Stroke experts at UT Health San Antonio are urging area residents not to let anything—including fear of the coronavirus—stop them from calling 911 if they have face, arm or speech symptoms.

“Patients should never hesitate to call an ambulance if they have signs of a stroke,” said Justin Mascitelli, M.D., assistant professor of neurosurgery in the Long School of Medicine at UT Health San Antonio. “Ambulances and hospitals have infection control protocols in place to treat patients safely. We don’t want anyone’s care to be delayed because of this pandemic.”

Yet Lee Birnbaum, M.D., M.S., associate professor of neurology, neurosurgery and radiology in the Long School of Medicine, said there has been a decrease in the number of patients coming in with stroke symptoms.

“If people think they are having the symptoms of a stroke, they should get help right away,” said Lee Birnbaum, M.D., M.S., associate professor of neurology, neurosurgery and radiology in the Long School of Medicine. “For years we’ve talked about FAST (face, arm, speech and time). Yes, COVID-19 is out there, but if any signs of a stroke occur, call 911 and be taken to the hospital. The sooner patients receive care, the better the outcomes are.”

If a coronavirus-positive patient requires emergency surgery, the stroke team is ready, said Dr. Mascitelli, who removes stroke-causing clots at University Hospital and St. Luke’s Baptist Hospital.

“We will wear all the protective equipment and do the surgery the same way we do it for all other patients,” he said.

Shelter in place and effect on care

Gretchel Gealogo Brown, Ph.D., RN
Gretchel Gealogo Brown, Ph.D., RN, School of Nursing

A multidisciplinary team led by Gretchel Gealogo Brown, Ph.D., RN, of the School of Nursing, will soon conduct a study of how the pandemic may be affecting the utilization of services by stroke patients.

“We are interested in analyzing hospital stroke admission, treatment and discharge before, during and after COVID-19 state-issued shelter-at-home orders,” Dr. Brown said. “We will use data from the American Heart Association’s ‘Get with the Guidelines’ stroke registry at a number of hospitals in the San Antonio and Austin area. Anecdotal evidence has shown that far fewer patients are seeking care for acute stroke symptoms at emergency rooms, and we want to know how that is impacting stroke treatment and severity.”

She added: “As a nurse, I want to know how COVID-19 shelter-in-place orders have influenced if/when people choose to seek help for stroke symptoms, and how that has contributed to missed opportunities for targeted stroke education (or re-education) and timely intervention.”

Kal Clark, M.D., director of radiology informatics in the Department of Radiology, is a study coauthor. He said the gains of stroke public health campaigns over the last few decades—such as the well-known phrase, time is brain—seemingly are being reversed in the pandemic.

“People are optimists, saying to themselves, ‘Oh, I think I’m OK, I have a headache. It’s temporary. I’m invincible. Maybe it’s just anxiety.’ We’ve been trying to combat that,” he said. “And now people are worried about contracting COVID-19. It’s a new element in the mental calculus that is preventing people from getting urgently needed medical care for stroke. We don’t know to what extent that is happening, and we want to find out with the data.”

The virus and stroke

Coronavirus infection may increase a person’s risk of developing a clot and suffering a stroke, according to recent published studies.

“We haven’t seen much stroke among COVID-19 patients in San Antonio, probably because we haven’t been hit as hard as other cities,” Dr. Mascitelli said. “But the team I used to work with when I was a resident at Mount Sinai in New York, obviously they’re at the epicenter of the pandemic, and they definitely saw an uptick in large-vessel occlusion stroke in COVID-19 patients.”

Mount Sinai Health System published correspondence in the New England Journal of Medicine April 28 describing five cases of large-vessel stroke in patients younger than 50. Severe coronavirus infection was diagnosed in all five. Meanwhile, researchers on April 30 reported a high incidence of clots in critically ill COVID-19 patients in three Dutch hospitals.

“The feeling is that symptomatic COVID-19 patients seem to be having blood-clotting problems that can result in deep vein thromboses (DVTs), which are blood clots in the legs; pulmonary embolisms, which are blood clots in the lungs; and also these large-vessel occlusion strokes, which are blood clots traveling to the brain,” Dr. Birnbaum said.

Experts believe the coronavirus disrupts the coagulation cascade in the body, which leads to formation of blood clots. Dr. Birnbaum said it is unlikely that infected individuals who are symptom-free would have this complication.