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Effects of the COVID-19 pandemic on stroke response times: a systematic review and meta-analysis
  1. Noah L A Nawabi1,2,
  2. Akiro H Duey1,
  3. John L Kilgallon1,3,
  4. Charissa Jessurun1,4,
  5. Joanne Doucette1,5,
  6. Rania A Mekary1,6,
  7. Mohammad Ali Aziz-Sultan1,2
  1. 1 Computational Neuroscience Outcomes Center, Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3 Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  4. 4 Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
  5. 5 Department of Library and Learning Resources, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
  6. 6 Department of Pharmaceutical Business and Administrative Sciences, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
  1. Correspondence to Noah L A Nawabi, Computational Neuroscience Outcomes Center, Harvard Medical School, Boston, MA 02115, USA; nnawabi{at}


Objectives COVID-19 presents a risk for delays to stroke treatment. We examined how COVID-19 affected stroke response times.

Methods A literature search was conducted to identify articles covering stroke during COVID-19 that included time metrics data pre- and post-pandemic. For each outcome, pooled relative change from baseline and 95% CI were calculated using random-effects models. Heterogeneity was explored through subgroup analyses comparing comprehensive stroke centers (CSCs) to non-CSCs.

Results 38 included studies reported on 6109 patients during COVID-19 and 14 637 patients during the pre-COVID period. Pooled increases of 20.9% (95% CI 5.8% to 36.1%) in last-known-well (LKW) to arrival times, 1.2% (−2.9% to 5.3%) in door-to-imaging (DTI), 0.8% (–2.9% to 4.5%) in door-to-needle (DTN), 2.8% (−5.0% to 10.6%) in door-to-groin (DTG), and 19.7% (11.1% to 28.2%) in door-to-reperfusion (DTR) times were observed during COVID-19. At CSCs, LKW increased by 24.0% (−0.3% to 48.2%), DTI increased by 1.6% (−3.0% to 6.1%), DTN increased by 3.6% (1.2% to 6.0%), DTG increased by 4.6% (−5.9% to 15.1%), and DTR increased by 21.2% (12.3% to 30.1%). At non-CSCs, LKW increased by 12.4% (−1.0% to 25.7%), DTI increased by 0.2% (−2.0% to 2.4%), DTN decreased by −4.6% (−11.9% to 2.7%), DTG decreased by −0.6% (−8.3% to 7.1%), and DTR increased by 0.5% (−31.0% to 32.0%). The increases during COVID-19 in LKW (p=0.01) and DTR (p=0.00) were statistically significant, as was the difference in DTN delays between CSCs and non-CSCs (p=0.04).

Conclusions Factors during COVID-19 resulted in significantly delayed LKW and DTR, and mild delays in DTI, DTN, and DTG. CSCs experience more pronounced delays than non-CSCs.

  • Stroke
  • COVID-19

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  • RAM and MAA-S are joint senior authors.

  • Twitter @RMekary

  • Contributors All authors were involved in the design of the study, organization of the study, manuscript writing, and approval of final version of the manuscript. JD generated the search strategy and performed the search. NLAN and AHD independently performed the abstract and full text screening. NLAN and JLK performed the data extraction and summarized the data. AHD performed the data-analyses and RAM checked the data analysis and validity. NLAN, JLK, AD, and CJ wrote the manuscript.

  • 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 None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.