Strokes Impacted as COVID-19 Hit the Northeastern US

Not only are the numbers of patients presenting with stroke different in the COVID-19 era compared with the time before, data from hospitals in New York and Connecticut show that their clinical characteristics also differ.

What’s clear, the researchers stress, is that many people stayed home with stroke symptoms rather than seeking care—yet again pointing to the need to get the word out that patients shouldn’t be afraid to go to the hospital.

Shahram Majidi, MD (Mount Sinai Health System, New York, NY), lead author of a study focused on emergent large-vessel occlusion (EVLO) strokes, said their work shows an “unprecedented surge” in these severe events, which more than doubled when COVID-19 hit New York—some of these patients had no other COVID-related symptoms.

On the whole, though, the number of patients hospitalized with acute ischemic stroke dropped.

A similar decrease in stroke—this time irrespective of severity—was seen in the Connecticut-based study led by Adam S. Jasne, MD (Yale University School of Medicine, New Haven, CT), who attributed it to fear of potential COVID-19 exposure at the hospital. “I’ve had patients tell me that directly, as well, and I think there really needs to be education that if you’re having symptoms of a heart attack or symptoms of a stroke, it’s very important to come to the hospital. We do have systems in place to help keep you safe, but the best way for us to keep you safe is giving us the opportunity to treat your stroke,” he told TCTMD.

Both papers were recently published online in Stroke.

ELVO in NYC

For their study, Majidi and colleagues retrospectively looked at 45 consecutive patients hospitalized in New York City’s Mount Sinai Health System with ELVO strokes during the 3-week peak of COVID-19’s surge there. Among them, 24 (53%) tested positive for the virus, “which is significantly higher than the 19.9% infection rate in the general population in NYC,” they observe.

The COVID-19 patients were younger than those not infected with SARS-CoV-2 (mean 59 vs 74 years; P = 0.004), more apt to be male (75% vs 43%; P = 0.032), and less likely to be white (8% vs 38%; P = 0.027). The influence of age echoes an earlier report led by Majidi.

“Among the COVID-19 cohort, only 58% had typical COVID-19-related symptoms on presentation,” Majidi et al report. During their hospital stay, 60% of these previously asymptomatic people developed typical COVID-19 symptoms—meaning that for some patients, ELVO was the first and only manifestation of the viral disease.

“They had severe forms of COVID, but they presented with a stroke rather than [what] you expect patients to present with: respiratory failure, shortness of breath, fever, and those sorts of things,” said Majidi. So the takeaway is that especially in regions facing a surge and when treating stroke in patients without classic risk factors, clinicians should evaluate for possible COVID. At Mount Sinai, this phenomenon was only detected because of universal testing for the disease, he added.

Typically, an average of 21 ELVOs were seen in 3-week spans prior the pandemic, half of the 45 witnessed during the surge. Thrombolysis and endarterectomy were used in similar proportions of ELVO patients in both eras.

Across the Stroke Spectrum in CT

Jasne et al, in their paper, document a drop in stroke similar to what was seen at Mount Sinai and much like the now-notorious missing STEMIs.

From January 1 through April 28, 2020, a total of 822 stroke codes were activated at Yale-New Haven Hospital as well as two affiliated centers, Greenwich Hospital and Lawrence and Memorial Hospital, all in the state of Connecticut.

From February 18 to March 15, the number of stroke codes decreased by 12.8 per week, reaching a nadir amounting to 39.6% of expected strokes between March 10 to 16. Overall, the decrease between the 2020 pandemic and the same period in 2019 was 30%. Notably, there was no rise in within-network telehealth utilization for stroke to balance out that shift.

“All three hospitals saw a significant decrease in patients presenting as acute stroke codes during the pandemic, consistent with anecdotes and early data suggesting declines in presentation for non-COVID-19-related medical conditions including stroke,” the investigators write. “There is little reason to think that the overall incidence of ischemic stroke decreased during this period. Stroke incidence may increase during humanitarian crises. COVID-19 may increase stroke risk by mechanisms of hypercoagulability, endothelial cell-related vascular inflammation, systemic inflammation, or complications including myocarditis, heart failure, and dysrhythmias.”

Additionally, they assessed patterns in patients at Yale-New Haven Hospital’s comprehensive stroke center. The 211 “pandemic-epoch” patients were more likely than prior patients to have histories of hypertension, dyslipidemia, CAD, and substance abuse; to have public health insurance or none at all, to have a lower median household income, and to live in the same city as the facility. There were no differences related to age, sex, race/ethnicity, time to presentation, treatment delays, or disability level at discharge.

Unlike in New York, there was no difference in National Institutes of Health Stroke Scale (NIHSS) score among patients who made it to the hospital, suggesting that those with more-serious strokes were just as likely to stay home as those with, for example, a transient ischemic attack.

Beyond the value of confirming a decrease in stroke codes, “the details are actually really important, especially the severity information, which was a little surprising for us,” Jasne said.

Fear may not be the only barrier to care, the researchers point out: “Undiagnosed acute strokes may be an unintended consequence of social distancing, since typical environments where patients may be seen by others (school, work, and family gatherings) are less available. In the setting of a financial crisis, Americans may be hesitant to seek medical care due to fear of associated costs. Early studies suggest an unexpected increase in deaths at home during the current pandemic; it is conceivable that individuals with large stroke are dying at home, rather than coming to medical attention.”

What worries him, said Jasne, is what will happen “as COVID is now spreading in other states, or as we get future waves.” Beyond public health campaigns, individual clinicians should remind their patients one-on-one about common stroke symptoms, he advised. “Our paper may identify certain individuals who maybe we should focus more on as far as opportunities for prevention and education.” For instance, people living in suburban areas outside of New Haven were less likely to come into the hospital than those living in the urban area.