Article In Brief
Stroke neurologists in certain cities have seen fewer strokes in the emergency department, in large part, they contend, because people are nervous about calling 911 and going to emergency departments during COVID-19.
Yale School of Medicine Professor Kevin Sheth, MD, FAAN, noticed something unusual happening at Yale New Haven Hospital amid COVID-19's first surge in his area: There was a steep decline in emergency stroke admissions.
Over a period of a month, admissions had fallen by as much as 60 to 80 percent. At first, he assumed the drop-off was due to patients avoiding the hospital emergency department. “Now, I'm not so sure,” he wrote in a perspectives article published April 9 in the Washington Post.
“Lulls in stroke admission in normal times last a day or two, not weeks and they will be seen in one center, not across the board,” said Dr. Sheth, chief of neurocritical care and emergency neurology at the hospital.
“In speaking with colleagues around the country, it is clear my medical center is not alone. Stroke volumes appear to be dropping almost everywhere, and the same may be true for heart attacks and other conditions, so I am more than a little concerned.”
Although still anecdotal, if patients with stroke symptoms are avoiding calling 911 or going to hospitals for fear of contracting the virus, neurologists need to make sure that at-risk patients and their families are made aware that stroke specialists and units remain ready to help if they or a loved one shows any signs of stroke, he said.
Fewer Admissions in Florida
At the University of Miami's McKnight Brain Institute, Executive Director Ralph L. Sacco MD, FAAN, professor and chair of neurology, told Neurology Today that Dr. Sheth's observations are similar to what he has witnessed himself, and that colleagues at hospital stroke centers in Florida have reported similar declines.
“We've all seen a reduction in emergency stroke admissions, notably in patients with mild-to-moderate symptoms. We're not sure why, but most of us believe that people are not calling 911 for mild-to-moderate symptoms, said Dr. Sacco, immediate past president of the AAN.
Dr. Sacco said that he recently reviewed a register of 120 centers around the state, and most have experienced similar declines in mild-to-moderate stroke admissions. “We are still seeing the same number of severe strokes, but that isn't surprising because it's not something that a person can put off seeking emergency medical care.”
Shazam Hussain, MD, director of Cleveland Clinic's Cardiovascular Center, also told Neurology Today that cases are down. “It is happening. We just don't know why,” he said.
Eliza C. Miller, MD, assistant professor of neurology and director of the Mothers Center Neurovascular Clinic at Columbia University Irving Medical Center, has witnessed the pandemic's impact from its epicenter in New York City.
“There has been a significant reduction in the number of acute stroke presentations to the ED here, although the numbers are starting to increase again,” she told Neurology Today.
Dr. Miller told Neurology Today that there has been high-level coordination from NewYork Presbyterian/Columbia leadership and the state's regional stroke care system, to make sure that beds are available for all the patients who need them, and that she has not personally encountered a situation where they could not find a bed for an acute stroke patient.
“We have had to adapt many of our protocols. All the stroke team members have been very flexible about adapting on an almost daily basis to the changes that are happening. I am proud to say that I think there has not been any negative impact on stroke patients once they present to our emergency department.”
The use of telemedicine has increased both in the hospital and on the outpatient side, she continued.
“We have transitioned all of our acute stroke care in the ED to telemedicine as first-line, with in-person backup as needed. Many stroke patients are not able to give a clear history of symptoms, so we have assumed that all acute stroke patients may have COVID-19 and have followed the appropriate protocols for protective equipment [PPE].”
This turned out to be a good decision, she told Neurology Today, because in many cases, they did turn out to have the virus.
“On the inpatient side, we have completely restructured our neurology teams to accommodate the large numbers of COVID-19 patients. However, our stroke patients with and without COVID-19 are still receiving the same level of care and services.”
On the outpatient side, she said, the stroke team transitioned all appointments to telehealth at least during the peak of the pandemic. For patients presenting to the ED with transient ischemic attack or minor stroke symptoms, or subacute strokes, they have obtained vascular imaging in the ED and then, in most cases, have discharged them to follow up the next day via telehealth with a vascular neurologist and complete an expedited outpatient evaluation.
“We were already implementing this at our institution pre-pandemic, but the use of telehealth for this is a novel addition. It's been an effective strategy for preserving inpatient beds for the COVID-19 patients.”
“I think telemedicine has come into its own during this pandemic, and vascular neurologists have led the way,” Dr. Miller said. “This expertise has been really helpful as we transition all kinds of things to telemedicine that didn't seem possible before.”
“Doing telemedicine well requires extremely good communication skills and ability to collaborate with the people who are on the ground with the patient, whether that's a family member at home, or an emergency department nurse who helps you examine the patient,” she continued.
“One thing I like about outpatient teleneurology is that it allows me to have a direct view of how the patient is functioning at home, and what the particular challenges are. I think a combination of teleneurology and in-person evaluation is going to be the future of stroke medicine as long as it continues to be supported by the reimbursement structure. We should absolutely advocate for that.”
“I predict that post-pandemic, many of us will incorporate telemedicine into our practices to a greater degree that we did before,” she said.
Stroke in Hard-Hit Detroit
In Detroit, hospital systems also have adapted stroke protocols in response to the COVID-19 surge. “In our hospital system in Detroit, the COVID-19 patients started rolling into the emergency rooms by mid-March,” Kumar Rajamani, MD, professor of neurology at Wayne State University School of Medicine and medical director of the stroke program at Detroit Medical Center, told Neurology Today.
“In the ED, all stroke patients would be considered COVID-positive and treated as such till proven otherwise. Because the PPEs were precious and in short supply, we had to use them judiciously. We consequently quickly adapted the stroke code protocols so that only one individual would attend the stroke code (rather than the whole team) to save and preserve the PPEs.”
An important early observation was the high incidence of thrombosis in especially continuous renal replacement therapy (CRRT), Dr. Rajamani said. The anticoagulation guidelines were rapidly modified to address the hypercoagulable state that COVID-19 patients experienced. The dosage of enoxaparin for prophylaxis was increased to 0.5 mg/kg every 12 hours, for example, and high-risk patients based on D-dimer levels > 3 mg/L were recommended for full-dose anticoagulation even without clinically obvious thrombosis. The team actively monitored these patients for bleeding, he added.
Dr. Rajamani said acute kidney injury was noted to be a significant finding in seriously ill COVID-19 patients, often with a need for CRRT. For patients with ischemic strokes due to large vessel occlusion, fairly large doses of iodinated contrast agents for CT angiogram and perfusion imaging for visualizing the site of vessel obstruction and the viable penumbra has been used and shown to be safe in the pre-COVID era, he noted.
“Because we started noticing severe renal injury in these COVID-19 patients, one couldn't be certain whether it was the effect of the iodinated contrast dye or the underlying disease,” Dr. Rajamani said. “Whether the contrast agents remain as safe in the COVID-19 era is something we are still uncertain about; we are monitoring every patient closely and looking at the overall risk-benefit ratio.”
“For patients with ischemic strokes due to large vessel occlusion that need endovascular treatment, we very early decided we will provide this standard of care in a safe manner for all concerned,” Dr. Rajamani said. “The only change to the protocol in COVID-19 patients has been elective intubation of these patients to maintain adequate control during the procedure.”
Stroke Centers Stand Ready
David S. Liebeskind, MD, FAAN, director of UCLA's Comprehensive Stroke Center, said changes are also underway at the center.
“We've already seen different management styles evolve with COVID-19,” Dr. Liebeskind told Neurology Today. “There are a lot of different approaches.”
At UCLA's Stroke Center, a backup system is in place to ensure that acute stroke patients are treated as quickly as possible, he said.
“The team is in place, and we have three-deep backup coverage. That's the good news: The stroke center is up and operating.”
When someone has milder stroke symptoms, it isn't always clear-cut, and hospitals need to position themselves to encourage anyone with symptoms to come forward sooner rather than later, he continued.
“People are avoiding hospitals if they have mild-to-moderate symptoms, but we have to be careful of our reaction to this because even mild symptoms require proper evaluation. What has emerged in the current scenario is our health care system adapting as best it can to treat patients with other medical conditions while integrating COVID-19 treatment into an evolving crisis treatment scenario,” he said.
“The fact is that the diagnostic tests that we rely on, like MRI and angiograms, have all been impacted by the pandemic, but I haven't heard of any stroke centers closing down entirely.”
Guidelines from the American Stroke Association
On April 1, the American Heart/Stroke Association's Stroke Council Leadership issued special guidelines for treating patients presenting with stroke symptoms, and several other organizations and individuals have published various strategies for overcoming obstacles to stroke care during the current crisis.
The AHA/ASA guidelines, published in Stroke, recommend that vascular neurologists adhere to treatment guidelines for patients to ensure appropriate stroke care is provided to the extent possible during the crisis; seek ways to minimize the use of scarce personal protective equipment (PPE) and reduce the number of team members responding to emergency stroke patients; and increase the use of interactive videoconferencing in the remote delivery of acute stroke care, among other strategies.
The guidelines also recommend that stroke neurologists continue to deliver multidisciplinary, collaborative stroke care to patients for a unified stroke system of care; and ask medical personnel who are exposed or contract COVID-19 to self-quarantine as appropriate.