Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic

Stroke. 2020 Sep;51(9):2664-2673. doi: 10.1161/STR.0000000000000347. Epub 2020 Jul 31.


Background: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic.

Methods: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic.

Results: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 (P=0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city (P<0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale.

Conclusions: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.

Keywords: coronavirus disease; pandemics; stroke.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Betacoronavirus
  • Brain Ischemia / diagnosis
  • Brain Ischemia / epidemiology*
  • Brain Ischemia / physiopathology
  • Brain Ischemia / therapy
  • COVID-19
  • Cohort Studies
  • Comorbidity
  • Connecticut / epidemiology
  • Coronary Artery Disease / epidemiology
  • Coronavirus Infections / epidemiology
  • Dyslipidemias / epidemiology
  • Emergency Medical Services
  • Ethnicity
  • Female
  • Humans
  • Hypertension / epidemiology
  • Income
  • Insurance, Health
  • Intracranial Hemorrhages / diagnosis
  • Intracranial Hemorrhages / epidemiology*
  • Intracranial Hemorrhages / physiopathology
  • Intracranial Hemorrhages / therapy
  • Male
  • Medically Uninsured
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Pandemics
  • Pneumonia, Viral / epidemiology
  • Retrospective Studies
  • SARS-CoV-2
  • Severity of Illness Index
  • Stroke / diagnosis
  • Stroke / epidemiology*
  • Stroke / physiopathology
  • Stroke / therapy
  • Substance-Related Disorders / epidemiology
  • Telemedicine
  • Thrombectomy
  • Thrombolytic Therapy
  • Time-to-Treatment / statistics & numerical data*