Cardiologists have a saying: “Time is tissue.” This describes the urgent need for heart attack victims to receive treatment and save precious cardiac muscle from dying. Neurologists and neurosurgeons have adopted and modified this old adage with a saying of their own: “Time is brain.” It might not be as catchy, but it’s just as important when treating victims of stroke.
When a person has a stroke, it means that there is a blockage of one of the larger arteries that supplies blood to the brain. If the blockage is not resolved quickly, brain tissue is deprived of oxygen and patients suffer from disastrous strokes that can result in paralyzation, speech deficits, coordination difficulties, coma or even death.
This is especially problematic because some strokes are fairly subtle and only present with mild arm or facial weakness. Sometimes, patients experience symptoms that are impossible for third parties to notice, such as dizziness or transient visual changes.
The good news is that stroke patients who receive treatment very soon after a stroke begins can avoid suffering from many of the permanent problems caused by strokes. However, there is a very specific time window that these patients can receive treatment before lasting damage begins to set in. If patients arrive at the hospital too late (often four and a half hours after stroke onset), then it is usually too late to receive clot-busting medications and treatments. Those unfortunate enough to miss this time window are unable to reverse the symptoms of the stroke and are only candidates for supportive care.
Although it’s not intuitive to many, the COVID-19 pandemic has had a remarkable impact on reported stroke cases. A recent study published in the New England Journal of Medicine evaluated use of neuroimaging software that functions as a tool to aid doctors in interpreting specialized brain scans and determining whether stroke patients are candidates for clot extraction procedures. The database included 231,753 patients from 856 hospitals in total from July 1, 2019, to April 27, 2020.
Interestingly, when comparing pre-COVID-19 numbers to data from the early weeks of the pandemic, there is a distinct drop off in the number of patients who received this specialized stroke neuroimaging. In fact, there was a decrease of about 40 percent from the pre-pandemic period to the pandemic period.
The drop-off in cases is incredibly worrisome for many health care providers. If stroke patients aren’t coming to the hospital as frequently, does that mean there have been fewer strokes, or is there some factor or combination of factors that are causing patients to choose not to travel to hospitals and instead face more serious health complications at home?
Some experts claim that social distancing rules are keeping stroke patients out of hospitals. In a time when everyone is being encouraged to stay home as much as possible, how are stroke patients supposed to know when it’s appropriate to leave their homes and come to the hospital, especially patients who are only experiencing relatively minor signs of stroke? Our new COVID-19-centric culture now embraces practices that avoid public places, especially clinical settings where coronavirus can be rampant. One only needs to walk down the street and find “stay at home signs” plastered all over shop windows and telephone poles. Could this be discouraging stroke patients from seeking care?
Dr. Akash Kansagra is an assistant professor of radiology at Washington University’s Mallinckrodt Institute of Radiology and the lead author of the previously cited study published in the New England Journal of Medicine. In an article in Science Daily, Kansagra was quoted as saying that he believes that there aren’t fewer cases of stroke, but rather that patients are choosing to stay home, a “heartbreaking” development.
“Nevertheless, we have seen a smaller number of stroke patients coming to the hospital and some patients arriving at the hospital after a considerable delay,” Kansagra said. “It is absolutely heartbreaking to meet a patient who might have recovered from a stroke but, for whatever reason, waited too long to seek treatment.”
Others are skeptical of this explanation and are unsure about the true reasons of why stroke numbers are plummeting across the country. Dr Luis Fernando Gonzalez, a professor of neurosurgery at Duke University Medical Center, agrees that there have been fewer reported stroke cases across the country, but he believes that the reason there are fewer cases is likely that there have been fewer strokes since the pandemic began, for reasons he and other experts are still trying to solve.
“People are not just sitting at home hemiplegic,” Gonzalez told me. “I think they just didn’t happen. We did social media and news campaigns, and told patients that if they have symptoms, they need to show up to the hospital. We still didn’t see an increase in stroke numbers.”
Gonzalez also added that some high-volume stroke centers located in cities with high COVID-19 caseloads, such as centers in Philadelphia and New York, actually experienced more strokes following the COVID-19 outbreak, especially with younger patients.
Regardless of why health care providers are seeing fewer stroke patients, two things remain clear.
First, health care and public officials must continue encouraging all people to practice proper social distancing to help limit the spread of COVID-19, including, when and where appropriate, shelter-in-place rules, six-feet distancing guidelines and the use of masks in public, to name just a few.
Second, media, health care providers and others must do a better job of supporting those people who are showing signs, however minor, of a stroke by encouraging them to seek immediate medical aid. And the same is true for many other major medical illnesses. The people most vulnerable and likely to need this support and knowledge are the elderly and those with pre-existing medical illnesses. Social support is key for them, now more than ever.
With that in mind, Dr. Gonzalez suggested in my conversation with him that public officials and health care providers should strongly consider establishing public health campaigns that would teach citizens how to recognize the early signs of stroke and when to seek care by calling an ambulance or going to the emergency department. Such campaigns could include radio or television commercials, public signs or features published in media outlets. These efforts have been proven to be successful in the past, both in the United States and around the world.
Careful consideration of other health issues needs to accompany any major societal change during a pandemic. Many people have suffered at the hands of coronavirus, but we shouldn’t forget that there are many other people enduring non-coronavirus-related illnesses as well who also need our attention and support.
The views in this opinion are those of the author and do not reflect those of her institutions nor her experiences at those institutions.