The pandemic changed how quickly stroke patients reached care

For some stroke patients, the biggest obstacle during the COVID-19 pandemic was not the stroke itself. It was getting through the hospital door in time.

A broad scoping review examining evidence published from December 2019 through September 2024 found that the pandemic disrupted stroke care across multiple stages, from patients' decisions to seek emergency help to hospital treatment and recovery. Researchers screened 1,405 studies and ultimately included 107 in their analysis.

The evidence points to a recurring pattern: fewer people reached hospitals for stroke treatment, those who did arrive often had more severe strokes, and healthcare pressures altered established treatment pathways.

Independent research from eight countries has reported similar changes, including longer door-to-needle times and less favorable functional outcomes during the pandemic period. PubMed Central (PMC)

Fear of COVID-19 kept some stroke patients away

One of the clearest problems was patient behavior.

Hospitals had become associated with infection risk. At the same time, lockdowns, social isolation and widespread reports of overwhelmed emergency departments created the impression that seeking medical attention might be difficult or unsafe.

That mattered particularly for people experiencing milder stroke symptoms.

Some patients delayed going to hospital, apparently believing their symptoms were not serious enough to justify an emergency visit or fearing exposure to COVID-19. By the time they sought treatment, they could be outside important treatment windows.

The result was a paradox. Stroke admissions fell, but the patients who did arrive could be considerably sicker.

A multicountry study similarly found fewer stroke admissions during the pandemic and higher stroke severity among patients who presented for treatment. PubMed Central (PMC)

Stroke admissions dropped sharply in some studies

The review found substantial reductions in hospital presentations for stroke in several studies.

Reported figures included:

• 31% decline in monthly ischaemic stroke admissions in one study.
• 44% decline in another analysis.
• A separate eight-country study found an overall 9.9% reduction in stroke admissions during its COVID-19 comparison period. PubMed Central (PMC)

These numbers do not necessarily mean fewer people were having strokes.

Rather, researchers have suggested that some patients may never have reached hospital. Fear of infection, restrictions on movement, difficulty accessing emergency services and social isolation all potentially played a role.

That distinction is important. A fall in hospital admissions can conceal unmet medical need.

Patients arriving at hospitals often had more severe strokes

The review also identified a worrying shift in the severity of cases reaching hospitals.

Patients who did seek treatment were, in several studies, more severely affected than patients treated before the pandemic. Delayed presentation was one possible explanation.

Social isolation may have compounded the problem. Someone living alone could have a stroke without immediately having another person nearby to recognize the symptoms and call emergency services.

The eight-country study found higher National Institutes of Health Stroke Scale scores at admission during COVID-19, alongside less favorable modified Rankin Scale outcomes at discharge and three months. PubMed Central (PMC)

Recovery was also affected

The consequences did not necessarily end once patients reached hospital.

The review identified evidence of poorer recovery in some pandemic-era cohorts. One study reported a median modified Rankin Scale score of 4 at discharge, compared with 2 before the pandemic. The difference remained at three months.

The modified Rankin Scale is commonly used to measure disability after stroke, with higher scores indicating greater disability.

That means the disruption was potentially affecting the entire chain of stroke care, not simply the initial emergency response.

Hospitals were under extraordinary pressure

Stroke treatment depends on speed and coordination. Emergency imaging, specialist assessment, thrombolysis, thrombectomy, intensive monitoring and rehabilitation all require staff and resources working together.

COVID-19 disrupted that system.

Healthcare workers were reassigned. Staff shortages emerged. Hospitals reorganized wards and emergency pathways. Infection-control procedures added additional steps to treatment.

A multicenter study involving eight countries found that door-to-needle time was longer during the pandemic, while the use of intravenous rtPA declined globally in its dataset. It also reported less favorable functional outcomes at discharge and three months. PubMed Central (PMC)

The effect was not identical everywhere. Some stroke services adapted better than others, and the researchers found meaningful differences between countries and healthcare systems.

Mortality also rose in some pandemic-era cohorts

The review identified studies reporting higher mortality among stroke patients treated during the pandemic.

One analysis cited in the review found mortality at discharge of 7.7% during the pandemic, compared with 2.5% in a pre-pandemic cohort.

Such comparisons need to be interpreted carefully. The pandemic changed far more than hospital capacity. Patient characteristics, timing of presentation, infection status, treatment availability and broader healthcare disruption could all influence mortality.

The findings nevertheless add to evidence that interruptions across the stroke-care pathway were associated with worse outcomes in some settings.

Telemedicine helped, but access was uneven

Not every change was negative.

Telemedicine expanded rapidly during the pandemic and helped maintain parts of stroke follow-up and rehabilitation when face-to-face appointments became difficult.

But the benefits were not distributed evenly.

Younger patients were more likely to use remote services, while older adults had lower utilization. Limited digital skills, access to devices, internet connectivity and the need for physical examinations can all make remote healthcare more difficult for some patients.

The lesson is not simply that telemedicine works. It is that remote care needs to be designed around the people most likely to be excluded from it.

What the findings mean for future health emergencies

The review's findings raise a broader issue for healthcare planning.

Emergency preparedness cannot focus only on treating the disease that causes a crisis. It also has to protect patients with other time-sensitive conditions.

For stroke, minutes can matter. A system that keeps COVID-19 patients moving through hospitals but allows stroke patients to delay treatment can still create serious secondary harm.

The researchers point toward several priorities for future emergencies:

• Keep dedicated stroke pathways operational during health crises.
• Make emergency stroke symptoms and the need for immediate treatment clear to the public.
• Reduce fear surrounding hospital-based emergency care.
• Expand telemedicine without leaving older or digitally excluded patients behind.
• Maintain staffing and specialist stroke services during major outbreaks.
• Build flexible systems that can absorb sudden changes in demand.
• Track treatment delays and patient outcomes during future emergencies.

Key Takeaways

• A scoping review examined 107 studies published between December 2019 and September 2024.
• Researchers initially screened 1,405 studies.
• Several studies reported substantial declines in stroke admissions during COVID-19.
• Reported reductions included 31% and 44% in separate studies of ischaemic stroke admissions.
• Patients who reached hospitals were often more severely affected.
• Treatment delays and disrupted stroke pathways were reported in multiple settings.
• Some studies found poorer functional recovery after stroke.
• One cited study reported discharge mortality of 7.7% during the pandemic versus 2.5% before it.
• Telemedicine helped preserve some continuity of care but was used less by older patients.
• Future emergency planning needs to protect rapid access to stroke treatment alongside pandemic response.

The next test is preparedness

COVID-19 exposed a vulnerable point in emergency medicine: when hospitals are under extreme pressure, patients with other medical emergencies can disappear from the system before they ever reach a treatment bed.

For stroke, that gap can have lasting consequences.

The evidence does not suggest that every healthcare system experienced the pandemic in the same way. But across multiple studies, delayed presentation, altered treatment pathways and poorer outcomes appeared often enough to raise a clear preparedness question: how can emergency stroke care remain fast and accessible when the healthcare system itself is under stress?

That question will matter long after the pandemic-era data are filed away.

Disclaimer & Source Note: This article is based on the supplied research summary and corroborating peer-reviewed medical literature. Findings from individual studies may differ by country, healthcare system, patient population and study design.