Kevin O’Connor, MD

Katsanos AH, Palaiodimou L, Zand R, Yaghi S, Kamel H, Navi BB, Turc G, Benetou V, Sharma VK, Mavridis D, et al. Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Stroke. 2021.

COVID-19 complicates many aspects of clinical care, including care of stroke patients. Katsanos et al. conducted a meta-analysis on the impact of COVID-19 on the provision of stroke care, independent of SARS-CoV-2 infection status. They collected 46 studies capturing data from 129,491 patients across Africa, Asia, Europe, and the Americas comparing common stroke care variables pre- and post-pandemic onset. These included demographic information, vascular risk factors, intravenous thrombolysis (IVT) administration, endovascular thrombectomy (EVT) performance, relevant time metrics, and hospitalization outcomes.

Pandemic era patients tend to be younger (mean difference [MD], −1.19 [95% CI, −2.05 to −0.32]) and were more often males (OR, 1.11 [95% CI, 1.01–1.22]). No difference was seen with the prevalence of hypertension, atrial fibrillation, diabetes, dyslipidemia, coronary artery disease, or smoking. Pandemic stroke patients presented with more severe strokes based on initial NIHSS assessments (MD, 0.55 [95% CI, 0.12–0.98]), and large vessel occlusions (LVO) were more common among presenting stroke patients (OR, 1.63 [95% CI, 1.07–2.48]). It is not clear how much of the larger proportion of LVO patients is the result of COVID-19-induced hypercoagulability versus confounders like milder stroke patients avoiding healthcare settings during the pandemic.

Among patients with LVO, there was no difference in the likelihood of receiving EVT between the two periods (OR, 0.90 [95% CI, 0.46–1.79]). EVT as an acute stroke treatment overall, however, was more common during the pandemic than in the pre-pandemic period (OR, 1.24 [95% CI, 1.05–1.47]) and was without continental differences. Again, this may be related to factors discussed above. Although there was no difference in the likelihood of IVT (OR, 0.97 [95% CI, 0.84–1.12]) overall, subgroups in both Asia (OR, 1.23 [95% CI,1.17–1.30]) and Africa (OR, 2.54 [95% CI, 1.23–5.26]) showed an increased likelihood of IVT, while Europe’s likelihood of IVT was decreased (OR, 0.79 [95% CI, 0.68–0.92]).

Between the periods, mean onset-to-door time was similar (MD, −5.33 [95% CI, −54.99 to 44.34]). Length of stay pre- and during the pandemic also showed no difference (MD, −0.80 [95% CI, −1.63 to 0.04]). In-hospital mortality, however, was higher during the pandemic (OR, 1.26 [95% CI, 1.05–1.52]).

Since this meta-analysis aggregates global data, its findings may not reflect regional or institutional trends. As the pandemic continues, additional studies will inform our understanding of how COVID-19 has—and will—impact the provision of stroke care.