple sclerosis /hemiplegic migraine

I:    Infections – meningitis, encephalitis, labyrinthitis, and abscesses

Stroke Mimic Case Study

EMTs examine a 50-year-old female experiencing a possible stroke. She is aware of the EMTs’ presence and oriented to date, day, time, and place. The primary assessment reveals no compromise in airway, breathing, or circulatory. A head-to-toe physical exam identifies: no head/neck trauma; bilaterally round and briskly reactive pupils, but the patient’s right eye is excessively tearing and she can’t move the eyelid; no JVD; anterior and posterior lung fields are clear with equal right and left-sided chest rise; abdomen is soft and non-distended; upper and lower extremities exhibit intact sensation, gross limb movement, and fine motor response. As a precaution, a Cincinnati Stroke Scale exam is performed. The patient is positive for slurred speech and complete right-sided facial droop, but negative for arm drift.  Vital signs: HR = 90, regular; RR = 16/min, normal depth; BP = 148/76 mmHg; SpO 2 = 98% room air; CO 2 = 39 mmHg; Temperature = 98.8 o F; Blood capillary glucose = 95 mg/dL.

Is she having a stroke, or is it a mimic? The EMS crew could speculate the possibilities, yet an important component of the assessment is still missing – a thorough patient history, ideally obtained from her.

When questioned, she states her right ear began hurting yesterday during breakfast, then she lost all sense of taste. Furthermore, her right eye has been tearing non-stop. This morning, the right ear hurt less but started ringing. Slurred speech and facial droop were still present. She says she takes hydrochlorothiazide, as prescribed, and has been taking an over-the-counter cold medication for the past three days.

History gathering is vital when differentiating a stroke mimic from a stroke. This patient’s two-day right-sided facial hemiparalysis, excessive tearing, tinnitus, loss of taste, and an intact extremity motor examination, leads the EMTs to suspect the patient is not experiencing a stroke. The crew transports the patient to a stroke center for definitive diagnosis, which later is confirmed as Bell’s palsy.

Conclusions

Stroke mimics are common. Differentiation between a stroke and a stroke mimic is difficult because of overlapping clinical presentations. This is even more challenging in the prehospital environment, due to the lack of diagnostic equipment. Ensuring the best patient outcome requires EMS professionals to conduct a thorough history and physical examination, and utilize all appropriate available tools. Suspected stroke mimics should be managed appropriately, but if in doubt, always expedite transport to the nearest stroke center.

• Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2009. CDC Wonder Online Database, Compiled for Compressed Mortality File 1999–2009 Series 20, No. 20, 2012. Underlying Cause-of-Death 1999–2009. wonder.cdc.gov/Mortsql.Html. Accessed June 1, 2015.
• Kochanek KD, Xu JQ, Murphy SL, et al. Mortality in the United States, 2013. NCHS Data Brief, No. 178. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, US Dept. of Health and Human Services; 2014.
• Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying cause of death, 1999-2016. CDC WONDER Online Database [database online]. Released January 2013. Atlanta, GA: Centers for Disease Control and Prevention. https://wonder.cdc.gov/ucd-icd10.html .
• Libman RB, Wirkowski E, Alvir J, et al. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. 1995;52:1119-1122.
• Merino JG, Luby M, Benson RT, et al. Predictors of acute stroke mimics in 8187 patients referred to a stroke service. J Stroke Cerebrovasc Dis. 2013;22:e397–e403
• Fernandes PM, Whiteley WN, Hart SR, et al Strokes: mimics and chameleons Practical Neurology 2013;13:21-28.
• Segal, J., Lam, A., Dubrey, S. W., & Vasileiadis, E. (2012). Stroke mimic: an interesting case of repetitive conversion disorder. BMJ case reports, 2012, bcr2012007556. doi:10.1136/bcr-2012-007556
• Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, Motu’apuaka M, Kondo K, Kansagara D. Benefits and harms of intensive blood pressure treatment in adults aged 60 years or older: a systematic review and metaanalysis. Ann Intern Med. 2017;166:419–429. doi: 10.7326/M16-1754

About the Author

Chris Ebright is an Education Coordinator with the National EMS Academy, managing all aspects of initial paramedic education for Acadian Companies, Inc. in the Covington, Louisiana area.  He has been a Nationally Registered paramedic for 24 years, providing primary EMS response along with land and air critical care transportation.  Chris has educated hundreds of first responders, EMTs, paramedics, and nurses for 23 years with his trademark whiteboard artistry sessions. Among his former graduates is the first native paramedic from the Cayman Islands.  Chris’ passion for education is currently featured as a monthly article contributor, published on the Limmer Education website.  He has been a featured presenter at numerous local, state and national EMS conferences over the past 12 years, and enjoys traveling annually throughout the United States meeting EMS professionals from all walks of life.  Chris is a self-proclaimed sports, movie and rollercoaster junkie and holds a Bachelor of Education degree from the University of Toledo in Toledo, Ohio.  He can be contacted via email at [email protected] or through his website www.christopherebright.com .

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