Delays in Stroke Onset to Hospital Arrival Time During COVID-19

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, χ², 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). There were fewer patients admitted with a TIA during COVID-19 (3/73 [4.1%] versus 14/89 [15.7%], P=0.016), despite no significant increase in referrals to the TIA clinic (P>0.05).

The median stroke onset-to-door arrival time during COVID-19 was ≈60 minutes longer compared with pre–COVID-19 (154 [60–618] minutes versus 95 [58–291], P=0.12), and there was a significantly lower proportion of individuals with onset-to-door time within 4.5 hours (40/73 [54.8%] versus 64/89 [71.9%], P=0.024; 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 better clinical outcomes.³ Also, as the therapeutic time window for reperfusion therapy is narrow, any delays in seeking care would seriously jeopardize the eligibility for treatment. Although we were unable to evaluate the actual number of patients with TIA who did not seek care during COVID-19, the lower number of TIAs going through the acute stroke pathway suggests many patients with TIA may not have sought medical attention. Not seeking care for TIA is potentially devastating, as around 10% to 20% of patients with TIA may subsequently develop a stroke within 90-days.^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 (82/122 [67.2%] versus 94/152 [61.8%]) and hemorrhagic strokes (32/122 [26.2%] versus 38/152 [25.0%]; all P>0.05) appeared similar during COVID-19 and pre–COVID-19 periods. Further studies in larger 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 al⁸ 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.