Shashank Shekhar, MD, MS
Jasne AS, Chojecka P, Maran I, Mageid R, Eldokmak M, Zhang Q, Nystrom K, Vlieks K, Askenase M, Petersen N, et al. Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic. Stroke. 2020.
Stroke management requires quick and timely evaluation by medical personnel and transfer to a primary stroke center to provide appropriate medical care. The American Heart Association/American Stroke Association recently revised the stroke guidelines in 2019 to reflect the recent advancement in clinical research to clinical practice. However, after the COVID-19 pandemic started in the United States in January 2020, the whole medical system came under severe strain. Around 72% of United States adults were no longer going to public places, including hospitals, to avoid COVID-19 exposure.
This study estimates this decline in stroke volume in the Comprehensive Stroke Centers (CSC) in Connective and eventually aims to increase public awareness. The aims of the study were: compare the volume of stroke codes before and during the COVID-19 local spread; describe the demographics and clinical characteristics of patients presented with acute stroke-like symptoms during this pandemic; and find the association between the onset of the pandemic and acute stroke metrics and outcomes.
This study is a retrospective pre and during event cohort analysis and was approved by the Yale-New Haven Hospital (YNHH) Institutional Review Board with a waiver of informed consent. The date was including from pre-pandemic cohort and pandemic cohort from 2019 and corresponding months in 2020. The number of stroke codes at three hospitals was analyzed from January 1 to April 28, 2020, and compared from the previous year.
For aggregate analysis, the results suggest that a total of 822 stroke codes were called at all three comprehensive stroke centers (CSC) hospitals from January 1, 2020 to April 28, 2020. There was a significant decline in weekly stroke activation at three hospitals, with 2.5 fewer stroke codes each week (p<0.0001, R2=0.7163). Figure 4 shows a nice comparison of stroke activation from the previous year. The authors believe that even though the number of stroke activations went down, there is little reason to think that the overall incidence of ischemic stroke in the community went down. It might have gone up during humanitarian crises.
At patient-level analysis, a total of 383 stroke codes were called at CSC in two epochs: 169 in February 2020 (pre-pandemic) and 214 from March 1 to April 28, 2020 (pandemic). Fewer pandemic-epoch stroke code patients were female (45.3% vs 55.6%, p=0.045). Potential explanations for this disparity provided by the authors are that it could have been women presenting with non-traditional stroke symptoms, greater concerns amongst women about disease exposure, etc.
Patients were more likely to have a prior diagnosis of hyperlipidemia, CAD, substance abuse as risk factors. Other notable findings were: 3% of the pre-pandemic cohort was tested for COVID-19 during index hospital encounters compared to 35% pandemic (p<0.0001). Nine patients (5.4%) received IV-alteplase in a pre-pandemic month vs. 18 patients (8.5%) during the 2-month pandemic period (p=0.2439) without a significant difference in door-to-needle time. Another interesting note of CSC data was a higher rate of stroke code from patients living in CSC city, patients with lower extrapolated income, and patients without private insurance. On the contrary, there was no significant difference in the proportion of stroke codes resulting in thrombectomy, median door to reperfusion time, proportion of patients obtaining at least TICI2b reperfusion, and no association between COVID-19 rule out status either door-to-needle or door-to-reperfusion times. This suggests the robustness of the system was in place despite the COVID-19 crisis.
The study had several limitations, including the retrospective nature of the analysis; fewer local CSC was included. Nevertheless, this study reflects a real-world experience of stroke admission and treatment during the COVID-19 pandemic. The authors conclude that the temporary decrease in acute stroke codes was COVID-19 related. This decrease was irrespective of stroke severity. Further studies are needed at a national level to determine the pattern if the research is generalizable and identify appropriate education and care strategy during a similar pandemic.
It is a well-designed study and shows the robustness of our stroke system, as noted by no delays in the door-to-needle or perfusion time despite the current COVID-19 pandemic. The study does highlight the current trend in the lower rate of stroke activation and overall patient admissions. This may not suggest the accurate picture of a lower incidence of stroke in the community, albeit a fear and avoidance response amongst patients. With proper education and similar research, we could highlight and correct such issues.