What collateral impact has COVID-19 had on stroke evaluations?

Written by Ilana Landau, Editor

Researchers have assessed the change in utilization of stroke imaging software during pre- and early-pandemic periods in the USA and determined that software use declined by 39%, suggesting fewer evaluations have been performed.

In a Letter recently published in the New England Journal of Medicine, researchers from the Washington University School of Medicine in St. Louis (MO, USA) and Stanford University (CA, USA) describe their assessment of the change in utilization of stroke imaging software at more than 800 hospitals across the USA during pre- and early-pandemic periods. Researchers observed a 39% reduction in software use, suggesting that fewer evaluations have been performed and many people who have been experiencing stroke symptoms may not be seeking potentially life-saving medical care.

Stroke is the fifth leading cause of mortality in the USA; approximately 800,000 US citizens experience a stroke each year. Stroke care and treatment have greatly improved in recent years, due to developments in diagnostics, surgeries and anticoagulant medications. With these advancements, individuals who experience a stroke face greater chances of recovery, if they receive care in a timely fashion.

In this study, researchers sought to determine how the COVID-19 pandemic has affected the provision of essential stroke care, based on personal and anecdotal experiences of colleagues attesting that worryingly low numbers of stroke patients have been being evaluated at medical centers.

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Brain scans are routinely performed on patients who arrive at medical centers displaying stroke symptoms, to determine what kind of stroke has occurred, where and what treatment regime may be most appropriate; ‘RAPID’ software is frequently employed in the analysis of these brain scans.

In this study, investigators compared the average daily use of RAPID software during the month of February — defined as a pre-pandemic period — with that during a 14-day, early-pandemic period from late March to early April.

Researchers observed that at 856 hospitals across all the USA, RAPID software was used for an average of 1.18 patients per day per hospital during the month of February. This was consistent with RAPID software use recorded during 2019. By contrast, during the 2-week, early-pandemic period from March—April, RAPID software use per hospital averaged 0.72 patients per day; this equates to a drop in software use of 39%.

Investigators observed decreases in software utilization even at hospitals in locations where the number of COVID-19 cases during the defined early-pandemic period were fewer.

Limitations of the study include that the database used to determine RAPID software use pertains predominantly to patients under consideration for endovascular thrombectomy and may therefore not be reflective of stroke care provision at other hospitals.

Nevertheless, in the study, the authors concluded: “We found that the collateral effect of Covid-19 was a decrease of approximately 39% in the numbers of patients who received evaluations for acute stroke between two recent epochs in U.S. hospitals.”

Lead study author Akash Kansagra (Washington University’s Mallinckrodt Institute of Radiology) explained: “I suspect we are witnessing a combination of patients being reluctant to seek care out of fear that they might contract COVID-19, and the effects of social distancing. The response of family and friends is really important when a loved one is experiencing stroke symptoms. Oftentimes, the patients themselves are not in a position to call 911, but family and friends recognize the stroke symptoms and make the call. In an era when we are all isolating at home, it may be that patients who have strokes aren’t discovered quickly enough.”


Kansagra, AP, Goyal MS, Hamilton S, Albers, GW. Collateral effect of Covid-19 on stroke evaluation in the United States. New Engl J Med. doi:10.1056/NEJMc2014816 (2020); https://medicine.wustl.edu/news/stroke-evaluations-drop-by-nearly-40-during-covid-19-pandemic/