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Abstract
Despite the evidence suggesting a high rate of cerebrovascular complications in patients with SARS-CoV-2, reports have indicated decreasing rates of new ischemic stroke diagnoses during the COVID-19 pandemic. The observed decrease in emergency department (ED) visits is unsurprising during this major crisis, as patients are likely to prioritize avoiding exposure to SARS-CoV-2 over addressing what they may perceive as mild symptoms of headache, lethargy, difficulty speaking, and numbness. In the central and south Texas regions where we practice, we suspect that patient admission, treatment, and discharge volumes for acute stroke treatment have decreased significantly since COVID-19–related shelter-at-home orders were issued. Symptoms of stroke are frequently noticed by a family member, friend, or community member before they are recognized by the patients themselves, and these symptoms may be going unnoticed due to limited face-to-face encounters. This possibility emphasizes the importance of patient education regarding stroke warning signs and symptoms during the current period of isolation and social-distancing. The south Texas population, already saddled with above-average rates of cardiovascular and cerebrovascular disease, has a higher stroke mortality rate compared to Texas and U.S. averages; however, the number of patients presenting to EDs with acute ischemic stroke diagnoses is lower than average. In our viewpoint, we aim to present the relative literature to date and outline our ongoing analyses of the highly affected and diverse stroke populations in San Antonio and Austin, Texas, to answer a simple question: where did all our stroke patients go?
Highlights
In the midst of a pandemic, the advice from medical professionals to “stay home, save lives” may be preventing patients from seeking medical care when symptoms of stroke arise due to fear of contracting COVID-19
Symptoms of stroke are frequently noticed by a family member, friend, or community member before they are recognized by the patients themselves, which emphasizes the importance of patient education regarding warning signs and symptoms of stroke during the current exigent period of isolation and social distancing
We will test the hypothesis that the overall stroke presentation rate, absolute numbers of stroke diagnoses, and stroke interventions decline during COVID-19 stay-at-home orders are in effect compared to control time epochs
Summary
In the midst of a pandemic, the advice from medical professionals to “stay home, save lives” may be preventing patients from seeking medical care when symptoms of stroke arise due to fear of contracting COVID-19. There is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection [38,39,40,41,42,43], anecdotal reports indicate a falling rate of new ischemic stroke admissions [30,31,32,34,37,44,45,46,47,48], stroke code activations [30,36,49,50,51,52,53], imaging numbers [44,45], and diagnoses [45] This decrease in patient load is hypothesized by some to be driven by fewer patients presenting to the ED [54,55]. Evaluation of time revealed that patients treated during the COVID-19 period had no significant delay from TLKW to arrival or from arrival to imaging or treatment [45] These results further support that the driving factor for the decrease in stroke volume is that patients experiencing mild strokes are not seeking acute care. Kruskal-Wallis and Levene tests will be used to assess differences in categorical and continuous GWTG variables between and within time periods and metropolitan area cohorts, and segmented regression will be used to assess whether stroke presentation, interventions, and outcomes are more or less severe over the pre-, during, and post–COVID-19 stay-at-home order time periods
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