key: cord-1052890-uz0qxm8z
authors: Wang, Jing; Chaudhry, Saqib A.; Tahsili-Fahadan, Pouya; Altaweel, Laith R.; Bashir, Sairah; Bahiru, Zelalem; Fang, Yun; Qureshi, Adnan I.
title: The Impact of COVID-19 on Acute Ischemic Stroke Admissions: Analysis from a Community-Based Tertiary Care Center
date: 2020-09-25
journal: J Stroke Cerebrovasc Dis
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105344
sha: baa6fe254ffa09c52df2df5a41e88048087953d2
doc_id: 1052890
cord_uid: uz0qxm8z

BACKGROUND/OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on hospital admissions and outcomes in patients admitted with acute ischemic stroke. METHODS: Single-center retrospective analysis of patients admitted to the hospital with acute ischemic stroke, between December 1(st), 2019 and June 30(th),2020. Outcomes were classified as none-to-minimal disability, moderate-to-severe disability, and death based on discharge disposition, and compared between two time periods: pre-COVID-19 era (December 1(st), 2019 to March 11(th), 2020) and COVID-19 era (March 12(th) to June 30(th), 2020). We also performed a comparative trend analysis for the equivalent period between 2019 and 2020. RESULTS: Five hundred and seventy-five patients with a mean age (years±SD) of 68 ±16 were admitted from December 1(st), 2019 to June 30(th), 2020, with a clinical diagnosis of acute ischemic stroke. Of these, 255 (44.3%) patients were admitted during the COVID-19 era. We observed a 22.1% and 39.5% decline in admission for acute ischemic stroke in April and May 2020, respectively. A significantly higher percentage of patients with acute ischemic stroke received intravenous thrombolysis during the COVID-19 era (p=0.020). In patients with confirmed COVID-19, we found a higher percentage of older men with preexisting comorbidities such as hyperlipidemia, coronary artery disease, and diabetes mellitus but a lower rate of atrial fibrillation. In addition, we found a treatment delay in both intravenous thrombolysis (median 94.5 min versus 38 min) and mechanical thrombectomy (median 244 min versus 86 min) in patients with confirmed COVID-19 infection. There were no differences in patients’ disposition including home, short-term, and long-term facility (p=0.60). CONCLUSIONS: We observed a reduction of hospital admissions in acute ischemic strokes and some delay in reperfusion therapy during the COVID-19 pandemic. Prospective studies and a larger dataset analysis are warranted.

The Coronavirus disease 2019 (COVID-19) pandemic has placed an unprecedented strain on healthcare systems and resources. [1, 2, 3] Despite the modifications in acute ischemic stroke (AIS) care due to the COVID-19 pandemic, 4 there is limited data to provide quantitative estimates of such changes. One of the research priorities identified by an international panel of stroke experts [4] was to better characterize the impact of COVID-19 pandemic on AIS epidemiology and workflow and guide resource allocation. A few recent publications reported reduced hospital admission for acute coronary syndrome, myocardial infarction, and AIS during the COVID-19 pandemic in several countries. [5, 6, 7, 8, 9, 10, 11] In addition, recent publications have reported decreased volume and delay in initiation of reperfusion therapy for AIS during the COVID-19 pandemic. [6, 8, 12] This study aims to assess the impact of the COVID-19 pandemic on AIS care at a large regional tertiary care center, focusing on admission volumes, time to reperfusion therapy, and patient outcomes.

This study was approved by the Institutional Review Board of Inova Fairfax Medical Center.

We identified all patients admitted to Inova Fairfax Medical Campus with a confirmed diagnosis of AIS or transient ischemic attack (TIA) from December 1 st , 2019 to June 30 th, , 2020 using a prospectively maintained stroke registry. We analyzed data from two distinct periods. First, we compared data from the 2.5 months prior to the first hospitalized COVID-19 patient at our facility (December 1 st , 2019 to March 11 th , 2020; pre-COVID-19 era) to the subsequent 2.5 month period (March 12 th to June 30 th , 2020; COVID era). Second, we performed a trend analysis which was compared to historic data in 2019 to assess potential seasonal variations.

Patient demographics including the primary diagnosis on admission, past medical history, the National Institutes of Health Stroke Scale (NIHSS), treatment modalities (intravenous thrombolytic and mechanical thrombectomy), and discharge disposition were collected. Outcomes were classified based on discharge disposition: none-to-minimal disability when patients were discharged to home or a short term facility; and moderate-to-severe disability when patients were discharged to a long term facility including acute rehabilitation, skilled nursing facility, and hospice. In-hospital mortality data were also collected. Previous studies have verified discharge destination as a surrogate for functional outcomes. 13 

Categorical variables are reported as absolute numbers and percentages. Continuous variables are presented as mean and standard deviation (SD) or median ± interquartile range (IQR). The Two-sample and paired t-tests were used to compare the numeric variables. Statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). All analyses were two-tailed, and the significance level was determined by p<0.05.

From December 1 st , 2019 to June 30 th , 2020, a total of 575 patients were admitted to Inova Fairfax Medical Campus with a clinical diagnosis of AIS or TIA, of whom 255 patients (44.3%) were admitted during the COVID-19 era. Baseline patient characteristics are summarized in Table 1 . Patients admitted during the COVID-19 pandemic were more likely to undergo intravenous thrombolysis (p=0.020) and mechanical thrombectomy (p=0.060). There were no differences in patient disposition between pre-COVID and COVID era (p=0.600).

Out of the 255 patients admitted with AIS, 130 patients (54.3%) were tested for COVID-19 infection using real-time reverse transcription polymerase chain reaction (rRT-PCR), of whom 9 patients (7%) tested positive. These 9 patients were more likely to be male, of older age, and with preexisting vascular comorbidities such as hyperlipidemia, coronary artery disease, and diabetes; however, they had a lower rate of atrial fibrillation. Only two patients received intravenous alteplase with a longer median door-to-needle time (94.5 versus 38.5 min), and one patient underwent mechanical thrombectomy with a longer median door-to-groin time (244 versus 86 min) compared to pre-COVID-19 era.

Since the outbreak of the COVID-19 pandemic, we observed a significant reduction of hospital admissions for AIS using the Cochran-Armitage trend test (p=0.002). The sharp decrease in volume started in March and persisted throughout May 2020, with 22.1% and 39.5% decline in April and May 2020, respectively. The number of AIS cases inversely correlated to the number of hospital admissions of COVID-19 cases (Figure 1 ). Acute ischemic stroke admission, when compared to the same period in 2019, remained relatively unchanged (Supplementary Figure 1a) .

The impact of the COVID-19 pandemic on hospital admissions for vascular diseases, including acute coronary syndrome [14] [15] and acute ischemic stroke, [6, [15] [16] [17] [18] [19] [20] has been reported. A 36.4% reduction in AIS admissions was seen in Brazil after COVID-19 compared to the same period in 2019. [16] In addition, data from four German comprehensive stroke centers showed reduced hospital admissions for AIS and TIA. 17 Our data, in line with the findings above, showed a reduction in AIS admissions associated with the COVID-19 pandemic in 2020. We found a relatively stable number of acute stroke admissions throughout 2019, devoid of seasonal variability (Supplementary data).

Interestingly, despite a reduction in the number of hospital admissions for AIS, a higher proportion of patients received reperfusion therapies compared to both pre-COVID-19 era in 2020 and from the same period in 2019. However, previous reports have shown a decreased number [21] [22] [23] but a relatively unchanged proportion [6, 18] of patients who received reperfusion therapy during COVID-19 pandemic. The first confirmed case in Virginia was reported on March 7, 2020, and the first confirmed case was admitted to our facility on March 12, 2020. Stay-athome orders were issued on March 30 th , 2020, in the Commonwealth of Virginia and Maryland and April 1 st , 2020, in the Washington D.C. We did not find a significant difference in initial NIHSS between pre-COVID and COVID eras in AIS patients who received IV thrombolysis, mechanical thrombectomy, or both although a trend towards higher initial NIHSS was observed during the COVID-19 era (Supplementary Table 1a ). This finding suggests that the increased rate of reperfusion therapies during the COVID-19 era is more likely due to a decline in minor and non-disabling stroke admissions, rather than an increase in stroke severity, leading to the increased ratio of patients presenting with disabling and large vessel occlusion. In patients with confirmed COVID-19 infection, we observed a higher percentage of older males with preexisting comorbidities, such as hyperlipidemia, coronary artery disease, and diabetes, similar to a previous report from Wuhan, China, [24] although we observed a lower rate of atrial fibrillation.

Acute Ischemic stroke may be the initial and the only presenting symptom in patients with COVID-19 infection. [25, 26] Early recognition and prompt reperfusion therapy are pivotal in reducing morbidity and mortality in AIS. We observed a significant delay in mechanical thrombectomy. Thorough assessment of one patient with a door-to-groin-puncture time more than 4 hours, highlighted several contributing factors, many attributable to the COVID-19 pandemic, including added time required for donning personal protection equipment leading to delay in symptoms recognition, neurological assessment, communication, transport, imaging, and procedures. Nevertheless, an unchanged median door-to-needle time for intravenous thrombolysis represents a consistent hospital-level approach to AIS treatment.

We did observe an increased length of stay in patients with COVID-19 infection. Factors that may be attributed to the delay are multifactorial. All patients required a negative COVID-19 test before discharge to rehabilitation facilities; two consecutive negative tests were required for those with COVID-19 infection. Completion of stroke workup including echocardiography and follow-up imaging, were delayed; and some studies such as brain MRI were postponed in COVID-19+ patients. We observed an increased percentage of patients with severe AIS and a decline in TIA and mild stroke admission that can also contribute to the increased length of stay.

Our study has a few limitations. This is an observational single-center retrospective study, and some prehospital data, including baseline functional status, symptom-onset to presentation time as well as discharge functional status and long-term functional outcomes, are not currently available for all patients. Only half of the patients with AIS were tested for COVID-19 infection. Also, stroke occurrence could have remained undetected in COVID-19 patients who were not clinically or radiographically evaluated for stroke.

In conclusion, we observed a reduction in the number of admission for AIS during the COVID-19 pandemic. A larger proportion of patients with AIS received reperfusion therapy. The long-term impact of COVID-19 pandemic on functional outcomes of patients with AIS, including those with TIA and minor strokes who did not seek medical care, warrants further investigation.

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