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Original research
Delayed presentation of acute ischemic strokes during the COVID-19 crisis
  1. Clemens M Schirmer1,2,3,
  2. Andrew J Ringer4,
  3. Adam S Arthur5,6,
  4. Mandy J Binning7,
  5. W Christopher Fox8,
  6. Robert F James9,
  7. Michael R Levitt10,
  8. Rabih G Tawk8,
  9. Erol Veznedaroglu7,
  10. Melanie Walker11,
  11. Alejandro M Spiotta12
  12. On behalf of the Endovascular Research Group (ENRG)
  1. 1 Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, PA, United States
  2. 2 Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Scranton, PA, United States
  3. 3 Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
  4. 4 Mayfield Clinic, Cincinnati, OH, United States
  5. 5 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  6. 6 Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  7. 7 Global Neurosciences Institute, Pennington, NJ, United States
  8. 8 Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
  9. 9 Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
  10. 10 Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
  11. 11 Neurological Surgery, University of Washington, Seattle, Washington, USA
  12. 12 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  1. Correspondence to Dr Clemens M Schirmer, Neurosurgery, Geisinger Health System, Danville PA 18711, Pennsylvania, USA; cmschirmer{at}


Background The COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US.

Methods The interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020.

Results There were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02).

Conclusion We present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.

  • stroke
  • statistics

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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  • Twitter @ClemensSchirmer, @MayfieldChair, @AdamArthurMD, @wchrisfox, @DrMichaelLevitt

  • Contributors Planning CMS, AMS, AJR, reporting all authors, conception and design CMS, AMS, acquisition of data or analysis all authors, interpretation of data CMS, editing, and approval of manuscript all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests CMS: Research Support: Penumbra, Shareholder Neurotechnology Investors. ASA: Consultant for Johnson and Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker, Research support from Balt, Cerenovus, Medtronic, Microvention, Penumbra, Siemens, and Stryker, Shareholder in Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad Medical, Vascular Simulations. WCF: Consultant for NuVasiveJames: Shareholder, Remedy Pharmaceuticals. MRL: Research support from Stryker, Medtronic, Philips Volcano, Shareholder in Cerebrotech, Synchron, eLoupes. RT: Shareholder in Medtronic. EV: Patentholder with Penumbra, Mizuho, Consultant for Toshiba. AMS: Consultant Penumbra, Cerenovus, Stryker, Terumo, Research support Penumbra.

  • Patient consent for publication Not required.

  • Ethics approval Geisinger IRB 2016-0483.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data in GWTG database.