A study recently published in the BMJ reports no observed delay in the treatment of patients with intracranial occlusion with endovascular thrombectomy (EVT) during the COVID-19 era when compared with the pre-COVID era.
The study is a retrospective review of observational registry data of patients with acute ischaemic stroke and intracranial occlusion who underwent emergent angiography and/or thrombectomy. A total of 1364 patients were included in the primary analysis across 14 comprehensive stroke centres in nine US states. These data were collected between March and July of 2020 and compared with data from the same period in 2019. As part of their secondary analysis researchers compared state-specific pre-peak and peak COVID-19 months.
Authors note that at the time of data collection in 2020, the states included in the study accounted for 47% of all recorded COVID-19 cases and 37% of COVID-19-associated deaths in the USA.
Of the subjects more than half (51%) were aged 70 or older, 48% were female, and 61% were white. The median national institutes of health stroke score (NIHSS) was 14 and 74% had an occlusion of the internal carotid, proximal middle cerebral (M1), or basilar artery.
Researchers observed a 28% decrease in the total number of patients who presented to the hospital with an intracranial occlusion during the COVID-19 period. Additionally, they noted that compared with patients who presented in the pre-pandemic group, patients in the COVID-19 period were more frequently Hispanic, had coronary artery disease, and had a higher probability of undergoing EVT.
While researchers hypothesised that the COVID-19 group would be more likely to have a delay in EVT time metrics, they observed no significant difference in door-to-puncture times for these patients. In fact, when researchers adjusted for candidate variables associated with door-to-puncture and clustering by site, a trend towards faster door-to-puncture times was observed among the COVID-19 group. Additionally, within this period researchers saw a greater proportion of patients discharged home over acute inpatient rehabilitation during the COVID-19 period when compared with the control period.
The findings from their primary analysis remained true in their secondary analysis, where researchers found no significant difference in treatment times among patients admitted during state-specific COVID-19 peak vs a pre-peak month. Researchers noted that this is important because the pandemic has affected regions in the USA at different time points, which could have confounded any effect of the pandemic on local treatment times.
Researchers noted in their secondary analysis that faster door-to-puncture times were associated with transfer from an outside institution and a higher NIHSS.
Investigators concluded that they, “observed no significant delay in thrombectomy treatment time during the COVID-19 pandemic.” Authors further commented on their findings, “an analysis limited to the first few months of the pandemic in the US might have been too early to detect any impact of COVID-19 surges on treatment times in these regions. In this secondary analysis–while the sample size was lower than that of the primary analysis–there was still no statistically or clinically significant difference in treatment times between pre-peak and peak periods.”
Researchers commented that of particular note was a significant difference in the likelihood of patients being discharged to rehab during COVID-19 when compared with the seasonal control. Authors theorise that this is likely mediated by several indirect effects of the pandemic including depletion of acute care beds, and patients admitted during this period having more comorbidities.
Jim Siegler (Cooper University Hospital, Camden, USA), lead author of this study comments: “The pandemic has not only claimed the lives of millions of people, but it is creating new barriers in acute care delivery as our healthcare system is overrun. We are excited to show that emergent management of severe strokes during the pandemic has not been slowed. But we would caution readers to feel satisfied with our treatment throughout even as resources are scarce and providers are overwhelmed. There are always opportunities for improvement!”