Lukas Mayer, MD

Jasne AS, Chojecka P, Maran I, Mageid R, Eldokmak M, Zhang Q, Nystrom K, Vlieks K, Askenase M, Petersen N, er al. Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic. Stroke. 2020;51:2664–2673.

Due to the rapid worldwide spread of SARS-CoV-2, the World Health Organization declared COVID-19 as a public health emergency on January 30, 2020. Measures to contain the pandemic have not only halted day-to-day living, but have shifted key health and societal priorities, as the pandemic posed an unprecedented situation.

Some recent evidence suggests a decrease in ischemic stroke incidence with some European stroke centers reporting a reduction in acute stroke admissions by as much as 50-80% during the initial phase of the COVID-19 crisis. Furthermore, stroke centers in China highlighted a drop in thrombectomy rates by about 25-50% in large cities and that a majority of stroke patients did not find access to dedicated stroke units. It is important to scrutinize whether these changes are indeed true.

In the September 2020 issue of Stroke, Jasne and co-authors present important data on stroke incidence, interventions, and outcomes before and during the COVID-19 crisis. The authors recorded stroke code calls in 3 major hospitals in Connecticut during the initial peak of SARS-CoV-2 infections from January to April 2020 and compared the stroke code activity with corresponding dates of previous years. Additionally, differences in patient characteristics (i.e., demographics, clinical presentation, pre-existing conditions, socioeconomic status, age), acute stroke management (door-to-needle/door-to-reperfusion time), and outcome were assessed to identify changes during the pandemic.

The authors evaluated 822 stroke code activations. A total decrease of about 13 stroke calls per week was recorded during mid-February and mid-March (P=0.0360) compared to non-pandemic times, with a rock bottom of stroke call activity from March 10 to 16, when stroke code activity decreased by 30%.

Further, Jasne et al. identified differences in patient characteristics in stroke code patients from February 2020 (initial phase of the COVID-19 crisis in Connecticut) to peak time pandemic patients (March and April 2020). Stroke code patients during the peak time were more likely to have preexisting cerebrovascular risk factors, prior cardiovascular disease, and come from lower income households in closer vicinity to one of the Connecticut Stroke Centers. Age, sex, and stroke severity, as well as acute management of stroke and outcome at discharge, did not differ, though.

Though well executed, the study’s limitations have to be discussed. The possibility that pandemic measures have shifted triage pathways or a quarantine effect of self-isolation have to be taken into account. Therefore, it is probable that stroke code activity in the 3 Connecticut centers does not reliably reflect real world data. For example, patients with minor symptoms might not have been triaged to comprehensive stroke centers but rather to smaller, rural hospitals, which may also explain the predominance of patients living in closer vicinity to the stroke centers during the pandemic. Therefore, the results of this study have to be interpreted carefully.

Regardless, these data imply a difference in the management of patients with suspected ischemic stroke during the COVID-19 crisis. This study emphasizes the need of nationwide collaborations to get the a full picture on whether measures to prevent the crisis have altered triage pathways or acute management of ischemic stroke. Additionally, more detailed analyses are required to validate the recently suggested impact that SARS-CoV-2 infections have on the cerebrovascular and the coagulation system.