Stroke Hospitalizations and IVT Decreased Globally During COVID-19 Pandemic

Raul Nogueira, MD

Data from a recent study suggest that the COVID-19 pandemic has been associated with a global decline in stroke hospitalizations, intravenous thrombolysis (IVT), and interfacility IVT transfers. 

Researchers found that stroke admissions declined by 11.5% (95% CI, –11.7 to –11.3; P <.0001), IVT therapies declined by 13.2% (95% CI, –13.8 to –12.7; P <.0001), and interfacility IVT transfers decreased by 11.9% (95% CI, –13.7 to –10.3; P = .001) during the pandemic months.

“The decreases in the volume of stroke care provided were noted across centers with high, intermediate, and low COVID-19 hospitalization burden, and also across high, intermediate, and low volume stroke and IVT centers. As hypothesized, the magnitude of decrease of stroke hospitalizations and IVT was greater in centers with higher COVID-19 inpatient volumes,” wrote first author Raul Nogueira, MD, director, neuroendovascular service, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital; and professor, neurology, neurosurgery and radiology, Emory University School of Medicine, and colleagues.

Nogueira and colleagues conducted a cross-sectional, observational, retrospective study across 457 stroke centers in 70 countries across 6 continents. They found that there were 82,465 stroke hospitalizations and 12,527 IVT therapies performed in the 4 months in the prior year to the pandemic (March 2019 to June 2019), 91,373 stroke hospitalizations and 13,334 IVT therapies performed in the 4 months prior to the pandemic (November 2019 to February 2020), and 80,894 stroke hospitalizations and 11,570 IVT therapies performed during the first 4 months of the pandemic (March 2020 to June 2020).

READ MORE: COVID-19 Diagnosis at Stroke Onset Linked to Worse Outcomes

Stroke admissions were found to have declined by the aforementioned 11.5% between the 4 months pre-pandemic and first 4 months of the pandemic. The monthly median stroke hospitalization volume per center dropped from 54.0 (interquartile range [IQR], 30.8-86.5) to 43.0 (IQR, 24.3-71.3; P <.0001) at 325 sites in the same time period.

Decline in stroke hospitalization pre- and early-pandemic varied geographically, with a 7.1% drop in Asia (95% CI, –7.4 to –6.9; P <.0001), a 18.8% drop in North America (95% CI, –19.3 to –18.3; P <.0001), a 10.0% drop in Europe (95% CI, –10.4 to –9.6; P <.0001), a 17.4% drop in South America (95% CI, –18.5 to –16.3; P <.0001), and a 30.2% drop in Africa (95% CI, –32.2 to –28.3; P <.0001). Stroke hospitalizations did not significantly fall in Oceania. Primary stroke centers (PSCs; 89 centers) experienced a decline of 17.3% (95% CI, –17.9 to –16.7) compared to comprehensive stroke centers (CSCs; 236 centers) which experienced a decline of 10.3% (95% CI, –10.6 to –10.1).

IVT therapies declined by 13.2% (95% CI, –13.8 to –12.7; P <.0001) between pre- and early-pandemic, with a median monthly IVT volume per center of 6.2 (IQR, 2.8-12.0) pre-pandemic and 5.3 (IQR, 2.0-10.5; P <.001) at 389 centers in the early-pandemic period.

IVT declined by 10.1% in Asia (95% CI, –11.2 to –9.1; P <.0001), 14.4% in North America (95% CI, –15.6 to –13.3; P <.0001), 13.4% in Europe (95% CI, –14.3 to –12.5; P <.0001), 24.2% in South America (95% CI, –27.6 to –21.0; P <.0001), and 23.5% in Africa (95% CI, –29.8 to –18.2; P <.01) during this time period. Again, no significant drops were seen in Oceania. IVT declines were greater in PSCs (–15.5% [95% CI, –16.9 to –14.2]; 138 centers) versus CSCs (–12.6% [95% CI, –13.3 to –12.0]; 251 centers; P = .0001).

Nogueira and colleagues compared the early 2 months of the pandemic (March 2020 to April 2020) with the later 2 months (May 2020 to June 2020) and found that stroke hospitalizations had increased from 38,616 to 42,278, representing a 9.5% increase (95% CI, 9.2-9.8; P <.0001; 325 centers). This recovery was seen in hospitals at all levels of COVID-19 hospitalization burden, with higher recovery seen in low burden hospitals (14.6% [95% CI, 14.0-15.2]; P <.0001) compared to intermediate (9.0% [95% CI, 8.4-9.5]; P <.0001) and high volume (4.6% [95% CI, 4.2-5.0]; P <.0001) COVID-19 hospitalizations.

Hospitals with baseline higher stroke hospitalization volume recovered the most (13.9% [95% CI, 13.5-14.3]; P <.0001), whereas intermediate and low baseline stroke volume hospitals did not significantly recover. Stroke hospitalization volume recovery was more significant in CSCs (10.9% [95% CI, 10.6-11.3]; P <.0001) compared to PSCs (1.8% [95% CI, 1.5-2.1]; P = .3).

IVT administration increased from 5,714 early pandemic to 5,856 late pandemic, representing a non-significant increase of 2.5% (95% CI, 2.1-2.9; P = .19). Intermediate IVT volume centers saw a more significant recovery in IVT volume (6.1% [95% CI, 5.0-7.4]) compared to low volume (2.6% [95% CI, 1.9-3.6]; P <.0001) COVID-19 hospitalization centers. A trend in IVT volume recovery was seen with CSCs (4.1% [95% CI, 3.6-4.7]; P = .053) compared with PSCs.

Interfacility IVT transfers decreased by 11.9% (95% CI, –13.7 to –10.3; P = .001). These declines were significant in low (–18.3% [95% CI, –23.9 to –13.9]; P = .03) and high-COVID-19 volume centers (-14.9% [95% CI, –18.1 to –12.1]; P = .008). 

Secondary analyses revealed declines in all stroke measures between the prior year and pandemic months, supporting primary analyses. Nogueira and colleagues also collected data from 269 centers on patients with stroke and COVID-19. They found that 1.48% (1778/119,967) of COVID hospitalizations had a stroke diagnosis. This varied between continents, with 1.6% in Africa, 1.5% in Asia, 0.4% in Oceania, 1.4% in Europe, 1.2% in North America, and 3.0% in South America.

Conversely, 3.3% of stroke hospitalizations were found to have SARS-CoV-2 infection, with 3.1% in Africa, 2.7% in Asia, 0.5% in Oceania, 3.3% in Europe, 3.0% in North America, and 8.4% in South America.

“Recovery of stroke hospitalization but not IVT volume was noted in the later phase of the pandemic months and associated with lower COVID19 hospital burden, high volume, and comprehensive stroke centers. The findings of our study can inform future studies, preparedness, and local policies in the event of a second COVID-19 surge or future pandemic,” Nogueira and colleagues concluded.

REFERENCE

Nogueira RG, Qureshi MM, Abdalkader M, et al. Global impact of COVID-19 on stroke care and intravenous thrombolysis. Neurology. Published online March 25, 2021. doi: 10.1212/WNL.0000000000011885