In 2020, the COVID-19 pandemic affected health care procedures globally, including the diagnosis and treatment of acute strokes. Two outbreaks occurred in Dalian, one on July 22 and the other on December 15, 2020, eliciting an enormous governmental response to control the spread of the disease. AIS is a common cerebrovascular disease whose treatment is aimed at promptly re-establishing cerebral perfusion and avoiding ischemic necrosis within the ischemic penumbra [5]. Therefore, the outcomes are highly time dependent. During the 2020 COVID-19 pandemic, epidemiological investigation and screening, among other factors, delayed the diagnosis and treatment of several patients with AIS.
The number of patients with AIS who underwent intravenous thrombolysis was significantly higher in 2021 (133.9%) than in the same period in 2020. However, the treatment outcomes of patients with AIS who underwent intravenous thrombolysis were unaffected by the COVID-19 pandemic. This is likely related to the strengthening of stroke health management, popular knowledge of science, and education provided by the National Brain Prevention Commission as well as by government departments and medical practitioners at all levels. Through initial adherence to publicity and educational efforts, stroke awareness among patients and their family members increased, as did the treatment rates.
When we compared patients from corresponding periods in two different years, we observed no significant differences in age, sex, or intravenous thrombolytic drugs. However, in 2020, DNT was prolonged, exceeding the average DNT of 45 min in China and the United States [6]. In addition to the signing of informed consent and other procedures [7], this increase was related to the heightened surveillance of fever; epidemiological history investigations; and screening for symptoms associated with respiratory disease, such as cough, sputum production, chest tightness, diarrhea, and fatigue, during the COVID-19 pandemic. This in-hospital delay could potentially have been shortened by 20 min if the requirement for informed consent had been waived [8]. Nevertheless, in the context of standardized disease prevention and control, we must consider how else we can shorten the in-hospital processing time of patients with AIS [9].
The stroke awareness rate was not as high in 2020 as that in 2021. Fewer rural AIS patients and a shorter ODT were observed in 2020 than in 2021. However, due to efficient public information, stroke is a well-known topic to health care consumers. The rate of early stroke recognition increased from 2020 to 2021, as did the rate of using “stroke maps” to visit nearby hospitals. At the same time, when the number of rural patients increased, the scope of medical treatment expanded. However, rural patients needed time to travel from the countryside to the nearest suitably equipped hospital; therefore, the ODT increased in 2021, which urges us to further improve the role of stroke maps and simultaneously improve the stroke emergency capacity of rural hospitals.
Regardless of the pandemic, AIS patients with an NIHSS score ≤ 5 were more likely to use their own vehicles to reach the hospital than to be transported by ambulance. This is likely related to the recent increase in car ownership in China, as reported by the Ministry of Public Security. Moreover, the stroke emergency map can be navigated such that patients can easily proceed to the nearest hospital with the appropriate treatment capacity. Moreover, self-transport was used not only to avoid an uncertain waiting period for an ambulance but also to avoid concerns regarding the sanitization of ambulances during the pandemic [9]. In contrast, patients with NIHSS scores ≥ 6 points were more likely to opt for emergency medical transport via the “120” rescue system.
Statistically significant differences were observed between the values: the NIHSS scores of the two groups in 2020 and 2021 before and immediately after thrombolysis were ≤ 5 and ≥ 15 points, and the NIHSS scores were 6–14 points in 2021. This indicates that more patients with AIS benefited from therapy. Such patients need to be followed-up for 1, 3, and 12 months after stroke onset to verify their prognoses.
This study has some limitations. First, the follow-up period in the present study was short. Further studies with additional timepoints such as 30, 60 and 90 days are needed to confirm these results. Second, the design of this study was retrospective and descriptive; therefore, our findings should be verified through prospective clinical studies. Third, all the patients who underwent intravenous thrombolysis required additional follow-up.
In summary, timely management is crucial for optimizing treatment outcomes in patients with AIS [10]. With standard prevention and control measures in place for the COVID-19 pandemic, stroke emergency maps should be actively promoted to allow patients to choose the nearest hospital that can provide emergency treatment, whether they reach the hospital without ambulance transport or by calling “120” for assistance. Hospitals should establish efficient, high-speed green channels to help shorten the DNT, provide additional time for intravenous thrombolysis, and reduce stroke death and disability rates.