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Abstract
Background The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).
Methods We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).
Results We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004).
Conclusion The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.
- thrombectomy
- stroke
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Introduction
The Coronavirus disease of 2019 (COVID-19) pandemic has affected all aspects of medical care for various conditions.1 Several studies reported a potential relationship between COVID-19 infection and ischemic stroke secondary to large vessel occlusion (LVO).2 3 Importantly, recent studies reported a significant decline in the number of patients presenting with acute stroke, raising concerns that stroke patients are avoiding hospitals for various reasons including fear of COVID-19 infection.4 5 Evidence from recently published studies suggested that this decline disproportionately affects African American (AA) patients, widening the already existed racial disparity in stroke care.6 In this study, we aimed to investigate the impact of the COVID-19 pandemic on the racial disparities related to MT.
Methods
Patient population and collected variables
Prospectively collected data from 12 thrombectomy-capable stroke centers included in the Stroke Thrombectomy and Aneurysm Registry (STAR) collaboration was interrogated to identify stroke patients who received mechanical thrombectomy (MT) between January 2017 and May 2020. Eleven of the included centers are located in the United States and one in Germany. Patients who presented before February 2020 were considered pre-COVID-19 pandemic and patients who presented after February 2020 were considered during the COVID-19 pandemic. We compared baseline demographics, procedural metrics, and outcomes between patients undergoing MT before and during the pandemic. Approval from the Institutional Review Board at the Medical University of South Carolina was obtained, and no consent was needed per the institutional policy.
Statistical analysis
We used univariate analysis to report patient demographic and clinical characteristics using median and IQR for continuous variables and percentages for categorical variables. Characteristics of groups were compared using the Mann–Whitney U test, and chi-square as appropriate. To assess for the relationship between the rate of AA (or Black Europeans of African ancestry) patients receiving MT and COVID-19 pandemic controlling for the center of presentation, we used the Cochran Mantel Haenszel test. An alpha level of 0.05 was used as the level of statistical significance. The analysis was conducted using SPSS v25 (IBM Corporation, New York, NY).
Results
Patients' characteristics
A total of 2083 stroke patients were included in this study, 1848 (88.7%) underwent MT before the COVID-19 pandemic and 235 (11.3%) during the COVID-19 pandemic. The median age was 69 (IQR 58–79) years, admission National Institure of Health Stroke Scale (NIHSS) 16 (10-21), and Alberta Stroke Program Eartly CT Score (ASPECTS) 9 (IQR 7–10). Online supplemental table I summarizes baseline features and clinical outcomes. The racial/ethnic distribution of the included patients was as follows: 1197 (57.8%) white, 665 (31.9%) AA, 215 (10.3%) Hispanic, and six (0.3%) others.
Supplemental material
Before vs. during the COVID-19 pandemic
Table 1 summarizes the comparison between stroke patients who underwent MT before vs during the COVID-19 pandemic. Five (2.1%) of the MT patients during the pandemic were positive for COVID-19 polymerase chain reaction (PCR) in nasopharyngeal swap. Significant differences in patients undergoing MT during the COVID-19 pandemic include: longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4, P<0.001), lower discharge mRS (4 vs 3, P=0.015), and higher in-hospital mortality (18.7% vs 11%, P<0.001), compared with patients who underwent MT before the pandemic. While the difference between the symptom onset to groin time was not significant in the overall population (P=0.065) and in non-AA patients (P=0.278), AA patients had longer onset to groin time during the COVID-19 pandemic (362 vs 275 min, P=0.047). In addition, the percentage of AA patients who underwent MT in the included centers decreased from 609/1848 (32.9%) before the COVID-19 pandemic to 56/235 (23.8%) during the COVID-19 pandemic (P=0.004). No interaction was noted between the percentage of AA patients receiving thrombectomy and the centers that performed the thrombectomy before and after the COVID-19 pandemic (P=0.192). No other statistically significant differences were noted in other races/ethnicities. Figure 1 shows the trend in the rate of AA patients receiving mechanical thrombectomy during the study period. Online supplemental tables II and III show the comparison between AA and non-AA thrombectomy patients before and during the COVID-19 pandemic.
Characteristics, procedural metrics, and outcomes of stroke patients receiving mechanical thrombectomy before and during the COVID-19 pandemic
The trend in the rate of African American patients receiving mechanical thrombectomy during the study period.
Discussion
In this multicenter, international study, we evaluated the procedural metrics and outcomes of MT patients presenting during the COVID-19 pandemic compared with patients presenting during the 3 prior years. We have found that patients who presented during the pandemic required a longer procedure time and had a higher rate of mortality. While only 2.1% of these patients were positive for COVID-19 PCR, these findings likely reflect the effect of COVID-19 precautions and the changes in healthcare workflow protocols.
Additional significant findings from our analyses included a reduction in the number of AA patients undergoing MT, which is highly alarming because racial disparities in cerebrovascular diseases care already exist. AA patients have higher vascular risk factors, and experience higher stroke-related in-hospital mortality.7 Also, studies have shown that AA/Hispanic patients are more likely to have received aneurysm treatment following a subarachnoid hemorrhage rather than getting treatment in the early stages for unruptured aneurysm.8
The reduction in the number of AA patients receiving MT during the COVID-19 pandemic threatens to widen the gap in racial disparities given that most patients with emergent LVO would suffer from significant long-term disability if they do not receive treatment.9–11 A recent study evaluating racial disparities among patients evaluated over a large telestroke network reported a significant drop among AA patients with acute ischemic stroke.6 The overall drop in the number of AA patients presenting with acute stroke is a likely reason that there is a drop in the number of AA patients receiving MT. It remains unclear the reasons behind this drop. However, studies have shown that AA patients have a higher incidence of COVID-19 infection and increased mortality12 13 which could be the reason why AA patients are reluctant to seek medical attention over concerns for safety due to fear of acquiring COVID-19.
Interestingly, there was an increase in the symptom onset to groin time in AA, but not non-AA patients which may also reflect the abundance of caution from presenting to hospitals during the early COVID-19 pandemic. A similar delay in care in all stroke patients during the COVID-19 pandemic was reported recently by Schirmer et al.14 One of the proposed causes for this delay is the changes in stroke triage protocols during the pandemic.15
Our study has a few limitations. First, our study is limited by its observational nature. Also, our study does not provide information related to the relationship between COVID-19 infection and emergent LVO. However, our study provides multicentric, early observations stroke centers in different regions.
Conclusion
Stroke patients receiving MT during the COVID-19 pandemic had a longer procedure duration and a higher mortality rate compared with patients presenting before the pandemic. Also, there is a decline in the number of AA patients receiving MT during the pandemic, which demonstrates the need for more work in the public health domain to educate patients with the importance of prompt medical evaluation for all those suffering from stroke symptoms.
Supplementary materials
Supplementary Data
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Footnotes
SAK and EA are joint first authors.
Twitter @samialkasab, @PascalJabbourMD, @AhmadSweidMD, @Starke_neurosurgery, @AdamArthurMD, @abhipandhi, @BrianHoward_MD, @alex_spiotta
Collaborators STAR collaborators: Dileep R Yavagal, MD; Eric C Peterson, MD; Alex Brehm, MD; Patrick A Brown, MD; M. Reid Gooch, MD; Nabeel Herial, MD; Dr. med. Jan Liman; Daniel Alan Hoit MD MPH; Violiza Inoa-Acosta MD; Christopher Nickele MD; Lucas Elijovich MD; Michael Cawley, MD; Gustavo Pradilla, MD
Contributors All authors have: provided a substantial contribution to the conception and design of the studies and/or the acquisition and/or the analysis of the data and/or the interpretation of the data. They have drafted the work or revised it for significant intellectual content and approved the final version of the manuscript. They agree to be accountable for all aspects of the work, including its accuracy and integrity.
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 PJ: consultant-Medtronics, Microvention. RMS: consulting and teaching agreements with Penumbra, Abbott, Medtronic, InNeuroCo, and Cerenovus. ASA: consultant–Balt, Johnson and Johnson, Leica, Medtronic, Microvention, Penumbra, Scientia, Siemens, and Stryker; research support–Cerenovus, Microvention, Penumbra, and Siemens; and shareholder–Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad Medical, Vascular Simulations. AR: consulting agreement with Stryker, Cerenovus, and Microvention. MNP: travel grants/honoraria–Phenox, Stryker, Siemens. AMS: consultant–Penumbra, Microvention, and Pulsar Vascular; travel grants/honoraria–Penumbra, Pulsar Vascular, Microvention, Stryker.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request. Data are available upon reasonable request.
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