Editor’s column J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2020-016683 on 14 August 2020. Downloaded from

acute strokes, predominantly affecting Misinformation in the COVID-19 era otherwise healthy people <50 years of age.12 13 Endothelial dysfunction, hyper- Gabor Toth ‍ ‍ ,1 Alejandro M Spiotta,2 Joshua A Hirsch ‍ ‍ ,3 coaguability, ACE2 receptor variability, 4 upregulated inflammatory response and David Fiorella ‍ ‍ resultant thrombotic events have all been hypothesized as possible causes for The COVID-19 pandemic has taken a toll of primary data sources”.7 Medical jour- these unusual cases, but definitive data on humankind that is remarkable for a nals not properly “vetting” and eventually are currently lacking. One of the alter- disease in modern times. As of late June publishing high-­impact articles that turn native explanations may be that some 2020, almost 500 000 people have died of out to be based on unverified data can of the “healthy” patients actually have the disease worldwide, including more misguide providers as well as the public. underlying but previously unknown than 120 000 in the USA, with estimates of Information on the disease that was previ- risk factors contributing to the vascular infected individuals approaching ously restricted to medical professionals is events. It is also possible that younger 10 million.1 The numbers of infected and now available to the broad public by the patients are more likely to have asymp- deceased patients will continue to rise. swipe of a screen, just like any other news- tomatic COVID-19 infection, and in In these times of considerable uncer- reel. The media is prone to pick up buzz high COVID-19 burden regions younger tainty, with no cure or vaccine in sight, worthy articles, and this then contributes patients are therefore more likely to have patients and physicians rely on the free to the rapid distribution of damaging incidental positive COVID-19 status flow of information to understand and misinformation without independent when presenting with stroke. fight this deadly disease. The internet and professional medical guidance. By the Undoubtedly, the original reports were social media have spawned an era of digital time doubt is raised about the validity of relevant and provided valuable informa- globalization where observations, reports the findings, it is often too late; broad tion about unique COVID-19 related and research on COVID-19 can readily be dissemination and public acceptance has neurologic phenomena. However, distributed across the world very quickly. already taken place. despite the short epoch studied and Within just a few months in the first half Another interesting phenomenon, the extremely small number of patients reported, these papers were almost of 2020, publications and information although not necessarily specific to the instantly featured in the media as related to COVID-19 have exponentially COVID-19 era, is the appearance of far-­ evidence for a “surge of acute stroke” in increased. It has quickly become clear that reaching, hasty and unfounded conclu- young “barely sick” COVID-19 patients, COVID-19 not only affects the respiratory sions associated with medical studies or copyright. who are “dying of strokes”.14 15 It did not system as initially thought, but can alter research, often fueled by media overin- help the cause that, almost immediately, hemostasis, endothelial function, and can terpretation of limited scientific data, a number of posts started appearing on damage the heart and the central nervous including small observational studies, 2–4 mostly personal but publicly accessible system. case reports or small case series. Recent Unfortunately, with the rapid dissem- social media sites featuring physicians headlines featured news about increased ination of valuable information often with anecdotal examples of “atypical” stroke rates in young coronavirus comes misinformation. There has been an thrombectomy procedures in COVID-19 patients without significant past medical understandable urge to publish ground- acute stroke patients, suggesting solid history. It is known that stroke rates in breaking and novel data. However, this evidence of a link between stroke, coro- the young, non-CO­ VID-19 population also opens the door to multiple poten- navirus and the young. Unfortunately, are considered to be relatively low, but tial pitfalls. In order to keep up with the the difference between online media http://jnis.bmj.com/ not rare, usually representing around ‘surge’ of COVID-related­ submissions, platforms lacking peer-review­ oversight 5–15% of all strokes.8 Contemporary many peer reviewed journals offered and high quality journal articles is well international multicenter data from over 16 expedited reviews and in some cases known. Although the scientific value 6000 thrombectomies enrolled in the brought noteworthy submissions to print of unfiltered social network accounts Stroke Thrombectomy and Aneurysm without subjecting them to a standard has always been debatable, they further Registry (STAR) establishes the propor- peer review. Not adhering to stringent exaggerate the media and public frenzy. review and rigorous selection processes is tion of patients undergoing thrombec- It is interesting to note that medical facil- on September 28, 2021 by guest. Protected a recipe for trouble which can impact even tomy under the age of 50 years at 11.6%, ities in other COVID-19 overrun areas in of which 48.5% did not have any known the USA did not clearly identify similar the most prominent publication forums as 9 10 evidenced by two recent COVID-themed­ stroke risk factors. stroke trends in general and in the young redactions in NEJM and the Lancet5 6 after Based on accumulating evidence, it thus far. On the contrary, more robust and concerns were raised about the “veracity does appear that severely ill COVID-19 much larger data sets have demonstrated patients may have an increased predis- a marked reduction in thrombectomy position to acute neurologic disorders, 1Cerebrovascular Center, Cleveland Clinic Foundation, and percutaneous coronary intervention Cleveland, Ohio, USA including stroke. A case series of 214 volumes during the COVID-19 epoch. 2Department of Neurosurgery, Medical University of patients (mean age 52.7 years) from It has been hypothesized that people South Carolina, Charleston, South Carolina, USA China comparing “more severe vs less 3 are delaying medical attention during NeuroEndovascular Program, Massachusetts General severe COVID-19 respiratory infection” the pandemic, possibly due to fears of Hospital, Boston, Massachusetts, USA 4Department of Neurosurgery, Stony Brook University, patients found acute cerebrovascular contracting the virus while being treated 17–19 Stony Brook, New York, USA disease in 5.7% versus 0.8%, respec- in the hospital. tively.11 A few additional recent brief Correspondence to Dr Gabor Toth, Cerebrovascular High quality scientific data should Center, Cleveland Clinic Foundation, Cleveland, OH communications detailed a handful be gathered, interpreted and presented 44195, USA; tothg@​ ​ccf.org​ of coronavirus cases associated with objectively in order to better understand

Toth G, et al. J NeuroIntervent Surg September 2020 Vol 12 No 9 829 Editor’s column J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2020-016683 on 14 August 2020. Downloaded from the relationship between COVID-19 purpose (including text and data mining) provided that 7 . Available: https://www.sciencemag.​ ​org/news/​ ​2020/​ and other health conditions, including all copyright notices and trade marks are retained. 06/whos-​ ​blame-these-​ ​three-scientists-​ ​are-heart-​ ​ surgisphere-​covid-​19-scandal​ [Accessed 21 Jun 2020]. stroke. Whether directly related to © Author(s) (or their employer(s)) 2020. No commercial re-­use. See rights and permissions. Published by BMJ. 8 Smajlović D. Strokes in young adults: epidemiology and COVID-19 or not, timely care for acute prevention. Vasc Health Risk Manag 2015;11:157–64. stroke remains the neurointerventionist’s 9 Chalhoub RM, Alawieh AM, Anadani M, et al. Abstract main concern. Going forward, investiga- 169: a comprehensive multicenter evaluation of the tors need to better understand this era impact of age on stroke thrombectomy outcomes— insights from the StAR collaboration. Stroke To cite Toth G, Spiotta AM, Hirsch JA, et al. of rapid global dissemination of medical 2020;51:A169. J NeuroIntervent Surg 2020;12:829–830. information through non-­traditional 10 Spiotta AM. Letter: Twinkle, Twinkle Little STAR, How methods. It is our responsibility to Accepted 27 July 2020 I Wonder What You Are: The Case for High-Quality,­ provide context and cautiously inter- Large-Scale,­ "Real-World"­ Databases. Neurosurgery J NeuroIntervent Surg 2020;12:829–830. pret these data rather than act to amplify 2020:nyaa168. doi:10.1136/neurintsurg-2020-016683 11 Mao L, Jin H, Wang M, et al. Neurologic manifestations the level of hysteria. Ideally, we would of hospitalized patients with coronavirus disease 2019 enlist the media to help improve health ORCID iDs in Wuhan, China. JAMA Neurol 2020;77:683–90. care. In this case that would mean raising Gabor Toth http://orcid.​ ​org/0000-​ ​0002-3646-​ ​3635 12 Oxley TJ, Mocco J, Majidi S, et al. Large-­vessel stroke as Joshua A Hirsch http://orcid.​ ​org/0000-​ ​0002-9594-​ ​8798 a presenting feature of Covid-19 in the young. N Engl awareness about the importance of David Fiorella http://orcid.​ ​org/0000-​ ​0002-2677-​ ​8780 seeking professional help without delay J Med 2020;382:e60. 13 Sweid A, Hammoud B, Weinberg JH, et al. Letter: for patients with acute stroke symptoms References thrombotic neurovascular disease in COVID-19 independent of the present pandemic. 1 The Johns Hopkins Coronavirus Resource Center. patients, neurosurgery, nyaa254. Available: https://​doi.​ Available: https://​coronavirus.jhu.​ ​edu/map.​ ​html org/ Twitter Gabor Toth @GaborTothMD and Joshua A [Accessed 27 Jun 2020]. 14 . Available: https://www.washingtonpost.​ ​com/health/​ ​ 2020/04/​ ​24/strokes-​ ​coronavirus-young-​ ​patients/ Hirsch @JoshuaAHirsch 2 Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically [Accessed 21 Jun 2020]. Contributors All authors contributed to the writing of ill ICU patients with COVID-19. Thromb Res 15 . Available: https://www.sciencedaily.​ ​com/releases/​ ​ this manuscript. 2020;191:145–7. 2020/​06/200604095600.​ htm​ [Accessed 20 Jun 2020]. Funding The authors have not declared a specific 3 Shi S, Qin M, Shen B, et al. Association of cardiac injury 16 Dmytriw AA, Sorenson TJ, Morris JM, et al. #Fake news: grant for this research from any funding agency in the with mortality in hospitalized patients with COVID-19 a systematic review of mechanical thrombectomy public, commercial or not-­for-­profit sectors. in Wuhan, China. JAMA Cardiol 2020;5:802. results among neurointerventional stroke surgeons on 4 Fiorella D, Fargen KM, Leslie-­Mazwi TM, et al. Twitter. J Neurointerv Surg 2019;11:460–3. Competing interests None declared. Neurointervention for emergent large vessel occlusion 17 Kansagra AP, Goyal MS, Hamilton S, et al. Collateral Patient consent for publication Not required. during the COVID-19 pandemic. J Neurointerv Surg effect of Covid-19 on stroke evaluation in the United 2020;12:537–9. States. N Engl J Med 2020;383:400–1. Provenance and peer review Commissioned; copyright. 5 Mehra MR, Desai SS, Ruschitzka F, et al. 18 Uchino K, Kolikonda MK, Brown D, et al. Decline in internally peer reviewed. Hydroxychloroquine or chloroquine with or without a stroke presentations during COVID-19 surge. Stroke This article is made freely available for use in macrolide for treatment of COVID-19: a multinational 2020;51:2544–7. accordance with BMJ’s website terms and conditions registry analysis. The Lancet 2020. 19 Schirmer CM, Ringer AJ, Arthur AS, et al. Endovascular for the duration of the covid-19 pandemic or until 6 Mehra MR, Desai SS, Kuy S, et al. Cardiovascular Research Group (ENRG). Delayed presentation of otherwise determined by BMJ. You may use, download disease, drug therapy, and mortality in Covid-19. N acute ischemic strokes during the COVID-19 crisis. J and print the article for any lawful, non-­commercial Engl J Med 2020;382:e102. Neurointerv Surg 2020:neurintsurg-2020-016299. http://jnis.bmj.com/ on September 28, 2021 by guest. Protected

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