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


From January 2019 to April 15, 2020, the registry included 1169 patients with stroke, of which 917 were admitted in 2019. Only one patient denied participation, whose admission occurred in 2020 before the onset of COVID-19 in the city. Of all registrations, 3 were obtained from death certificates (all in 2019), 3 from ambulatory services (2 in 2019 and 1 in 2020 before COVID-19), and the remaining 1163 from hospital admissions.

Since the onset of COVID-19 restrictions in Joinville, we observed a significant reduction of 36.4% of all causes of stroke (P=0.0126) on hospital admissions, when compared with the same period in 2019 (Table 1 and Figure 1).

Figure 1.

Stroke admissions comparing before and after coronavirus disease 2019 (COVID-19) with the same periods in 2019.
The admission rates per 100 000 inhabitants of ischemic stroke (IS), transient ischemic attack (TIA), intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH) and strokes of unknown cause for the 30 days before and after the onset of COVID-19 are compared with the same period in 2019.

During 2019, the monthly stroke incidence in Joinville varied from 9.48 to 17.1 per 100 000 inhabitants (test for normality P=0.882; mean 12.94, SD 1.99; Figure 2). When the period after COVID-19 was compared with 2019, a reduction in admissions was observed in patients with TIA, mild, and moderate stroke (Table 2). In patients with TIA, a reduction was observed from an average 2.28 cases per 100 000 inhabitants per month in 2019 (SD 0.8) to 0.51 after COVID-19 (P=0.0049). In stroke with NIHSS score 0–4, we observed a decrease from an average 7.72 (SD 1.08) to 5.25 (P=0.0425), with NIHSS score 5–8 from 1.95 (SD 0.85) to 0.51 (P=0.0103), with NIHSS score 9–14 from 1.11 (SD 0.37) to 0.85 (P=0.1521) and with NIHSS score >14 from 1.83 (SD 0.67) to 1.52 (P=0.6181). The reduction in stroke admissions for TIA and mild stroke is shown in Figure 3. Age varied from mean 66.9 (SD 13.7) to 67.2 (SD 11.8, P=0.8995) and the proportion of female patients from 47.3% to 46.9% (0.5752).

Figure 2.

Stroke admissions by time period.
The admission rates per 100 000 inhabitants of ischemic stroke (IS), transient ischemic attack (TIA), intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and strokes of unknown cause are demonstrated for each month in 2019 and the first quarter of 2020. COVID-19 indicates coronavirus disease 2019.

Figure 3.

Time from stroke onset to admission according to time period.
These graphs demonstrate the proportion of patients according to time between stroke onset to admission, stratified by 0.5-h period. Of note, the shape of the distribution is similar between periods, with a peak around 1.5 h for all groups. COVID-19 indicates coronavirus disease 2019.

The proportion of patients with severe presentations increased in the period, although a significant change in absolute numbers was not observed. While in 2019, severe strokes accounted for 23%, after COVID-19, they corresponded to 29%. The admissions for intraparenchymal hemorrhage remained similar to those in 2019 (0.8 in 2019 [SD 0.4] and 0.5 after COVID-19), as well as those for subarachnoid hemorrhage (0.4 in 2019 [SD 0.2] and 0.2 after COVID-19), while admissions for patients with ischemic stroke reduced from 9.4 in 2019 (SD 1.4) to 6.3 after COVID-19 (P=0.0195; Table 1 and Table 2).

The hypothesized delay in time from onset to admission was not observed. We observed a nonsignificant decrease in median delay from 4 to 3.4 hours (P=0.659). The distribution of hours from stroke onset was right-skewed, with a peak around 1.5 hours, and was similar between periods (Figure 4).

Figure 4.

Hospital admissions for mild stroke and transient ischemic attack (TIA) before and after the spread of coronavirus disease 2019 (COVID-19).
This graph illustrates a correlation between cases diagnosed with COVID-19/100 000 inhabitants in Brazil and Joinville, and the number of patients admitted with TIA or mild stroke to a hospital in Joinville.

The number of patients provided with reperfusion therapies (IVT and IAT) in 2019 ranged from 0.51 to 1.35/100 000 per month (test for normality P=0.051, mean 1.04, SD 0.29). In the 30-day period after COVID-19, only 0.34/100 000 were treated with IVT or IAT, but there was no statistical difference from 2019 (P=0.1024).