Are Acute Stroke Patients Avoiding Emergency Care Due To COVID-19?

Doctor hold EEG image of brain patient at operating room in hospital.

You’re sitting on your couch and notice suddenly that you don’t feel “quite right.” And then your arm gets weak. Your first thought is to call 911. But it’s quickly replaced by a strong desire to avoid ground zero in the middle of a global pandemic.

“While we’re all at risk to be exposed to the virus anytime we leave our house, it’s a question of balancing the level of risk,” observes Brett Cucchiara, MD, a Penn Medicine neurologist who is a member of Penn’s stroke team and involved in research efforts related to stroke and COVID-19 (the disease caused by the novel coronavirus). “It’s important to realize that not coming to the hospital if you've had a minor stroke, or transient ischemic attack (TIA), is probably way more dangerous than the risk of getting coronavirus.”

That’s why Dr. Cucchiara is among a growing army of doctors and medical professionals sounding the alarm about the importance of getting needed emergency care.

Why Avoiding Care for TIAs Is Dangerous

COVID-19 is changing our habits — and not always for the better. When the virus first hit the United States, Dr. Cucchiara noticed less patients coming into Penn for emergency care. “There were less patients during the last two weeks of March and the first week of April. Now it’s getting back to normal, with a similar volume for big strokes to what we saw before COVID. But we are seeing fewer patients with minor strokes.”

While Dr. Cucchiara suspects there are many reasons for this change, he believes they all center around the pandemic. “People definitely were fearful of coming to the hospital and avoided it.”

But ignoring minor strokes (TIAs) can have major consequences. They’re like canaries in a coal mine: They’re often a signal that greater danger is on the horizon.

“People who have TIAs are clearly at risk of having a big stroke if they don’t get evaluated and treated. And if they avoid coming in, they miss an important window of opportunity.”

Be F.A.S.T: Know the Signs of a Stroke

When you’re having a medical emergency, such as a stroke or heart attack, every minute matters. So it’s critical to know what symptoms spell trouble. Dr. Cucchiara says there’s no difference between the warning signs for major strokes and TIAs, so learning the acronym FAST can be effective for both:

  • F: Facial drooping on one side of the face
  • A: Arm weakness on one side of the body
  • S: Speech changes, including slurred or garbled speech
  • T: Time to call 911

Dr. Cucchiara says you should also seek immediate medical care if you suddenly experience:

  • Chest pain or tightness
  • Loss of vision
  • Numbness on one side of your body
  • Severe headache
  • Shortness of breath

“If you're having stroke or heart attack symptoms, you’re much more likely to die or be severely injured from it than have anything bad happen to you from getting COVID-19,” notes Dr. Cucchiara. “Not that COVID-19 can’t be dangerous, but relatively speaking, the risk is much, much higher of something bad happening if you have stroke symptoms and stay home.”

Risk Factors for Stroke

The risk factors for stroke include:

  • High blood pressure or high cholesterol
  • Diabetes
  • Previous strokes
  • Heart disease or atrial fibrillation (AFib)
  • Age (over 55)
  • Smoking
  • Experiencing deja vu? Turns out, stroke risk factors are the same factors that increase your risk for severe COVID-19 infection.

The Connection Between COVID-19 and Stroke Risk

Some doctors have reported that the virus is causing strokes in COVID-19-positive 30- and 40-year-olds who aren’t very sick. While Dr. Cucchiara hasn’t seen this at Penn, he has observed a higher stroke risk for hospitalized COVID-19 patients than among the general population. “They’re probably more vulnerable because they have stroke risk factors, and that's why you’re seeing them disproportionately affected.”

A recent data analysis showed a 2.5 percent stroke risk for hospitalized COVID-19 patients at Penn. Dr. Cucchiara says that while those odds are still low, they’re higher than the average American’s. “The risk in the general population would be closer to 0.1 percent chance of having a stroke over the course of a year.”

Most strokes occurred about three weeks after the patient first showed signs of COVID-19 infection. This timing only adds to mounting evidence that the virus makes blood clot more easily. In response to this, Penn doctors now put hospitalized COVID-19 patients on blood thinners.

“The virus could possibly invade the lining of the blood vessels and cause inflammation in them. That could then lead to clots forming where there’s inflammation, leading to strokes or other problems,” explains Dr. Cucchiara.

7 Ways Penn Is Protecting Non-COVID-19 Patients

Penn has changed policies and procedures to ensure the safety of all their patients during the pandemic. COVID-19 safety measures include:

  • Daily symptom screenings: Penn staff screen all patients, visitors, and employees for COVID-19 using temperature checks and by asking questions about health. Anyone with symptoms is then tested for COVID-19. If you test positive, we will make sure you receive the appropriate care. If a Penn employee tests positive, they must stay home until they are fully recovered and have a negative test.
  • Universal mask policy: All staff, patients, and visitors must wear masks or face coverings.
  • COVID-19 testing before procedures: If you’re coming in for surgery, you will receive a COVID-19 test 24 to 48 hours before you’re due to be admitted. If you test positive, we will postpone your surgery or procedure until you are fully recovered, and a repeat test comes back negative.
  • Physical distancing: All surgical waiting areas and pre- and post-operative areas now have enough space for everyone to keep at least 6 feet apart.
  • Cleaning: Each operating room is thoroughly cleaned between procedures according to infection control guidelines. Waiting areas are also cleaned several times each day.
  • PPE: Penn staff have and wear face masks, face shields or goggles, gowns, and gloves when treating patients.Separate COVID-19 patient areas: Doctors and providers treat COVID-19 patients in dedicated areas. These locations are physically separate or far from where non-COVID-19 patients are being cared for.

Penn’s new safety procedures and research efforts are helping shift the momentum. “We're incredibly fast at studying this,” says Dr. Cucchiara. “We’ve taken two and a half weeks from conceiving a COVID-19 research project to having data in a form that can be published. That’s just unheard of. Pre-COVID-19, it would have taken six months.”

Using Telemedicine to Provide Heart and Stroke Care

Penn cardiologists have been proactively reaching out to heart patients using telemedicine visits. The goal? To make sure patients get the care they need, especially when COVID-19 concerns cause them to avoid the hospital. While patients can also virtually meet with Penn neurologists and the stroke team, Dr. Cucchiara says the new cardiology system wouldn’t prevent strokes.

“The problem with stroke is that if we know about you already, you’ve probably already been evaluated and put on the right treatment. Its’ the ones who we don’t know about who are really at risk. And there’s no way for us to reach out to those people since we have no idea who they are.”

Instead, Penn’s using technology to prevent COVID-19 infection when you visit the emergency department.

“We also use telemedicine in the Penn emergency department and in the hospital. The emergency medicine physician or treatment team identifies the patient they’re concerned about and calls us. They then turn on a cart that’s equipped with a video camera and audio, so we can examine the patient and talk to them to see what’s going on,” explains Dr. Cucchiara. “We're doing it much more widely than we used to because it means that there are fewer people in the emergency department and less risk of infection.” 

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