Pleasure to be here. So brain fog after COVID-19. First of all, no disclosures. What I want to talk about today is a little bit about what we do and what we don't know about brain fog after covid. Um, but I also I'm going to borrow a couple of ideas from similar conditions that are relevant to, I think, the stroke community as well. And those are attention and fatigue. Those are things we do know a little bit more about, and I think they're very closely related to covid. There are lots and lots of papers out now that talk about the common symptoms of Long Covid 19. So I picked out three a little bit at random just to show you the variety and also the similarities with some of the symptoms that people describe. But you'll notice in these lists that fatigue is frequently at the top, ranging from 40% in one study to 85% of people reporting fatigue in another. So it's clearly a very important component of long covid and related to brain fog. Um, attention is the other one, and you'll see also that attention is is frequently mentioned UM one of the study's doesn't talk about brain fog, but it does include attention, so brain fog and attention are both frequently listed. So what is brain fog? So brain fog is really the persistent, troubling experience of not being able to focus, not being able to remember things not being able to problem solve. So people have described it in lots of different ways, so people say they feel mentally slow. They're fuzzy, they're spaced out, they're out of it. They don't have clarity, they can't concentrate. And one of my favorite ones is someone who said It's like swimming in molasses in my brain so it can result in fairly mild problems such as that. Why did I come into this room phenomenon? And it can also result in problems serious enough to result in loss of work and major life life impediments. So what causes brain fog? Well, we don't totally know for sure, but there are a number of physiological causes that we think are related, including stroke, which we're talking about today. Brain structural and metabolic anomalies, lack of oxygen inflammation, immune system problems and also aspects of medical treatments such as sedation, intubation and medications, which many patients with long covid endure while they're in the hospital. There are also psychological complications to that can contribute to the experience of long covid. So the stress and anxiety of being in the hospital for many people, the social isolation that comes with all of us living in a time of pandemic, and particularly for those who are in the hospital without people around them. How long does it last? We don't really know yet because Covid hasn't been around long enough to really know what the extent and duration of the experience is going to be. Some people get better in the first few months. Some people have brain fog that goes on for a really long time afterwards. So what helps with treating brain fog? Well, this was supposed to go in order, but I won't. So these are standard advice that we give to everybody for any kind of medical condition, Really? So we give that people with brain fog as well, so that includes getting good sleep, exercising, eating well, don't drink too much alcohol, don't smoke, do stress reduction activities, do intellectual activities, mind stimulating activities, and really important is socializing, too, which is in the middle there. So another approach is to say, we just treat the symptoms. So some say that we borrow from other conditions that have similar kinds of situations, such as, uh, CFS pots acquired brain injury, people who have similar symptoms. Then we would treat those in the same way we would for other people. We can also do personalized rehabilitation. So for people with shortness of breath, they're breathing treatments. Um, cognitive behavioral therapy for some of the emotional consequences of the experience, um, and other kinds of symptomatic treatments. one of my very favorite ways of treating um, these these problems is to say to the patient, What's the worst problem that you're having now? And they tell you, and then that's what you treat. And I do a lot of that in in my work. So this is a formulation. It's a way of taking the experience of covid. But incorporating it into the whole person is as I'm a psychologist, I like to work holistically and look at the person's background, their family, their social network as well as their identity. Who they are, what things are important to them. with their coping styles have been in the past when they've dealt with illness or other adversities. Yeah, the middle row here is reflects the that cognitive, emotional and physical consequences that are typical of covid. And I would individualize this to individual, Um, but physically, of course, we've got fatigue, sleep disorders, headaches, smell, taste problems, shortness of breath, pain, cough and so on. The cognitive problems that we hear most commonly our brain fog, which is a bit amorphous, Um, attention, concentration and memory problems and problems with executive functions and executive functions really refers to that initial ability to initiate and maintain goal directed behavior. Emotionally, people often experience depression anxiety, which makes sense anger at their experience. I've also been reading more about people feeling misunderstood because they have these odd symptoms and they go in. And if people aren't familiar with covid, they're often misunderstood and dismissed. So I think that's a very relevant and common feeling that people have, and also that feeling of feeling alone, because this isn't a common experience in the formulation. Then we take all of those things and look at the consequences on that person's life. So we look at how it affects their ability to work their personal care, their household tasks, their social and leisure relationships. They're driving all of those things and which ones are the most important for that person. And then all of this gets funneled into looking at goals for rehabilitation. So how what are the person's goals Doesn't have to go do with going back to work? Is that their level of independence? Is it relationships, et cetera. So I'm going to talk about both attention and fatigue. Starting with attention, I'm just going to mention a couple of models of attention. The first one is Posner and Peterson, who have done a lot of work on theoretical models of attention and also a lot of work in linking certain kinds of attention to their neuro anatomical substrates. So they talk about the orientation system, and that has to do with engaging and moving and then disengaging our attention from different things. The alerting network has to do with being vigilant and sustaining our attention, so being ready to respond to things and the executive network is really relevant to selecting stimuli and processes and inhibiting irrelevant kinds of information. So another model of attention is, um, the one by Solberg and Mature. This one is very patient friendly, and it's very easy for people to relate to in a clinical kind of way. So they talk about selective attention where you focus on one thing and you rule out other things dividing your attention, which means sharing your attention among more than one thing at a time. Switching your attention. So moving your attention from one stimulus to another and then sustaining our attention is keeping an eye on focus for a long period of time. So there are a number of guidelines and recommendations for the rehabilitation of attention. One of the ones that I really like is the NCAA Group, which is a group of international researchers who have looked at the literature and developed a series of evidence based guidelines for managing, uh, problems with attention as well as other cognitive problems. This one is really nice because they address not only the cognitive aspects of attention but also the environment and the emotional kinds of things that can interfere with good attention. So they start out with what is the most common, um, evidential evidence based guidelines for dealing with any kind of cognitive difficulty, which is that we learn meta cognitive strategies to manage these problems. We don't do computer training. We don't learn how to tie our shoes. Only we learn strategies that we can apply to various situations in our lives. So this is what they say here, too. Meta cognitive strategy training. It needs to be applied to relevant and functional activities that the person cares about, and it's their own goals. So it's it's tailored individually in that way. They also talk about dual task training, which is a cognitive rehab technique, Um, one of the few with an evidence base for attention training, and they talk about making sure that the person sleep is okay. And if it's not, then you need to get a screening and treatment of sleep because poor sleep obviously can make it hard to pay attention. I'm a little bit jet leg from having been in Europe a couple days ago, so if I'm sounding a little bit, lack of attention is because of poor sleep. So we also talk about people's emotional reactions, So if we're really worried and anxious about things, we're not going to be able to pay attention. I think one of the most common symptoms that I notice in all of the folks that I work with who have any kind of brain injury is rumination set tendency to keep something usually a negative thought in your head, over and over and over again, and you can't get rid of it. And that comes up and it becomes much more of a common problem for people. So cognitive behavioral therapy or any other kind of psychotherapy is often engaged to deal with the anxiety, the depression, those kinds of things that interfere with our attentional functioning. And finally, they talk about adapting the environment. So a cluttered environment, a noisy environment, is going to make attention problems worse so really practical kinds of common sense things that actually have an evidence based to approve our attentional functioning. So this is an example, and you hear me talk about formulation quite a bit. So I really like to use this model of formulation to help patients understand their own attention. Problems come up with their own solutions together in therapy. So this is one that a patient developed and they start out saying a pension for me really affects my reading. It affects my ability to follow recipes. That's where I noticed the problem, and I don't like it. And then for this person, they consider their attention as it's like those miners hats that have a beam on them. So it's like that flashlight that's on the top of a miner's hat, and they can being very brightly at one thing, or they can diffuse it. If needed. They can switch it from side to side. And that image is really useful in helping people become aware of and manage their attention more effectively. This person says their attention deteriorates when they're fatigued. They're distracted there for separating, and that causes them to feel cheesed off. So use their own words. Um, for them, it affects their memory, their ability to problem solve and their feelings. And so they get very frustrated if things don't go the way they want them to. And then finally, through the course of therapy, this person has developed strategies that helps their attention, and for this person, it to do things. But I'm not tired. Pace myself, remove distractions from the environment, be compassionate and kind to myself and choose a quiet environment for completing complex tasks. So you can see that there are emotional ones, their cognitive things, and there are physical and environmental kind of management. All of those things together can create a good approach to managing attention. Click. There we go. Okay, I'm going to talk about fatigue, which is also very common for people who have stroke. This image is from a booklet on fatigue that is a really wonderful booklet developed by Headway, which is an organization in the UK that develops materials, educational materials for people with brain injuries and their families. And so this one's on fatigue, and I highly recommend it. And I handed out to my folks a lot, so I'm also going to refer to this study by Herrera and colleagues. It just came out in the Journal of PM and are, um, a couple of months ago, and it's a multidisciplinary, collaborative consensus guidance statement to assess and treat post covid fatigue, and I highly recommend that for anyone who is working with people with post covid fatigue, so they talk about the experience of fatigue, which I think we pretty well understand is feeling weariness, tiredness, no energy. Um, being exhausted without any real good reason for that being weighed down, having a good day and then, um, having that feeling of crashing, which is a pretty common experience for people. Um, being really tired, even though you've just woken up or haven't been doing anything in particular. So the types of fatigue, so there are various types of fatigue. Physical fatigue is something that we all have. So if we exercise or if we do something strenuous, we're going to feel fatigue in our limbs. And it's a normal feeling that we it's kind of nice feeling to have. But mental and cognitive sorry. Mental and emotional fatigue are are different. They are much more specific to brain injury related fatigue, and they are confused. It's confusing experience, so people have find that when they're think a lot, or when they're asked to concentrate, or if the room is crazy or someone's talking too fast like I tend to do, then it gives them cognitive fatigue, and that's very wearing. They're using up a lot of brain resources. Because of this, the emotional fatigue is also very relevant, so a lot of our folks will have, um, problems with family members. They'll get in arguments, they'll feel sad. They're anxious. And those kind of emotionally distressing experiences can also lead to the experience of fatigue. So primary and secondary fatigues primary fatigue is directly caused by damage to the central nervous system to brain structures to the connections in the brain and can be also caused by impaired excitability of the motor cortex. Secondary fatigue are those factors that contribute to the experience of fatigue, but they're not directly due to something in the brain. So that would be things like poor sleep pain, mood problems, cognitive problems that contribute and add additional factors to fatigue. So I'm going back to the Herrera article here, and there is a lot more in this article about the careful assessment of fatigue. So again, if you're if you're looking to do a really good assessment, take a look at that article. So, of course, they describe such things, taking a good patient history, um, looking at underlying conditions, looking at the medications, lab workups and using fatigue scales. There are quite a few fatigue scales out there. They all tap different elements of fatigue, and I don't think there's anyone good fatigue scale that captures everything. You need to kind of look at maybe two or three different ones. So again, with formulation. So this is, uh, an example of a fatigue formulation from a patient that I worked with and here I'm going to go through it fairly quickly. But for this person, he'd had a very severe right hemisphere stroke and was using a wheelchair and had a lot of pain associated with his stroke and a lot of other complications. So for him, his fatigue came from the consequences of the brain areas that were affected by the stroke as well as the pain, all the medication he was taking, um, and his cognitive difficulties for him, his triggers were not being in control, being pressured when he was in unfamiliar situations. Um, being in a noisy environment. I like this particular example because his it's very particular individual, and sometimes people come up with things that for them represent fatigue that we wouldn't necessarily think of if we didn't let them really kind of think and talk about it themselves. So for him, sleepiness hard to focus, headaches or fatigue. For him, being fidgety was fatiguing. For him was a symptom of fatigue and feeling overwhelmed. And the things that he had learned were not helpful in managing his fatigue and triggering it actually were things like having a fight with his partner, um, eating too much chocolate, which I'm so grateful. I don't have that problem. I would be exhausted if I had to not eat chocolate eating a big breakfast. Various things like that that we would never think of are associated with fatigue, But for this person they are. During the course of his rehab, he started paying attention to the helpful strategies that would help him minimize and prevent his fatigue. So the preventive kinds of strategies for him We're doing a lot of planning ahead so that he didn't have a lot of stress at any given moment, developing routines that were familiar for him, so that he didn't have to think through novel kind of situations, delegating tasks to other people, pacing himself, um, sleeping well as much as he could managing his pain, better lighting and temperature. Who'd have thought those things will be relevant to fatigue, but for this guy, they are and doing more exercise. And then once he if he did feel fatigue, he used mindfulness, and he also used short power naps to help him. Manchester City. So fatigue factors are, as I say, are really different. We have to talk to people, and it's a process of having people monitor and evaluate and notice their fatigue during the day. So I do a lot of fatigue monitoring with people, give them a sheet, asked them to rate how they're feeling during the day on a scale. And what are the triggers and what are the things that help and that can really be helpful in managing. So for this one, someone says, I'm trying to read directions. Um, I can't keep my focus. I made an error. I must be so stupid. Um, a failure. I'm bored. I'm sad. I'm not trying this again. I'm exhausted. So it's those steps that people go through when something is hard that we criticize ourselves, we get mad about it. We might excuse it. Those kinds of things are all exhausting. And so breaking those patterns can help people focus more on what they're actually trying to do and get rid of some of the intervening kind of problems. So fatigue management there are lots of this is these are the four PS of fatigue management. So pacing, planning, prioritizing and positioning are all strategies that we teach folks to help reduce the impact of fatigue. I think one of the ones that's most important is the pacing. So almost everybody that I work with who has fatigue gets into the boom and bust cycle. They feel good, and so they're going to get everything done. They possibly can, and then they crash out for a couple of days. So I I tell them it's a little bit like my brand new electric car that if I deplete the battery, I'm going to ruin the battery on it. So I've learned that I can only go so far down, and then I have to charge it up again so that I don't harm the battery and the same thing for them. So we kind of liken it to, you know, you're you're dehydrated if you're thirsty and you should have taken a drink earlier, and the same thing with fatigue, you really want to minimize and over doing the fatigue We look a lot at people who have mood issues with their fatigue. We look at how mood management can also impact on fatigue experience. This is a particular patient for whom he identity. This is his part of his toolkit for his strategy, his neuro psych rehab strategies for mood. And so for him, keeping a gratitude journal was really important. Um, taking his Cymbalta was very important. Doing some mindfulness, doing some calming breathing, listening to jazz for him and paying attention to his faith were all things that became part of his daily practice and minimized his fatigue and also improved his mood. He also had some cognitive strategies that this is also someone who had a stroke with fatigue and with cognitive and mood issues. So for the cognitive issues, we used memory and planning AIDS, and that helped him a lot to plan and organize his day so that he wasn't punching things up and getting too tired. And we use cognitive strategies such as self talk, which is for the if anybody in here ever has the experience of why did I come into this room? You say it out loud from the minute you think of it? I want to go get a drink of water and you say it out loud. I'm going to get a drink of water. I'm going to get a drink of water until you get to the kitchen. You have your water in your hand, and that helps focus your brain on the task at hand. And over time you reduce that to a whisper and then two sub vocal, Um, just sort of thinking it to yourself. But it's a way of training attention to a particular target, Sort of like a horse with blinders. Um, and the attention beam is also something I mentioned earlier. All these things work because they draw attention of the person to the problem. They give them a focus, and they give them skills to start building up in any kind of situation. So they're they're pretty effective managing the environment we've talked about. So making sure that your space is not cluttered having good lighting um, having a place where you can go and rest with nobody to bother you can be really helpful. Mhm. There we go. Um, and finally, just some recharging the battery kinds of ideas that we've we've mentioned power naps can be helpful not too long. There are guidelines for that. Using relaxation techniques and mindfulness Um, depending on the person listening to music going outside, switching activities. So it's important to switch from a fatiguing activity to a relaxing activity over the course of the day. Um, some people get energized by being in a group. Some people prefer to be alone. So whatever works for you. So these are just some of the ways that we manage attention and fatigue. And in nurse like rehab, Um, if they are actually manageable kinds of experiences, uh, kinds of difficulties, and you can make a difference for folks. So back to Covid, we have a relatively new, long haul covid recovery clinic at U H. It's opened its doors in August, and we've seen quite a few people already. It's very multidisciplinary group. It's headed by, um, pulmonary, but includes sleep medicine, digestive health, infectious disease, euros. I can neurology, um, heart and vascular integrated behavioral health and E N. T. So it's a very comprehensive kind of, um, of experience with patients. It's physically located at Ahuja and offers both inpatient or in person and virtual visits to people. So depending on what people need, um, the idea is really for people to feel understood by a group of people who see a lot of people with covid symptoms so that they can get a good, strong evaluation of their experiences and have a treatment that includes both mind and body. So I would recommend, if you don't know if it already take a picture of that slider right down the information. Um, I sent a patient. She was one of the first patients to go to the Covid clinic, and she had complained about every single medical service she had received prior to that because people weren't understanding her. She went to the Covid clinic and she said, Oh, my God, they sat there and they listen to me. They talked to me. They conferred among themselves. They made referrals for me. I really love this. I feel understood for the first time, so good for our covid clinic. I think that's it. I'll turn it over to Dr Pastor. Mhm. Uh, so our last, uh, formal speaker is Amanda? Oh, Pastor Amanda finished her stroke fellowship with us, and now she's the director of the Advanced Primary Stroke Center at ST John Medical Center. And she's going to speak to us on thrombosis and stroke with COVID-19. Um, well, I'll just get started. I'm going to be talking about our current understanding of the cerebral vascular complications of covid. And what we're really understanding is this kind of new form of covid associated coagulate apathy, how that relates to stroke and the our treatment management that we're using right now and, lastly, about the impact that Covid has had on stroke care. So just to take a step backwards will it's important to think about our current understanding of the initial coronavirus epidemic. So the first one was Stars Cove wine in Asia in the early two thousand's, and that now hails in comparison a number of cases but, uh, 9000 cases roughly with a 10% mortality and start one, which was vital logic. I'm never going to say this word right. Final logically similar to SARS Cove to, um, actually had direct neuro invasion. And so you saw both central and peripheral peripheral nervous system manifestations in these patients, and we learned a lot about the coronavirus and the neurologic complications from this initial epidemic, Um, specifically actually related to some of the long term brain fog and the chronic fatigue syndrome that some of these patients also experienced. Uh, there were autopsy series that actually directly isolated the virus in SARS Cove one from the nervous system, um, as well as case reports that talked a lot about the central and peripheral nervous system manifestations such as stroke, um, auto, immune encephalitis or viral post viral encephalitis. These in the MERS epidemic, which was in 2012 in the Middle East. They actually did not isolate the virus from the central nervous system. And so you actually see less, uh, neurologic complications in the MERS epidemic. Um, and more of them were post immune Guillain Barre syndrome and other post viral immunological syndromes. Instead, to briefly review. I think this really helps us understand why there's a covid curricula, apathy, and that starts with the direct virus invasion invasion in the human host. And it starts with binding to the ace two receptor, and we know that the ace two receptor exists in the lungs and the small intestine, and that's the primary manifestation of the respiratory illness. But there are eight to receptors. Importantly, on the end, Ophelia cells and they raced to receptors in the brain stem, the cortex, the striatum and hypothalamus. And so this direct, uh, invasion into the central nervous system is most likely causing some of these neurologic complications. Furthermore, the impact of covid on the lack of or dis regulation of the Reno Reno and angiotensin Valdosta phone system is causing a lot of the pro inflammatory effects. No covid sorry. The renown angiotensin testosterone system just to review starts with angiotensin origin, it becomes converted to angiotensin one and angiotensin two, and this side of the pathway has these pro inflammatory properties to it, causing vessel constriction, hypertrophy and inflammation. However, that is down regulated in our, um, in the human host, normally by the ace two receptor. So the ace two will then down regulate the whole system, and you'll have actually anti inflammatory and euro protective effects. And when the SARS cov two virus binds to the ace two receptor actually end of psychosis that receptor and you no longer have it available, and therefore there's going to be, um, lack of regulation, and so you're gonna see this more pro inflammatory, pro coagulant pathway that is no longer regulated by the downstream anti inflammatory pathway. Now what we've learned from this covid associated kogel apathy, which conveniently is now have its own acronym a C A. C Uh, it's kind of a combination of four different types of known coagulate apathy, so it's uniquely its own. It shares some features with sepsis induced coma girl apathy, um, which is primarily manifested in the cytokine storm and the downstream effects of all of that. Except it doesn't really look like substance induced cardiomyopathy, at least not in the beginning stages. Because we actually see these really high fibrinogen levels, which is, um, not really classic in the consumptive curricula apathy that you see in sepsis. But it's still there, and we definitely get there in the later stages of Covid. There's another condition, and, um, it is the hemo frank acidic syndrome, which is one of the more, uh, newer times that I've heard of this. But it has a whole series of inflammation and thrombosis complications. And so this syndrome has fever, Splenda, medley and a number of other findings that go with it and we actually see some of this in the covid associated Kregel apathy, most notably the high ferreting levels. But it doesn't fit the rest of the features. There's no split Omega Li. There's no hyper triglyceride anemia, Um, and so it doesn't quite fit that picture either. Additionally, we're also seeing, um, this robotic microalgae apathy. And I think this is a lot of what, uh, what we see in the covid associated Venus and arterial thrombosis. Symbolic disease. Um so there's elevated LDH levels, reduce half the globe in elevated bilirubin levels and high rates of micro thrombosis, arterial and venous thrombosis. And lastly, we've actually had lots of several case reports of the induction of production of the anti fossil lipid antibody. So anti fossil lipid antibody syndrome is primarily thought of as an auto immune disorder, kind of in the Lupus spectrum where these, uh, anti fossil lipid antibodies are produced and their associated with arterial clotting in viral illnesses. This has actually been reported in other types of viral syndromes, where they will induce production of the anti fossil lipid antibodies in lower tigers and have an association with arterial and venous thrombosis, and that has again been reported in some of the covid patients. So it is something in the middle. As far as neurologic complications go, there are many, and they are part of both the systemic disease, equality, the hypoxia, the thrombosis, the inflammation, the direct neuro invasion of the virus, which primarily hearing about with, um, the last of sense of taste and smell. And so we know there's some direct neural invasion into the olfactory there from the virus. But presumably there's also some other direct neural invasion, especially with some of our post cognitive deficits. And then there's immune mediated para and post infectious effects. These are much more rare. These are going to be the G ombre syndrome and some of the other post viral encephalitis these that have been seen. We're learning a lot about stroke in the setting of the post of covid related stroke, and most of the case reports that sorry case series that have come out stem from the first wave from about February to June of last year. But they've they've been kind of holding. True for our current experience, the incidence is overall quite low. Well, as far as the Venus Trumbo anabolic disease, which is very frequent in the sending of covid, the arterial Trumbull anabolic disease, whether that stroke or limb ischemia is actually quite low. So this is 123% of hospitalized patients, 6% of patients that are admitted to an ICU so still a very low incidence. We see this pretty within the first month of the virus. So in 10 to 21 days is when we're seeing the stroke. Events happen as long as it's not related to a secondary effect of covid. So that would exclude our patients, who develop a covid related cardiomyopathy and down the road, have atrial fibrillation and then come back a couple months later with anabolic infarct. These are patients who have respiratory symptoms and are having covid related micro robotic disease as a as a part of their initial presentation. There are several different mechanisms which the stroke occurs in pretty much spans the entire spectrum. But the primary type of stroke was that we are seeing is large vessel inclusions and multi multi vessel territory infarction, and that goes with the endothelial effects of the virus we're seeing on labs what we're seeing with a lot of other covid patients, so elevated D dimmers elevated ldh, abnormal LFTs and the induction of the anti possible lipid antibodies and the outcomes. The outcomes are, I guess what you would expect. But it is surprising in some ways is that patients who are older have worse outcomes. Those patients admitted with covid in the hospital who then have a stroke, have a worse outcome, Um, those that have higher baseline NH stroke skills, higher D timers and worse kidney function. This is actually a great review article if you're interested at all. The Doctor Vogue rig is actually an Italian neurologists. And they produced this, uh, systemic review of covid related stroke and neuroscience letters recently. And they go through a lot of the features, um, really down to all the different subtypes of stroke that have been presented that have been presented. Now we can go through the covid related mechanisms. I've talked a lot about the endothelial apathy and the traumatic migraines. Apathy. I think that's primarily what we're seeing. But in addition, um, the sepsis induced cardiomyopathy is no an important mechanism and the cardio embolism. So I've seen a couple of patients with this. And in talking to our cardiologist, they have actually seen a number of patients develop postcode cardiomyopathy and then the related atrial fibrillation. So I have a few patients in my clinic who have come back a few minutes a few months post covid, um, with a cardio anabolic stroke related to their A fib and their cardio myopathy from covid. Additionally, there are a few case reports of arterial dissections in vasculitis. A lot of this really, um, mimics what we see normally in our, um, distribution of ideologies from stroke as far as, uh, covid stroke outcomes. Though this is a case series out of Mount Sinai in New York City. So this compared, uh, patients admitted with stroke diagnosis to their hospital and whether they were covid positive or covid negative. I think early in the pandemic, we were reading a lot of these reports and news articles about young patients coming in with large vessel strokes and really concerned that that was the population we were going to see. And it turns out that's actually not what we're seeing, at least not here. Um, in the United States, the mean age is 65. Most of these patients have very similar vascular risk factors, and they're largely ischemic strokes. The main difference is the elevated SRC R p and D dharma that we're seeing in the covid patients. But I think importantly, and I guess you would understand this. But, um, we're seeing higher rates of in hospital mortality, higher rates of discharge, build, nursing rehab facilities and worse outcomes. And that's really kind of the biggest thing that's come out of several different case series that have been reported. Now let's talk a little bit about what can we do related to covid curricula? Apathy? This is, uh, I guess, an ongoing discussion we don't know. And there are several trials trying to address this, uh, this topic. Currently, we have an anti coagulation protocol at university hospitals that recommends that we risk stratify patients and we use early anti coagulation or early systemic anti coagulation for our patients. And that is still where we stand with things. But, um, but their clinical trials are still coming out, and there's some challenges to all of this. So in general right now, the recommendation from the American Society of Hematology is actually just Lovenox or D V T prophylaxis dose is for all patients who are hospitalized with covid. Um, and that comes out of the MPC, MPC T and Inspiration trials. The challenge with the trials that have been produced recently is that there is a lack of equal poise, and they're having difficulty enrolling patients, all patients, into the trials to randomize them properly to systemic into coagulation versus, um, versus DVT prophylaxis dozing, especially when when providers think this patient needs anti coagulation systemically. And so that's biasing some of the trial results that are coming out, but it's an ongoing investigation. We have a lot of unanswered questions. What should we do in the outpatient setting? When patients are diagnosed with covid, should they be put on an aspirin? Should they be put on D V T prophylaxis dozing? Should they be put on systemic anti coagulation as an outpatient? Is that going to actually prevent them from coming into the hospital with, uh, saddle pes? Um, micro thrombosis. Worst respiratory failure? These are unanswered questions, Um, what should we do in patients in the hospital? I've heard arguments with hematologist out of Boston that there is some investigations for intermediate dozing, systemic dozing and our current DVT prophylaxis dozing. Um, the current recommendation again is just D v T prophylaxis, but there's a lot of investigation that we should be doing. Systemic anti coagulation and intermediate protocols early on, when patients are not critically ill is a way to try and prevent them from getting critically ill. Um, again, we don't know the answer to this yet. And then what should we do when patients are discharged from the hospital? And I just had this question recently and again, we don't know. Um, but And if they have a stroke, we most likely you're going to put them on aspirin unless they have a known cardio metabolic source. And they have other reasons to be on systemic anti coagulation. Then we may discharge them on systemic anti coagulation. Uh, there is there has been a practice to discharge patients on DVD prophylaxis dozing. So Lovenox or eloquence or something? Um, for I guess Xarelto for 30 days, post hospital. We don't have enough data to support doing this, and it's not an unreasonable thought, but it is something that is going to require ongoing investigation are anti coagulation Committee at University Hospitals, is aware of this issue and is currently reviewing all of the Venus rumble symbolic and arterial thrombosis symbolic data to try and come up with some new recommendations. The other thing I would like to know is just be aware that antique regulation can interact, especially the dough acts with some of the covid target COVID-19 targeted therapies. Just keep that in mind if you're going to be prescribing them. How has the pandemic impacted the quality of our stroke care? And the good news is actually not significantly. So this is a get with the guidelines review for, um all of the participating hospitals that are in get with the guidelines. And I believe this is, um earlier in the pandemic, so compared pre pandemic November of 2019 to February of 2020 and then February of 2022 June of 2020 which is an important time frame. When there was a lack of access to PPE, we were developing all of these protocols. There was there were delays in trying to evaluate these patients, get them in to seek the scanners and the like, and they actually found that We had similar door to C T door to tp a indoor to endovascular therapy times, whether or not the patient, the patient's were covid positive or not and pre pandemic and during the pandemic. So I think all of the providers across the country and nurses and hospital teams have done an excellent job of trying to continue to provide high quality and timely care to all of our stroke patients. So that concludes my talk for today. Just, um, going through our current understanding of our new covid associated kogel apathy and what we are learning about the Venus and Crumble Venus and arterial thrombosis, symbolic disease, our current understanding of stroke and covid 19, which is a rare, uh phenomenon but presents primarily as large vessel inclusions or multi territory in parks, and that the role of antique regulation is ever evolving and stay tuned. Maybe in a year we'll have more information. Thank you all. All right, let's chance for questions. Do you think the strokes that you've seen in the setting of covid are like typical of the strokes that you see? Not with covid Or are they different? I mean, they're typical in the sense that they if they're a large vessel occlusion or multi territory infarct, they follow the pattern of that. But they're pretty. I mean, this insight to thrombosis is a very different mechanism than what we've been seeing in most of our, um, most other strokes. So that the theory is that it attacks, you know, the vessel in sight, you right in that area. So if its distal, I see A or M c A. That the platforms right there. And it's not a clot that's developing in the heart and traveling up to the brain. So that's unusual. Um, but beyond that, it still is going to affect the same territory of the brain and cause the same damage and outcomes. So, Jill, I noticed some of the things that you talked about. You know, we're sort of alluded to in the Post. I see you fatigue talk. You know, we've talked about this with the cognitive and fatigue related issues after stroke, probably with other illnesses as well. Do you think that these are really the same, like, almost like, independent of ideology? Or do you think the ideologies make a difference? Mhm. I think the experience of fatigue is very much similar across various ideologies. I see people with all kinds of of brain injury ideologies, from stroke to traumatic injury and several apathy, tumors. And I think one of the very most common consequences that people always talk about is fatigue, and each person has an individual experience of it. But it's far more common than we, I think, ordinarily give credit for. So we should really be looking a lot more. We should be looking at fatigue a lot. I have a question. You have questions for each other. I have a question for her. How long post covid are? How long do patients have to be post covid to be eligible for the long haulers clinic? I think it's three months. Oh, good. We said the same thing as well. So that's what we're reliable is not valid three months. All right, Melissa, you don't have any questions. They're too fatigued. Question. Mhm. Alright, is there? Is there any correlation between severity of covid illness and long haul symptoms? If there doesn't seem to be so lots of people who aren't in the hospital and don't have serious cases then come down with the long covid experience and vice versa. Some people recover well after a terrible in hospital experience, so thank you very much.