Background and Purpose: Anecdotal evidence suggests that the coronavirus disease 2019 (COVID-19) pandemic mitigation efforts may inadvertently discourage patients from seeking treatment for stroke with resultant increased morbidity and mortality. Analysis of regional data, while hospital capacities for acute stroke care remained fully available, offers an opportunity to assess this. We report regional Stroke Team acute activations and reperfusion treatments during COVID-19 mitigation activities. Methods: Using case log data prospectively collected by a Stroke Team exclusively serving ≈2 million inhabitants and 30 healthcare facilities, we retrospectively reviewed volumes of consultations and reperfusion treatments for acute ischemic stroke. We compared volumes before and after announcements of COVID-19 mitigation measures and the prior calendar year. Results: Compared with the 10 weeks prior, stroke consultations declined by 39% (95% CI, 32%–46%) in the 5 weeks after announcement of statewide school and restaurant closures in Ohio, Kentucky, and Indiana. Results compared with the prior year and time trend analyses were consistent. Reperfusion treatments also appeared to decline by 31% (95% CI, 3%–51%), and specifically thrombolysis by 33% (95% CI, 4%–55%), but this finding had less precision. Conclusions: Upon the announcement of measures to mitigate COVID-19, regional acute stroke consultations declined significantly. Reperfusion treatment rates, particularly thrombolysis, also appeared to decline qualitatively, and this finding requires further study. Urgent public education is necessary to mitigate a possible crisis of avoiding essential emergency care due to COVID-19.

Background The effect of the COVID pandemic on stroke networks performance are unclear, particularly with consideration of drip&ship versus mothership models. Aims We systematically reviewed and meta-analyzed variations in stroke admissions, rate and timing of reperfusion treatments during the 1st-wave COVID pandemic versus the pre-pandemic timeframe depending on stroke network model adopted. Summary of findings The systematic review followed registered protocol (PROSPERO-CRD42020211535), PRISMA and MOOSE guidelines. We searched MEDLINE, EMBASE and CENTRAL until 9/10/2020, for studies reporting variations in ischemic stroke admissions, treatment rates and timing in COVID (1st wave) vs control-period. Primary outcome was the weekly admission incidence rate ratio (IRR=admissions during COVID-period/admissions during control-period). Secondary outcomes were (i)changes in rate of reperfusion treatments and (ii)time metrics for pre- and in-hospital phase. Data were pooled using random-effects models, comparing mothership vs D&S model. Overall, twenty-nine studies were included in quantitative synthesis (n= 212960). COVID-period was associated with a significant reduction in stroke admission rates (IRR=0.69,95%CI=0.61-0.79), with higher relative presentation of large vessel occlusion (RR=1.62,95%CI=1.24-2.12). Proportions of patients treated with endovascular treatment increased (RR=1.14,95%CI=1.02-1.28). Intravenous thrombolysis decreased overall (IRR=0.72,95%CI=0.54-0.96) but not in the mothership model (IRR=0.81,95%CI=0.43-1.52). Onset-to-door time was longer for the drip&ship in COVID-period compared to the control-period (+32 minutes,95%CI=0-64). Door-to-scan was longer in COVID-period (+5 minutes,95%CI=2-7). Door-to-needle and door-to-groin were similar in COVID and control period. Conclusions Despite a 35% drop in stroke admissions during the 1st pandemic wave, proportions of patients receiving reperfusion and time-metrics were not inferior to control-period. Mothership preserved the weekly rate of intravenous thrombolysis and the onset-to-door timing to pre-pandemic standards.

Background: The University of Cincinnati Stroke Team provides acute stroke care to the southwest Ohio, northern Kentucky, and southeast Indiana catchment area of ~2 million people and 30 healthcare facilities. We previously published a significant decline in stroke activations and reperfusion treatment (IV thrombolysis and EVT) rates following state announcements of COVID-19 mitigation measures. Here, we update these trends after state reopening guidelines. Methods: We compared Stroke Team activations and reperfusion treatments logged in a prospectively collected database, comparing the same period in 2020 versus 2019. Kentucky and Ohio announced school and restaurant closures on March 12 and 13, respectively, followed by Indiana. A stepwise reopening of our tristate area started on May 1, 2020. We also compared trends in activations and treatment rates before (Weeks 1-10), during (Weeks 11-17), and after (Weeks 18-26) the lifting of COVID-19 mitigation efforts using the Poisson test, and graphically with segmented regression analysis. Results: Compared to 2019, stroke team activations declined by 12% in 2020 (95% CI 7 - 16%; p<0.01). During 2020, an initial decline in stroke activations following COVID-19 mitigation announcements was followed by a 28% increase in activations after reopening (Weeks 18-26: 95% CI 15 - 42%; p<0.01). In contrast, compared to 2019, treatment rates were unchanged (0%, 95% CI -15 - 18%; p=1.00), including specifically IV thrombolysis and thrombectomy rates. Similarly, an initial decline in reperfusion treatments was followed by a 24% nonsignificant increase after reopening (95% CI -10 - 71%; p=0.19) in 2020. Conclusion: The initial decline in stroke team activations during COVID-19 mitigation efforts was followed by an increase in activations after reopening. Hospital capacity and 911 services remained fully intact, suggesting that the reduction in activations were related to reduced presentation by patients for emergent stroke care.