COVID-19: Are Acute Stroke Patients Avoiding Emergency Care?

Damian McNamara

April 08, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Neurologists across the country are reporting a drop in the number of acute stroke patients seeking emergency care during the COVID-19 pandemic ― suggesting that some patients may be intentionally staying home rather than risking coronavirus exposure at hospital emergency departments (EDs).

Stroke specialists in New Orleans, Chicago, Seattle, and elsewhere told Medscape Medical News they are seeing a precipitous drop in the number of acute strokes at their institutions ― and not just in the number of milder cases. Doctors on Twitter are sharing similar reports and are using social media to highlight this issue.

Gabriel Vidal, MD, a vascular and interventional neurologist at the Ochsner Medical Center, New Orleans, Louisiana, said there are "definitely" fewer patients with stroke and transient ischemic attack (TIA) seeking care at his facility and others throughout the New Orleans area, which has been hard hit by COVID-19.

"Even in Louisiana, we have a very large 53-hospital telestroke network, and the number of consults has diminished greatly," Vidal added.

In Chicago, emergency medical service activations for patients with suspected strokes are down about 30%, Shyam Prabhakaran, MD, professor and chair of neurology at the University of Chicago Biological Sciences, Illinois, told Medscape Medical News.

"It appears to be that mild stroke and TIA patients may be more likely to stay at home and seek alternative care rather than come to the ED," Prabhakaran said. However, "the severe strokes may be less affected and continue to come to emergency departments."

"Getting the Word Out"

That may not be the whole story in Seattle, Washington, where a stroke specialist at Harborview Medical Center reported a drop in patients across the stroke-severity spectrum.

Some patients with milder strokes no longer come to Harborview for a comprehensive evaluation and workup, but that is only "a partial explanation," said David Tirschwell, MD, medical director of comprehensive stroke care at the University of Washington (UW) Medicine Stroke Center at Harborview and a professor of neurology at UW.

"The thrombectomies are down also," he added. "It's hard to have great numbers in real time, but it's probably safe to say it's at least a 50% reduction in the number of admissions."

As a stroke referral center, his institution is seeing fewer local cases and referrals from outside hospitals. "I think both of those sources for admissions of stroke cases are down," Tirschwell said.

Recognizing the seriousness of forgoing essential care for acute stroke, neurologists, institutions, and medical groups are taking to social media to potentially save lives.

"Across our @FLStrokeReg we are seeing less patients with #stroke symptoms coming to our hospitals. We need to get the word out that our teams are working hard to safely provide care when needed during #COVID19," tweeted Ralph Sacco, MD, chief and professor of neurology, University of Miami Miller School of Medicine in South Florida, shared this tweet:

Although Florida Stroke Registry data are not publicly available, anecdotal reports suggest that stroke admissions are down among many hospitals, Sacco told Medscape Medical News.

Furthermore, this is not a phenomenon only in the United States. "This has also been reported in other nations hit by COVID-19," he said.

China is a prime example. There, many stroke centers have shown reduced functioning "because of fear of in-hospital cross infection and lack of experienced stroke care experts," Jing Zhao, MD, PhD, and colleagues write in an editorial published online March 31 in Stroke.

Preliminary data show that "thrombectomies in Shanghai decreased by 50% in the first month after the Spring Festival compared with the same period in 2019," write the editorialists, who are from Kings College London and the University of Pennsylvania in Philadelphia.

"Although the control of the COVID-19 is very important, at the same time, the management of stroke must not be neglected," they add.

"Over 9000 new stroke cases occur each day in China alone. It cannot be right that treatment for one potentially curable disease is euthanized at the expense of another."

Fear Factor?

The reasons individuals who may have experienced a stroke are avoiding emergency care is unclear at the moment. "I'm not really sure anyone really understands why, quite honestly," Tirschwell said.

Until survey data or other data emerge, many experts are assuming that fear of COVID-19 is trumping other medical concerns, including emergency treatment of stroke.

"We believe this could represent patients being fearful to come to medical facilities with stroke-like symptoms, given the COVID-19 pandemic," said Sacco, who is also incoming editor-in-chief of Stroke.

The BBC has been getting the word out in the United Kingdom via social media, with a tweet to "Dial 999 for stroke emergencies despite coronavirus."

The World Stroke Campaign is also using Twitter to emphasize the need for urgent stroke care when appropriate:

"Don't let concerns about COVID19 prevent you from seeking emergency treatment for stroke. If you spot the signs of stroke act FAST. Get emergency medical assistance," the group urged in a tweet.


Don't Hesitate

The American Heart Association (AHA) has addressed this troubling trend as well.

"People with serious symptoms shouldn't ignore them," Sarah Perlman, MD, associate professor of emergency medicine at the University of Colorado School of Medicine, Denver, states in an article on the AHA website.

Perlman added that some individuals who have signs of stroke and heart disease may hesitate to seek care because of fear that they are adding to an overburdened healthcare staff and system. However, she dismissed those concerns outright.

"If you're experiencing warning signs of a heart attack or stroke, call 911," she said. "Clearly, if there's an emergency, we are available and capable and eager to take care of you."

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