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Letter by Rose et al Regarding Article, "Acute Cerebrovascular Events in Hospitalized COVID-19 Patients".

To the Editor: We read with interest the recent article entitled, Acute cerebrovascular events in hospitalized COVID-19 patients by Rothstein et al.1 Although reporting rates of hospitalized coronavirus disease 2019 (COVID-19) stroke patients is worthwhile, it represents a subset of the total effect of this pandemic upon cerebrovascular disease. Because of gaps in COVID19 testing, pandemic-associated nosocomephobia, and misinterpretation of Stay at Home, selectively analyzing only hospitalized COVID-19–stroke patients may underestimate its full public health burden. Essentially, during the pandemic, stroke patients have been presenting with: • Upper respiratory viral symptoms, receiving a diagnosis of COVID-19, and then having a stroke while hospitalized. Most patients in the Rothstein study1 fit this description, as their stroke was, on average, diagnosed 3 weeks after COVID-19 was diagnosed. Estimates for COVID-19–stroke hospitalization in the United States range from 0.9% to 2.4%,1,2 similar to 2.3% reported in China.3 • Stroke symptoms that receive treatment and subsequently with screening tests are diagnosed with COVID19. Less commonly, COVID-19 presents as a stroke, despite its association with hypercoagulable state, arrhythmogenesis, and vasculitis/vasospasm. COVID19-strokes may occur at a younger age with increased severity.2 • A stroke at home—NOT immediately seeking medical attention, due to pandemic misperceptions or COVIDophobia. For this group, stroke symptoms are either mild, resolve completely, or conversely, exacerbate at home (without treatment) resulting in disability or death from cerebral edema/herniation, COVID-19 itself, or cormorbid complications like aspiration pneumonia or seizures. Nosocomephobia (explicitly, COVIDophobia) keeps patients away from hospitals; overinterpretation of Stay at Home, unfortunately, is superseding our mantra of Time is Brain—overruling years of well-developed, hyperacute stroke care. To estimate this impact, our stroke team in Tampa calculated the difference between the average monthly stroke census (prepandemic, 2017– 2019) versus those from 2020.4 Our stroke volume decreased by about 15%; other centers report up to a 23% drop.4,5 If this trend persists, at our institution, ≈200 fewer stroke patients will receive care versus a typical year. Paradoxically, our mechanical thrombectomy rate increased 8%, upwards of 50% elsewhere.4,5 Plausibly, sicker patients are arriving at the hospital after family, friends, or caregivers insist; those with milder strokes or transient ischemic attacks are staying home, ignoring symptoms, or seeking outpatient attention. • The usual way—patients without COVID-19 who appropriately present to hospitals with stroke symptoms, receive treatment, and are discharged COVID19-negative. This group resembles a prepandemic stroke pattern but still deviates from usual care because of reduced resources. Well-intentioned efforts to liberate hospital beds for COVID-19 surges and mitigate infectious spread reduces length of stay but results in abbreviated evaluation for etiology as echocardiography, extended cardiac monitoring, and conventional cerebral angiography become outpatient orders. Additionally, stroke patients who are rehabilitation candidates face restrictions and staff shortages. Lastly, family/friend visitation regulations result in psychological stress and suboptimal communication. Patients with stroke with asymptomatic, presymptomatic, or atypical COVID-19 symptoms are inadvertently excluded from recently reported analyses because of pandemic-related screening constraints. Testing all hospitalized patients for COVID-19 regardless of viral symptoms may better elucidate the full COVID-19 impact upon stroke care. The unintended detrimental effect of Stay at Home upon stroke patients, with or without COVID-19, remains incomplete. This needs further evaluation, particularly in vulnerable/underserved communities.