key: cord-0866600-0yc0tdqb
authors: Teo, Kay-Cheong; Leung, William C.Y.; Wong, Yuen-Kwun; Liu, Roxanna K.C.; Chan, Anna H.Y.; Choi, Olivia M.Y.; Kwok, Wing-Man; Leung, Kung-Ki; Tse, Man-Yu; Cheung, Raymond T.F.; Tsang, Anderson Chun-On; Lau, Kui Kai
title: Delays in Stroke Onset to Hospital Arrival Time During COVID-19
date: 2020-05-26
journal: Stroke
DOI: 10.1161/strokeaha.120.030105
sha: da52f250ceb34ccf30963fd9e8feb73c6d43c842
doc_id: 866600
cord_uid: 0yc0tdqb

BACKGROUND AND PURPOSE: The current coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis, disrupting emergency healthcare services. We determined whether COVID-19 has resulted in delays in stroke presentation and affected the delivery of acute stroke services in a comprehensive stroke center in Hong Kong. METHODS: We retrospectively reviewed all patients with transient ischemic attack and stroke admitted via the acute stroke pathway of Queen Mary Hospital, Hong Kong, during the first 60 days since the first diagnosed COVID-19 case in Hong Kong (COVID-19: January 23, 2020–March 24, 2020). We compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways with patients admitted during the same period in 2019 (pre–COVID-19: January 23, 2019–March 24, 2019). RESULTS: Seventy-three patients in COVID-19 were compared with 89 patients in pre–COVID-19. There were no significant differences in age, sex, vascular risk factors, nor stroke severity between the 2 groups (P>0.05). The median stroke onset-to-door time was ≈1-hour longer in COVID-19 compared with pre–COVID-19 (154 versus 95 minutes, P=0.12), and the proportion of individuals with onset-to-door time within 4.5 hours was significantly lower (55% versus 72%, P=0.024). Significantly fewer cases of transient ischemic attack presented to the hospital during COVID-19 (4% versus 16%, P=0.016), despite no increase in referrals to the transient ischemic attack clinic. Inpatient stroke pathways and treatment time metrics nevertheless did not differ between the 2 groups (P>0.05 for all comparisons). CONCLUSIONS: During the early containment phase of COVID-19, we noted a prolongation in stroke onset to hospital arrival time and a significant reduction in individuals arriving at the hospital within 4.5 hours and presenting with transient ischemic attack. Public education about stroke should continue to be reinforced during the COVID-19 pandemic.

S troke is a devastating disease with high mortality and morbidity rates. The timely and effective delivery of acute stroke care, especially reperfusion therapy for ischemic stroke, significantly improves stroke outcomes. 1, 2 The provision of acute stroke care has been put to the test during the coronavirus disease 2019 (COVID-19) outbreak. Since its emergence in December 2019 in China, it has rapidly evolved into a global pandemic crippling healthcare services around the world.

Hong Kong (HK) recorded its first COVID-19 case on January 23, 2020, and is still in its containment phase as of the current writing, without sustained community spread. Nonemergency services throughout hospitals in HK have been adjusted to cope with the outbreak, and workforce allocation for acute stroke pathways has been maintained as much as possible.

Nevertheless, it remains uncertain whether COVID-19 has influenced public behavior in seeking medical attention for stroke and whether stroke services have been affected. We, therefore, compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways during the COVID-19 outbreak with a similar period in 2019.

The data that support the findings of this study are available from the corresponding author on reasonable request. We retrospectively reviewed consecutive patients with transient ischemic attack (TIA)/stroke who were admitted to Queen Mary Hospital, HK, via the acute stroke pathway during the first 60 days since the first diagnosed case of COVID-19 in HK (COVID-19: January 23, 2020-March 24, 2020). We compared these patients with those admitted during the same period in 2019 (pre-COVID-19: January 23, 2019-March 24, 2019). Patients were retrieved from the ongoing Queen Mary Hospital stroke registry, which is approved by the local research ethics board.

Queen Mary Hospital is a comprehensive stroke center in HK that admits ≈800 patients with TIA/stroke every year. Our acute stroke pathway encompasses a multidisciplinary team that enrolls patients with stroke presenting to the A&E Department within 24 hours of symptom onset or last seen well time. The diagnosis of TIA/stroke was confirmed by the attending neurologist or neurosurgeon. We excluded patients who did not have a TIA/stroke or were admitted to Queen Mary Hospital without going through the acute stroke pathway, such as patients presenting >24 hours after symptoms onset.

We collected details of baseline demographics, vascular risk factors, stroke subtype and severity, and details of acute stroke treatment of patients during the COVID-19 and pre-COVID-19 periods. Stroke onset-to-door time was defined as the duration between symptoms onset or last seen well time to A&E Department arrival; door-to-needle time was the duration between A&E Department arrival to the administration of IV r-tPA (intravenous recombinant tissue-type plasminogen activator), whereas door-to-groin time was the time between A&E Department arrival to groin puncture for endovascular thrombectomy.

Baseline demographics, vascular risk factors, stroke subtypes and severity, stroke onset-to-door time, and critical time points in inpatient acute stroke care between COVID-19 versus pre-COVID-19 were compared using t test, χ 2 , and Mann-Whitney U test where appropriate. All analyses were done with Stata version 14, and a P value of <0.05 was considered statistically significant.

During the period January 23, 2020 to March 24, 2020, a total of 386 COVID-19 cases were diagnosed in HK ( Figure 1 ). Seventy-three and 89 patients with TIA/ stroke were admitted through the acute stroke pathway during the COVID-19 and pre-COVID-19 periods, respectively. No significant differences in age, sex, vascular risk factors, nor stroke severity were noted between the 2 groups (Table) Figure 2 ). There were otherwise no significant differences in the ambulance scene arrival to hospital arrival time, proportion of patients receiving reperfusion therapy, door-to-needle time, and mechanical thrombectomy procedural times during the 2 periods (Table) .

Our results highlight the possible increased reluctance of patients in seeking hospital treatment for TIA/stroke symptoms during the COVID-19 outbreak. Compared with the same period in 2019, during COVID-19, the median symptom onset-to-door time was up to 60 minutes longer, fewer patients with TIA sought hospital treatment, and the proportion of patients arriving within the therapeutic time window of IV r-tPA was significantly lower.

Delays in seeking care or not seeking care would be detrimental to stroke outcome. Time is brain, and earlier reperfusion for ischemic stroke is associated with 4, 5 Early treatment of TIA could reduce this risk by 80%. 6 Hence, to ensure appropriate treatment could be provided to patients with TIA/stroke during COVID-19, public awareness campaigns on symptoms of TIA/stroke and the importance of seeking immediate medical care should be enhanced. Our study is limited by its retrospective nature and inclusion of a small number of subjects managed in a single comprehensive stroke center based in HK. Although our results reflected patients' possible reluctance to attend hospitals, we were unable to confirm this with individual patients due to the retrospective nature of the study. Further studies focusing on the changes in patients' behavior during COVID-19 are warranted. As a hospital-based stroke registry, we were also not able to determine whether ambulance response times have changed during COVID-19. Nevertheless, this is indeed possible due to the need for enhanced disinfection procedures between patients (personal communication with ambulance services). Our study was also limited, as due to a small number of subjects, we were unable to determine whether stroke epidemiology has changed during COVID-19. A brief analysis on all patients with TIA/stroke admitted to our hospital (mainly including those presenting beyond 24 hours into the current study cohort) revealed that the proportion of ischemic ( population-based cohorts are nevertheless required to determine further how COVID-19 has led to a change in stroke epidemiology and also functional outcomes. Although HK is still in the containment phase of managing COVID-19, the stroke service appears to have mostly maintained. However, in countries that are hard-hit by the outbreak, stroke centers have been reorganized to assist the fight against COVID-19, 7 reflecting the impact of COVID-19 on stroke care. Globally, every effort is needed to ensure that acute stroke care is not compromised. As Zhao et al 8 poignantly pointed out, centralized diversion to protected stroke centers that remain fully operational, and informing the public of such system is vital to prevent tragedies of potentially treatable patients with stroke being denied appropriate treatment during this pandemic.

Stroke Thrombolysis Trialists' Collaborators Group. Effects of alteplase for acute stroke on the distribution of functional outcomes: a pooled analysis of 9 trials

Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials

Acute stroke intervention: a systematic review

Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services

Incidence and short-term prognosis of transient ischemic attack in a population-based study

Early Use of Existing Preventive Strategies for Stroke (EXPRESS) Study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

Stroke Care During COVID-19 Pandemic

Challenges and potential solutions of stroke care during the coronavirus disease 2019 (COVID-19) outbreak

Received April 4, 2020; accepted May 1, 2020. Fan Stroke and Dementia Research Fund during the conduct of the study, grants, personal fees, and nonfinancial support from Boehringer Ingelheim, grants from Sanofi, grants from Eisai, grants from Amgen, and grants and nonfinancial support from Pfizer outside the submitted work. The other authors report no conflicts.