Nguyen-Huynh MN, Tang XN, Vinson DR, Flint AC, Alexander JG, Meighan M, Burnett M, Sidney S, Klingman JG. Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic. Stroke. 2020;51:2918–2924.

There is an increasing evidence base for dramatic shifts in patient presentation patterns in response to the COVID-19 pandemic, and this article presents the Northern Californian experience in the stroke alert population subgroup. Presented is a before-and-after cohort analysis of presentation volumes, demographics, and short-term outcomes.

Data from 21 medical centers serving a population of 4.4 million were aggregated — 19 primary stroke centers and 2 comprehensive stroke centers. All participated in the ‘Stopping Stroke’ program, which involved rapid CT angiography, telestroke assessment, and expedited treatment for large vessel occlusion. The breakpoint chosen was the institution of ‘Shelter-in-place (SIP)’ orders, the period of lockdown during the pandemic, with the date cutoff of March 15, 2020.

The visual representation in Figure 1 tells the main story. The orange trend line representing 2020 demonstrates a dramatic fall in total stroke alerts and in stroke discharges when compared with the previous year. Without the statistics to prove it, one can already see the overall pattern.

Figure 1. Stroke alert volumes and ischemic stroke discharges for 2019 and 2020.
Figure 1. Stroke alert volumes and ischemic stroke discharges for 2019 and 2020.

Not surprisingly, statistically significant reduction in volume was noted when the post-SIP period was compared with: the pre-SIP period, the months leading up to the pre-SIP period, and the same period the year prior (2019).

Demographic differences between the pre- and post-group were few, with a higher percentage arriving by ambulance, and with lower comorbidity scores post-SIP. Higher NIHSS scores were seen, and a higher proportion of patients went for endovascular stroke therapy for large vessel occlusion.

Such results add to the ever-growing evidence that lockdown periods are reducing presentation rates to acute hospitals, and it appears that Northern Californian stroke alerts have been no exception. This study confirms these trends in this particular population. It was noted that t-testing was used for pre- and post-intervention comparisons. While the methodology was sound, and while attempts to control for seasonality were acknowledged by using the corresponding time frame from the year prior, interrupted time series analysis with or without dynamic regression techniques may have strengthened the paper.

The concern remains regarding what happens to those patients who did not seek acute care as a result of the lockdown intervention. At present, data addressing this is scarce. Currently there is a concerted effort led by Monash Health to pool data from multiple sites in Australia, New Zealand, and several international centres to explore 90-day recurrence rate of stroke between baseline and pandemic cohorts. If successful, the results of this are not expected until later this year.