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COVID-19
with severe stroke symptoms continued
to present to the emergency department; however, those with more minor symptoms may have delayed presentation and ultimately been ineligible for treatment. However, the June 2020 data, which showed decreased treatment with alteplase and decreased mechanical thrombectomy, does seem to suggest that there may be other causes of decreased presentation, even for severe stroke symptoms. Minor stroke and transient ischemic attack mandate a workup equivalent to major stroke in order to prevent a recurrent ischemic event. Any acute neurologic change should prompt urgent medical
It is important for residents and health care providers in Delaware to understand the critical nature time plays in terms of treating acute ischemic stroke. Although of COVID-19 patients presenting with stroke as their primary diagnosis,5,6 we on a recent paper by Werkler et al, the rate of strokes in COVID-19 vs. strokes higher or 1.5% of emergency room visits/ hospitalizations with COVID-19.7
Anecdotally, a few COVID-19 patients have been diagnosed with pulmonary embolus or deep venous sinus thrombosis.
number of patients seen in Delaware due
REFERENCES
1. Larson, A., *Correspondence to: Anthony S. Larson, Savastano, L., Kadirvel, R., Kallmes, D., Hassan, A., . . . Larson, *. (2020, May 12). Coronavirus Disease 2019 and the Cerebrovascular-Cardiovascular Systems: What Do We Know So Far? Retrieved October 27, 2020, from https://www.ahajournals.org/doi/10.1161/JAHA.120.016793
2. Huang, C, Wang, Y, Li, X, Ren, L, Zhao, J, Hu, Y, Zhang, L, Fan, G, Xu, J, Gu, X, Cheng, Z, Yu, T, Xia, J, Wei, Y, Wu, W, Xie, X, Yin, W, Li, H, Liu, M, Xiao, Y, Gao, H, Guo, L, Xie, J, Wang, G, Jiang, R, Gao, Z, Jin, Q, Wang, J and Cao, B, 2020. Clinical Features Of Patients Infected With 2019 Novel Coronavirus In Wuhan, China.
3. New England Journal of Medicine. 2020. Large-Vessel Stroke as A Presenting Feature Of Covid-19 In The Young | NEJM. [online] Available at: https://www.nejm.org/doi/full/10.1056/NEJMc2009787
4. New England Journal of Medicine. 2020. Collateral Effect of Covid-19 On Stroke Evaluation In The United States | NEJM. [online] Available at: https://www.nejm.org/doi/full/10.1056/NEJMc2014816
5. Stroke. 2020. Impact of the COVID-19 Epidemic on Stroke Care and Potential Solutions | Stroke. [online] Available at: https://www. ahajournals.org/doi/10.1161/STROKEAHA.120.030225
6. Avula, A., Nalleballe, K., Narula, N., Sapozhnikov, S., Dandu, V., Toom, S., Glaser, A. and Elsayegh, D., 2020. COVID-19 Presenting As Stroke.
7. Merkler AE, Parikh NS, Mir S, et al. Risk of Ischemic Stroke in Patients with Covid-19 versus Patients with Influenza. Preprint. medRxiv. 2020;2020.05.18.20105494. Published 2020 May 21. doi:10.1101/2020.05.18.20105494
to a combination of early and decisive government action, compliance with stay- at-home orders, and a smaller population with less movement in and out of the state.
In this retrospective review, we assessed the impact of COVID-19 on stroke alert activations in the emergency department, radiology utilization, alteplase delivery, and mechanical thrombectomy at ChristianaCare, serving the populations of Delaware, Maryland, New Jersey, and Pennsylvania.
CONCLUSION
We found that the number of patients presenting with stroke-like symptoms
has decreased during the COVID-19 pandemic, and continues to be below average for alteplase treatment and mechanical thrombectomy. This offers insight into the health care and stroke resource utilization during the COVID-19 pandemic. It is unlikely that the true number of stroke or transient ischemic attacks has decreased, but rather, this population may be reluctant to seek medical care in the midst of the COVID pandemic. These potential explanations require further investigation.
The impact of lower rates of patients
determine and only seen in trends at 90 days and one year.
Any patient with stroke-like symptoms should be evaluated as quickly as possible, as time to reperfusion and complete reperfusion are the best predictors of a good outcome. All health care providers should expedite evaluation and care
of these patients, while maintaining appropriate contact precautions during COVID-19, given the potential risk of stroke in terms of disability and death.
CONTRIBUTORS
■ SRIDHARA S. YADDANAPUDI, MD is a quadruple-boarded neurologist, vascular neurologist internist and hypertension specialist and is currently a neurohospitalist at ChristianaCare in Newark.
■ KIM GANNON, MD, PHD is board certified
in neurology and vascular neurology, and serves as Medical Director for the Stroke Program across the ChristianaCare system, including the Comprehensive Stroke Center
at the Newark campus, Primary Stroke
Center at the Wilmington Campus, and the Acute Stroke Ready Hospital at Middletown. Gannon also serves as the leader for the Acute Neurosciences Community of Practice at ChristianaCare in Newark.
■ SUDHAKAR R. SATTI, MD, FAHA is a neurointerventional radiologist who specializes in minimally invasive surgery for complex cerebrovascular disorders, including stroke and aneurysm; currently serving as the Associate Director for Neurointerventional Surgery at ChristianaCare in Newark.
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