Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic

Abstract

Background: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic. Methods: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic. Results: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 ( P =0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city ( P <0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale. Conclusions: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.

Successful conduct of an acute stroke clinical trial during COVID

“…Other demographic criteria for exclusion such as NIHSS did not differ, leaving time from symptom onset to 911 alert as the most likely explanation. This is consistent with data from other centers documenting that patients delay calling 911 for emergency conditions because of fear of contracting COVID in the ED or hospital [ 8 , 9 ].…”

COVID-19 and Cerebrovascular Diseases: A Systematic Review and Perspectives for Stroke Management

“…This analysis has limitations, deriving primarily from the possibility that cerebrovascular events in patients with COVID-19 are underreported, especially in patients in critical clinical conditions but also in asymptomatic or paucisymptomatic patients presenting mild stroke-related symptoms and not evaluated by a neurologist. Another consideration is that many patients are expected to have remained undiagnosed because they did not have access to hospital facilities during the period of greatest pandemic burden (153).…”

Decrease in Stroke Diagnoses During the COVID-19 Pandemic: Where Did All Our Stroke Patients Go?

“…As people continue to adjust to social distancing, a shift in the epidemiology of stroke and other medical conditions will most likely be observed, as is being seen in myocardial infarction [29] and in other countries [30][31][32][33][34][35][36][37] in the context of acute ischemic stroke. Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection [38][39][40][41][42][43], anecdotal reports indicate a falling rate of new ischemic stroke admissions [30][31][32]34,37,[44][45][46][47][48], stroke code activations [30,36,[49][50][51][52][53], imaging numbers [44,45], and diagnoses [45].…”

“…Persons who are African American, Black, or Latino are contracting SARS-CoV-2 at higher rates and experiencing higher mortality [75][76][77][78], and comorbidities may explain these differences [74]. Due to this increased risk, Black and Hispanic or Latino patients, particularly those without health insurance [52], may avoid medical care. Observations from a telestroke registry in North Carolina reported that a lower percentage of Black patients presented during the pandemic (13.9% versus 29% before the pandemic, P<.001).…”

“…Accurately identifying the root cause of the decrease in stroke volume is challenging due to a combination of socioeconomic and pathophysiologic factors. Widely observed decreases in acute ischemic stroke presentation are potentially influenced by the risk profile of the population: during the COVID-19 era, patients with risk factors such as hypertension, hyperlipidemia, coronary artery disease, lack of insurance, or urban location increased their proportion of the stroke cohort [ 52 ]. Population health strategies to reduce COVID-19 may also lower infection rates with vasculotropic viruses and allergens that can trigger atherosclerosis and plaque rupture, which may result in neurovascular and cardiovascular morbidity [ 67 , 68 ].…”