Evaluate impact of COVID-19 pandemic on mortality and care limitations in critically-ill stroke patients.

COVID-19 pandemic overwhelmed medical systems leading to resource shortages in many regions, which may impact care limitations and mortality in non-COVID patients.  This is of particular concern in severe stroke population where perceived poor prognosis can lead to early care limitations and the self-fulfilling prophecy of worse outcomes.  

During first 3 months of COVID-19 pandemic (03/28/30-06/28/20) we prospectively enrolled consecutive adults with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) meeting pre-pandemic criterial for intensive care unit (ICU) admission at single comprehensive stroke center, systematically recorded COVID-19 status, pre-existing code status, disease severity, transition to do-not-resuscitate (DNR), do-not-intubate (DNI), and comfort measures (CMO) code status and in-hospital mortality.  Results were compared with a 3-months retrospective cohort from prior to global COVID-19 pandemic  (10/1/19-12/31/19). 

Pandemic cohort (N=196, mean age 63, 48% female, 60% AIS, 26% ICH, 14% SAH, 22% COVID-19 person-under-investigation) and pre-pandemic cohort (N=199, mean age 63, 46% female, 58% AIS, 26% ICH, 16% SAH) were similar.  Our hospital did not experience resource shortages during peak pandemic.  Compared with the pandemic cohort, pre-pandemic cohort had similar stroke severity scores but more pre-existing care limitations at admission (90% vs. 98% full code, p=0.005), more frequent transition to DNR (13% vs. 5%, p=0.0025), DNI (10% vs. 3%, p=0.0078), and higher in-hospital mortality (21% vs. 9%, p=0.0012).

COVID-19 pandemic was associated with lower incidence of care limitations and in-hospital mortality in severe stroke patients at a stroke center that did not experience resource shortages.  Further studies are needed to determine whether these results are due to in-person family visit restrictions during the pandemic.  Multicenter studies are needed to determine whether these observations hold true in centers impacted by resource shortages.