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

Disclosures

Stroke. 2020;51(8):2315-2321. 

In This Article

Discussion

In the present article, we provide evidence of a significant reduction in stroke admissions after the onset of COVID-19 in Joinville, Brazil. The decrease was observed only in cases with transient, mild, or moderate stroke presentations (TIA and NIHSS score 0–8). The number of patients submitted to reperfusion therapies did not significantly decrease, and a change in the time between stroke onset and hospital admission was not observed.

Neurologists around the world have reported decreases in stroke cases admitted during the COVID-19 pandemic era.[15–17] However, we found no published population-based cohort to compare our data. Authors of a study in South Korea, during the MERS (Middle East respiratory syndrome) outbreak, found a 33% reduction in admissions to emergency services, with a 16.6% decrease in admissions for ischemic stroke.[18] A decline was also noticed in cardiology services for coronary artery disease admissions during the COVID-19 pandemic.[19] Therefore, the finding is probably not restricted to stroke, nor to the geographic region where the present study was conducted.

It is not clear to what extent the reduction in admissions is related to the population's behavior or to changes in the healthcare system. It does not appear that patients are having fewer strokes than before since cases of severe ischemic stroke, intraparenchymal hemorrhage, and subarachnoid hemorrhage are not declining. We hypothesize that the number of less severe strokes is also not falling. Instead, patients are not seeking hospital care. This may be because patients with stroke do not seek any medical care or because they are not correctly forwarded to a hospital.

Patients may be reluctant to seek hospital care for fear of becoming infected. Also, some people may be confused about stay-at-home orders meant to slow the spread of COVID-19. If patients look for medical care, they may consult with less-busy health services, which are not stroke facilities. Doctors in these services may be diagnosing fewer cases of stroke or not referring all cases to hospitals. Of note, the hospital reference for stroke treatment in Joinville for patients using SUS is the HMSJ, which is also the region's reference for treating COVID-19.

Although people may be concerned about seeking a hospital, where they may have an increased risk of COVID-19 infection, appropriate management of cases of suspected stroke continues to be recommended.[20,21] A delay in evaluation of mild cases may have severe consequences, such as pneumonia and early stroke recurrence, and may increase the burden on intensive care units. The correct management of TIAs, for example, has been demonstrated to reduce in 80% the risk of early stroke recurrence.[22,23]

Another possibility is that social restrictions cause individuals to be alone more often, and mild stroke signs or deficits accompanied by negligence may be unnoticed. Such an effect has suggested being a cause of delay in hospital admissions.[24]

Joinville is an industrial city, and since social restrictions, industrial activity, and car traffic have been reduced. Authors from the Global Burden of Disease Study estimated that the population-attributable risk factor of ambient air pollution for stroke is 18.4%.[25] There is also evidence that short-term increases in PM2,5 and NO2 levels are correlated with more hospital admissions for stroke.[26] Therefore, a reduction in air pollution may have contributed in reducing stroke incidence, although it is unlikely to be the sole cause because of a disproportionate reduction of admissions for TIA and other less severe presentations of stroke.

Our data do not provide evidence of a significant difference in median time from stroke onset to admission. Although some patients may experience a delay in seeking medical care (which our data do not support), a higher proportion of patients admitted with severe stroke creates a selection bias. In more severe cases, patients may seek help faster and call ambulances more often.[24]

As initial measures to mitigate the situation in Joinville, doctors in emergency departments and emergency medical services were contacted and instructed to continue referring all patients with suspected stroke to the stroke center. Following the instructions of the World Stroke Organization, healthcare professionals and stroke patients' associations began to inform the population through local media about the importance of acting correctly in a suspected case of stroke.

Strengths and Weaknesses

The study uses prospectively obtained incidence of stroke on a population-basis according to the World Health Organization Steps Criteria,[7] using patient-level data. To our knowledge, this is the first population-based study to publish data about hospital admissions for stroke after the spread of COVID-19.

Of particular concern to the present analysis is the integrity of the process of collecting data in a time of a pandemic. The authors reviewed if the same protocols were being undertaken and found no changes in the number of staff or routine of data collection. There was also no change in official referral pathways of patients with suspected stroke or other severe illness. However, it is unknown if some doctors have individually chosen to stop referring patients to hospitals. Additional cases of patients with stroke may enter the registry from death certificates or ambulatory cases, but those cases were not included in the present analysis.

The article is unable to demonstrate how epidemiological data evolve months after the spread of COVID-19. The authors are highly concerned about the long-term consequences of the pandemic in stroke. Changes in the healthcare system such as a reduction in GP visits, the suspension of patients' groups for managing hypertension, smoking, and diabetes mellitus, a reduction of 16% in beds in the stroke unit, and a decrease in the number of staffs may have consequences observed in the following months to years. Also, it was not possible to demonstrate the impacts of stroke directly related to COVID-19 since no case of stroke with COVID-19 was detected in the city.

Conclusions

The onset of COVID-19 was correlated with a reduction in hospital admissions for stroke in patients with less severe presentations. A rapid reorganization of stroke-care networks is necessary to reduce collateral damage caused by COVID-19. Particular attention should be given in reassuring the population about the importance of seeking medical assistance in case of symptoms of stroke, even if the presentation is mild or transient.

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