Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era

Henrique Diegoli, MD; Pedro S.C. Magalhães, MD; Sheila C.O. Martins, PhD; Carla H.C. Moro, MD; Paulo H.C. França, PhD; Juliana Safanelli, RN, MSc; Vivian Nagel, RN, PhD; Vanessa G. Venancio, RN; Rafaela B. Liberato, MSc; Alexandre L. Longo, MD


Stroke. 2020;51(8):2315-2321. 

In This Article


All data were obtained from a population-based stroke registry known as Joinville Stroke Registry (Joinvasc)—Population-Based Epidemiological Study on Cerebrovascular Diseases in Joinville. The anonymized data supporting the findings of the study are available from the corresponding author upon reasonable request.

The city is located in southern Brazil with an area of 1128 km2 and 590 466 inhabitants.[4] It is the city with the largest population in the state. Joinville has 6 hospitals, of which 3 are public, and 3 are private. The largest hospital (Hospital Municipal São José [HMSJ]) is a state-run public institution that only works through the Unified Health System (SUS). The SUS is Brazil's universal public healthcare system, having among its principles to provide healthcare of all complexity levels to all individuals without out-of-pocket payments. Around 80% of patients admitted with stroke in Joinville are treated in the HMSJ, whereas 5% are admitted to other hospitals also using SUS, and the remaining 15% use private hospitals (private health insurance or out-of-pocket payments). Around 30% of patients with stroke admitted to the HMSJ come from other cities and are not included in the registry. The hospital holds a TIA unit (4 beds), an acute stroke unit (5 beds), and a comprehensive stroke unit (21 beds) and performs IVT and MT routinely on patients with large vessel occlusion. Other hospitals do not have stroke or TIA units. IVT and MT are performed routinely in HMSJ and 2 private hospitals. Computed tomography or magnetic resonance is routinely performed in all patients with suspected stroke at hospital admission in the city. Therefore, no patient without brain imaging was included in the present analysis.

Data on stroke incidence in Joinville in 1995, 2005 to 2006, and 2012 to 2013 have been published previously.[5,6] The Joinville Stroke Registry is designed to identify patients using a 3-step approach to obtain incidence data,[7] including a daily revision of admissions at all hospitals in the city, a revision of death certificates (every 3 months), and diagnosis of stroke made in neurologists' clinics that do not admit to a hospital (monthly). The registry is regulated by municipal law. The process of data collection is coordinated by a neurologist and performed by 3 nurses, and the diagnosis and cause of stroke are reviewed by a neurologist on a weekly basis. All patients with suspected stroke are interviewed to collect demographic and clinical data. Economic, radiological, and genetic data are also obtained but are not covered in the present study. All study participants or their legal representatives provided informed consent, and the study design was approved by the appropriate ethics review board in the respective hospitals. Only Joinville's residents were taken into account, and cases from death certificates, ambulatory services, or patients that refused to participate were not included in the present analysis.

Data about COVID-19 diagnosis and deaths in Joinville and Brazil were obtained from publications on official governmental websites and were used to provide a clearer view of the pandemic situation in the locations of interest.[8,9] Most confirmed cases are on patients with severe presentations of the disease because large-scale testing was not recommended on patients that are asymptomatic or have mild cases at the time of the study.

The first confirmed case of COVID-19 in Brazil was in February 25.[9] Although there was a provisional measure for the federal government to take responsibility for social restrictions and other COVID-19 control measures,[10] the judicial system decided that such endeavors were the responsibility of states and municipalities.[11] The first confirmed case of COVID-19 in the city was on March 13, 2020,[8] when Brazil had 98 confirmed cases. On March 17 and 18, official decrees to start restrictions on social activities on municipal and state levels were published,[12,13] when there was still one confirmed case of COVID-19 in the city. March 17 was chosen as the cutoff date for the statistical analysis because it was the starting date for social restrictions, corresponding to the most significant changes in the daily activities of residents in the region. Up to that day, no official restrictions were in place at local, state, or national levels. The restrictions took place immediately and included the suspension of educational activities, public gatherings, cultural activities, some public services, the closing of restaurants, commerce, public transportation, reduction in industrial activities, and among other measures. There was also a reduction in ambulatory medical activities in the city, and part of general practitioners' time was reserved to accommodate spontaneous demand.

No additional facilities were opened that could divert patients with suspected stroke, and there was no change in protocols for forwarding patients with stroke. The hospital wards to treat patients with severe COVID-19 were opened in the same hospital that is the reference for stroke treatment in the city for the SUS.

Statistical Analysis

The number of COVID-19 and stroke cases was presented as cases/100 000 inhabitants, using as the denominator the 2019 official population estimates.[4,14] Population was assumed to remain stable from 2019 to 2020 because the change in population in recent years has been small (eg, a 1.2% increase from 2018 to 2019). Also, the 2020 official demographic estimates for 2020 are not yet available.

We compared stroke admissions from February 16 to March 16 and from March 17 to April 15 (30 days before and after the onset of COVID-19 restrictions) to the same periods in 2019. The period from March 17 to April 15 was also compared with 2019 as a whole. Incidence rates were displayed in cases/100 000.

We investigated if there was a change in mean age, sex, time between stroke onset and hospital admission, the number of patients that underwent revascularization procedures, type of stroke (ischemic stroke, intraparenchymal hemorrhage, subarachnoid hemorrhage, and TIA), and stroke severity, which was classified as mild (National Institutes of Health Stroke Scale [NIHSS] score 0–4), moderate (NIHSS score 5–8), and severe (NIHSS score >8). A Shapiro-Wilk test for normality was conducted for monthly stroke incidence and number of revascularization procedures (IVT or MT) per month, and the distributions of time from onset to admission were evaluated in histograms.

Data were compared by univariate analysis using the Wilcoxon-Mann-Whitney test for time from onset to admission and 2-tailed Fisher Exact Test for other variables using SAS Studio 3.8 (SAS Institute Inc, Cary, NC). Differences with P <0.05 were considered statistically significant.