Odds of Door-to-Needle Time Within 60 Minutes for Thrombolysis in Stroke Decreased by 45% During COVID-19

Using the AHA Target: Stroke campaign goal of a 60-minute door-to-needle time for intravenous thrombolysis, patients admitted to the hospital for acute ischemic stroke during the COVID-19 pandemic had a 45% lower likelihood of being treated in that 60-minute time window (adjusted OR 0.55, 95%CI 0.35-0.85).

This finding is from a team of researchers working under the auspices of the Society of Vascular and Interventional Neurology. They conducted a multicenter observational study evaluating the timeline of critical care provided for acute ischemic stroke in 2020 vs 2019. The investigators pooled prospectively maintained data from 14 Comprehensive Stroke Centers (CSCs) in 9 States between January 2019 and July 2020. Together, these 9 states accounted for nearly half of all COVID-19 cases in the US and more than one-third of all COVID-19-associated mortalities.

Many reports have indicated that patients are avoiding health care institutions to prevent contact with COVID-19 patients and healthcare professionals. Falling rates have been observed across a range of acute and critical conditions including myocardial infarction, stroke, and various cancers. The long-term consequences of health care avoidance remain unknown but will become clear in the coming months and years.

Time from arrival to neuroimaging and thrombolysis were also evaluated. The largest delay was in time from head imaging to bolus (median delay of 7 minutes across all sites). Despite the increased need for personal protective equipment, contact precautions, and other barriers between patients and providers, there appeared to be no delay in time from arrival to first neuroimaging. Furthermore, the delay in care appeared to persist throughout the months of June and July as the second wave of the pandemic spread across the southeastern and western US. Although the overall delay to thrombolysis was minimal (median delay of only 4 minutes), this delay was observed in CSCs, known to have faster throughput and treatment times compared with other healthcare institutions. It is possible that this delay may be magnified in community hospitals, and these findings warrant exploration in nonCSC institutions.

Altogether, these findings suggest large scale gaps in acute medical care for a common neurologic problem that affects almost 1 million Americans yearly. It is important for healthcare institutions to appraise their local paradigms in acute stroke care to determine if similar gaps exist, and what steps they can take to reduce delays in care during a global crisis.