Burton J. Tabaac, MD
Diegoli H, Magalhães PSC, Martins SCO, Moro CHC, França PHC, Safanelli J, Nagel, V, Venancio VG, Liberato RB, Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020.
On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic. As of this writing, the global number of cases exceeds 8.1 million. However, despite the rapidly increasing prevalence of COVID-19, many questions remain regarding this unusual and highly lethal disease. The pathogenesis of COVID-19–associated neurologic injury remains to be established. SARS-CoV-2 has been shown to induce a hypercoagulable state, thus increasing the risk of arterial thrombosis with acute ischemic stroke.(1)
From late 2019 to early 2020, COVID-19 started to disrupt the healthcare systems of many nations. From the beginning of the pandemic, it has been a major concern for doctors and public authorities that resources needed to treat other conditions such as stroke are diverted for COVID-19.(2) The authors are keen to note that “patients may be unwilling to go to a hospital for stroke treatment due to fear of becoming contaminated with the disease.” Using a population-based stroke registry, the authors of this original contribution investigated the impact of the onset of the COVID-19 pandemic on stroke admissions in Joinville, Brazil. The authors’ hypotheses were as follows: First, hospital admissions for stroke were reduced after the onset of the COVID-19 pandemic. Next, the reduction occurred only in transient ischemic attacks (TIA) and mild cases. Also, there was a change in the time between stroke onset and hospital admissions. Finally, the number of patients receiving reperfusion therapies (IVT and MT) has decreased.
The paper does a good job demonstrating evidence of a significant reduction in stroke admissions after the onset of COVID-19 in Joinville, Brazil. The decrease was observed only in cases with transient, mild, or moderate stroke presentations (TIA and NIHSS score 0–8). The number of patients submitted to reperfusion therapies did not significantly decrease, and a change in the time between stroke onset and hospital admission was not observed.
Importantly, the authors discuss, “It does not appear that patients are having fewer strokes than before since cases of severe ischemic stroke, intraparenchymal hemorrhage, and subarachnoid hemorrhage are not declining. We hypothesize that the number of less severe strokes is also not falling. Instead, patients are not seeking hospital care. This may be because patients with stroke do not seek any medical care or because they are not correctly forwarded to a hospital.”
The authors continue to detail and theorize that patients may be reluctant to seek hospital care for fear of becoming infected: “Also, some people may be confused about stay-at-home orders meant to slow the spread of COVID-19. If patients look for medical care, they may consult with less-busy health services, which are not stroke facilities. Doctors in these services may be diagnosing fewer cases of stroke or not referring all cases to hospitals.” An interesting citation within the paper suggests another possibility that social restrictions cause individuals to be alone more often, and mild stroke signs or deficits accompanied by negligence may be unnoticed. Such an effect has suggested being a cause of delay in hospital admissions.(3)
It is concluded that the onset of COVID-19 was correlated with a reduction in hospital admissions for stroke in patients with less severe presentations. The authors underscore that particular attention should be given in reassuring the population about the importance of seeking medical assistance in case of symptoms of stroke, even if the presentation is mild or transient.
(1) B. Bikdeli, M.V. Madhavan, D. Jimenez, T. Chuich, I. Dreyfus, E. Driggin, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up. J. Am. Coll. Cardiol. (2020)
(2) Worp B, Sandset EC, Dichgans M, Caso V. Likely Increase in the Risk of Death or Disability from Stroke During the COVID-19 Pandemic. https://eso-stroke.org/eso/likely-increase-in-the-risk-of-death-or-disability-fromstroke- during-the-covid-19-pandemic/. (2020)
(3) Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke. 2006;37:1248–1253. doi: 10.1161/01.STR.0000217200.61167.39