COVID-19 Cuts Stroke Cases Nearly 40% Nationwide

Damian McNamara

May 12, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Almost 4 in 10 people experiencing an acute stroke during the COVID-19 pandemic in the United States appear to be avoiding emergency hospital care, new evidence suggests.

The number of people seeking stroke treatment dropped 39% in 2 weeks from late March through early April — at the height of stay-at-home orders nationwide — compared to pre-pandemic levels.

"I was very surprised by the magnitude of the decline. One of the reasons that hospitals reduced elective care was to maintain availability of hospital resources to treat COVID-19 and other critical conditions like stroke," lead author Akash Kansagra, MD, told Medscape Medical News.

The decrease, he added, is "unexpected and alarming."

The study was published online May 8 as a Letter to the Editor in the New England Journal of Medicine.

The findings add data to a series of anecdotal reports about a noticeable drop in stroke patients in New Orleans, Chicago, Seattle, and elsewhere, as previously reported by Medscape Medical News.

"Unlike earlier anecdotal reports, we have an enormous dataset representing almost a quarter million patients across virtually all of the United States," said Kansagra, director of endovascular surgical neuroradiology and codirector of the Stroke and Cerebrovascular Center at the Washington University School of Medicine and Barnes-Jewish Hospital in St Louis, Missouri.

The investigators analyzed data for 231,753 patients from 856 hospitals nationwide from July 1, 2019 to April 27, 2020. All patients underwent brain imaging interpreted with the help of RAPID software (iSchemaView, Menlo Park, California). The manufacturer collects results on a continuous basis.

Kansagra and colleagues compared the number of people in this neuroimaging database during 14 days from March 26 to April 8, 2020 versus cases in February 2020.

They found the rate dropped from 1.18 patients per hospital per day seeking acute care in February to 0.72 per hospital per day, a 39% decrease.

"What was also very unexpected was that this decline affected even patients with severe strokes or living in states with low COVID-19 burden," said Kansagra, who is also assistant professor of radiology, neurological surgery, and neurology at the Washington University School of Medicine.

"Before these data were available, many stroke experts believed that only patients with minor symptoms might be deterred from seeking care," he said. "Our data shows that this was decidedly not the case."

The investigators saw the decrease in stroke evaluations across all ages, sexes, and stroke severities. The finding held across different geographic regions and a range of hospital volumes as well.

"It is not just the old or the young or the people with minor strokes who aren't showing up," Kansagra said in a news release. "Even patients with really severe strokes are seeking care at reduced rates. This is a widespread and very scary phenomenon."

"The message here is that there are substantial collateral effects of the COVID-19 pandemic on care for other acute illnesses, such as stroke," he told Medscape Medical News. "Monitoring and responding to these trends is going to be an important part of how we as stroke experts can minimize the enormous impact of COVID-19 in the months ahead."

A Global Phenomenon

"I believe that the decrease of the stroke image evaluation in the United States is from the negative psychologic impact of COVID-19," Renyu Liu, MD, PhD, told Medscape Medical News when asked to comment.

"We observed about a 40% drop of stroke admissions across China," added Liu, who coauthored a study in press in Stroke also evaluating data about the decrease in patients.

A similar drop "is seen in many countries. This is a global issue," added Liu, professor of anesthesiology and critical care at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and director of the Stroke 1-2-0 Special Task Force for the Chinese Stroke Association.

Liu said the findings emphasize the importance of patient awareness and education about seeking stroke care, particularly during the COVID-19 pandemic.

"It is critical to reassure patients that they will not only be tested for potential coronavirus infection, but also be evaluated for potential stroke and managed in a timely manner to avoid sudden death and miserable potential life-long disability," Liu said.

Liu and colleagues also published an editorial in Stroke in March 2020 outlining the challenges and potential solutions regarding stroke care during the pandemic.

Consistent Findings

"This paper confirms reports from other countries and some early reports from select cities in the US suggesting that the number of patients being evaluated for acute stroke have decreased by 40% to 50% since the COVID-19 pandemic began," Mitchell Elkind, MD, told Medscape Medical News when asked to comment.

"One novel and interesting aspect of this paper is that they were able to look at a large swath of the US, including hundreds of hospitals, and found the trends were broadly consistent across all areas, as well as levels of stroke severity, age, and sex," added Elkind, president-elect of the American Heart Association, and professor of neurology and epidemiology, and head of the Division of Neurology Clinical Outcomes Research and Population Sciences (NeuroCORPS) at Columbia University in New York City.

The analysis focuses on patients with more severe stroke because it evaluates people undergoing specialized imaging, Elkind said.

Other factors beyond fear of exposure to COVID-19 could be driving the decrease in stroke evaluations, he added.

"For example, people who are isolating at home may not be as likely to be detected when the stroke occurs as if they were at work or in public. Also, air pollution is an important stroke trigger, and it is possible that decreases in air pollution with the economic shutdowns may have decreased stroke incidence."

ischemaView provided the data but played no other role in this unfunded, investigator-initiated study. Kansagra, Liu, and Elkind had no relevant disclosures.

N Engl J Med. Published online May 8, 2020. Full text

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