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. 2023 Mar;163(3):543-553.
doi: 10.1016/j.chest.2022.10.033. Epub 2022 Nov 5.

Trends in Intensive Care Admissions and Outcomes of Stroke Patients Over 10 Years in Brazil: Impact of the COVID-19 Pandemic

Pedro Kurtz  1 , Leonardo S L Bastos  2 , Fernando G Zampieri  3 , Gabriel R de Freitas  4 , Fernando A Bozza  5 , Marcio Soares  6 , Jorge I F Salluh  7
Affiliations

Trends in Intensive Care Admissions and Outcomes of Stroke Patients Over 10 Years in Brazil: Impact of the COVID-19 Pandemic

Pedro Kurtz et al. Chest. 2023 Mar.

Abstract

Background: The coronavirus 2019 (COVID-19) pandemic affected stroke care worldwide. Data from low- and middle-income countries are limited.

Research question: What was the impact of the pandemic in ICU admissions and outcomes of patients with stroke, in comparison with trends over the last 10 years?

Study design and methods: Retrospective cohort study including prospectively collected data from 165 ICUs in Brazil between 2011 and 2020. We analyzed clinical characteristics and mortality over a period of 10 years and evaluated the impact of the pandemic on stroke outcomes, using the following approach: analyses of admissions for ischemic and hemorrhagic strokes and trends in in-hospital mortality over 10 years; analysis of variable life-adjusted display (VLAD) during 2020; and a mixed-effects multivariable logistic regression model.

Results: A total of 17,115 stroke admissions were analyzed, from which 13,634 were ischemic and 3,481 were hemorrhagic. In-hospital mortality was lower after ischemic stroke as compared with hemorrhagic (9% vs 24%, respectively). Changes in VLAD across epidemiological weeks of 2020 showed that the rise in COVID-19 cases was accompanied by increased mortality, mainly after ischemic stroke. In logistic regression mixed models, mortality was higher in 2020 compared with 2019, 2018, and 2017 in patients with ischemic stroke, namely, in those without altered mental status. In hemorrhagic stroke, the increased mortality in 2020 was observed in patients 50 years of age or younger, as compared with 2019.

Interpretation: Hospital outcomes of stroke admissions worsened during the COVID-19 pandemic, interrupting a trend of improvements in survival rates over 10 years. This effect was more pronounced during the surge of COVID-19 ICU admissions affecting predominantly patients with ischemic stroke without coma, and young patients with hemorrhagic stroke.

Keywords: COVID-19 pandemic; coronavirus 2019; hemorrhagic; ischemic; outcomes; stroke.

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Figures

Figure 1
Figure 1
Trends in number of admissions and in-hospital mortality for patients with ischemic (A and C) and hemorrhagic stroke (B and D).
Figure 2
Figure 2
Trends in systemic and neurological severity measures on admission for patients with ischemic (A) and hemorrhagic stroke (B).
Figure 2
Figure 2
Trends in systemic and neurological severity measures on admission for patients with ischemic (A) and hemorrhagic stroke (B).
Figure 3
Figure 3
(A) Weekly cumulative Variable-adjusted life display (VLAD) for all stroke patients during 2020, shown per week. Increases in VLAD suggest a lower-than-expected mortality, whereas downward shifts suggest the inverse trend. (B) Weekly cumulative VLAD, stratified by ischemic and hemorrhagic stroke. (C) Number of COVID-19 cases admitted to the participating ICUs according to the epidemiological weeks of 2020. Solid lines represent absolute values for VLAD (A and B) or n of COVID-19 admissions (C) per epidemiological week. Dotted lines and shaded areas represent smoothed averages and 95% CI.
Figure 4
Figure 4
OR and their corresponding 95% CI for mortality in 2020 vs other years (references in x-axis) for fixed age (panels) obtained through marginal means, in patients with ischemic stroke (n = 13,634). The dashed line marks OR = 1.00.
Figure 5
Figure 5
OR and their corresponding 95% CIs for mortality in 2020 vs other years (references in x-axis) for fixed age (panels) obtained through marginal means, in patients with hemorrhagic stroke (n = 3,481). The dashed line marks OR = 1.00.
Figure 6
Figure 6
OR and their corresponding 95% CIs for mortality in 2020 vs other years (references in x-axis) for the presence or absence of altered mental status obtained through marginal means, in patients with ischemic (A, n = 13,604) and hemorrhagic stroke (b, n = 3,477). The dashed line marks OR = 1.00.
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