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Received: 4 September 2020    Accepted: 4 November 2020

DOI: 10.1111/ene.14640

ORIGINAL ARTICLE

The impact of the COVID-19 outbreak on acute stroke care in

Slovakia: Data from across the country

Zuzana Gdovinová1 | Marianna Vitková1  | Anna Baráková2 | Alena Cvopová2

1
Department Neurology, Faculty of
Medicine, P.J. Safarik University and
University Hospital L. Pasteur, Košice
2
National Health Information Center,
Bratislava, Slovakia
Correspondence
Marianna Vitková, Department of
Neurology, Faculty of Medicine, P.J.
Safarik University and University Hospital
L. Pasteur, Tr. SNP 1, 04011 Košice,
Slovakia.
Email: marianna.vitkova@gmail.com
Abstract
Background and purpose: A few studies using data from regional databases have recently
pointed to a decreased number of patients with stroke. The aim of the present study
was to describe country-level data (the number of patients with stroke, the proportion
of patients with acute stroke and transient ischemic attack (TIA), the proportion of pa-
tients treated with intravenous thrombolysis [IVT] or mechanical thrombectomy [MT],
the door-to-needle times [DNT], and the onset-to-needle time [ONT]) during the COVID-
19 pandemic in Slovakia.
Methods: The study examined data from the stroke register at the National Health
Information Centre. Data from three time periods (March to April 2020; March to April
2019; January to February 2020) were compared using an independent samples t-test
and the Wilcoxon–Mann–Whitney two-sample rank-sum test.
Results: The number of stroke patients admitted to hospitals in Slovakia during the
COVID-19 period showed a decrease (1673 vs. 2328 in period 2 and 2155 in period 3).
The proportions of patients with TIA remained the same in periods 1 and 2 (9.7% vs.
11.7%) and in periods 1 and 3 (9.7 vs. 11.8%). The percentage of patients treated with IVT
during the pandemic (22.4%) did not differ from period 2 (20.0%) or period 3 (21.4%). No
difference was found in the rate of MT between the COVID-19 period (10.2%) and the
same period in 2019 (10.7%) and in January to February 2020 (13.1%). The median DNT
remained unchanged in periods 1 (30 min), 2 (35 min) and 3 (30 min), and no differences
were found in median ONT in periods 1 (130 min), 2 (130 min) and 3 (140 min).
Conclusion: We found a decreased number of stroke patients during the COVID-19 out-
break in Slovakia, but no evidence of a change in the quality of acute stroke care.

KEYWORDS
acute stroke, COVID-19, intravenous thrombolysis, thrombectomy

I NTRO D U C TI O N
The COVID-19 pandemic is an ongoing pandemic caused by severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Since the
onset of the pandemic, several groups have reported a decreased
number of patients admitted to hospital with acute ischemic stroke.
However, up to now, only a few studies have attempted to quantify
the impact of the COVID-19 outbreak on the incidence and treat-
ment rates of acute stroke [1–8], and none have included data from
an entire country during the COVID-19 pandemic. The aim of the
present study was to perform a detailed analysis of variations in the
acute stroke pathway in Slovakia during 2 months of the outbreak,
using the same time period from 2019 and 2 months of 2020 be-
fore the outbreak as comparators. This was possible thanks to the

© 2020 European Academy of Neurology     1

Eur J Neurol. 2020;00:1–4. wileyonlinelibrary.com/journal/ene |
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2       GDOVINOVÁ et al.

mandatory stroke register for all 43 hospitals included in the net-

Note: Abbreviations: DNT, door-to-needle time; IQR, interquartile range; IVT, intravenous thrombolysis; mRS, modified Rankin Scale; MT, mechanical thrombectomy; NIHSS, National Institutes of Health
work for acute stroke treatment in Slovakia.

(IQR; range)

2 (1–4; 0–6)
3 (1–5; 0–6)

3 (1–5; 0–6)
Median
mRS
M E TH O D S

This retrospective cohort study was performed based on an

analysis of data from the stroke register at the National Health

14 (3–32; 2–40)

14 (3–32; 1–39)

14 (3–27; 2–39)
NIHSS score
Information Center and was approved by Ethical Committee of P.J.

(IQR; range)
Safárik University, Medical Faculty, Kosice. All patients brought to

Median
one of 43 hospitals for acute stroke care are entered in the regis-
ter. This applies to both ischemic stroke and transient ischemic at-
tack (TIA), as well as to intracerebral or subarachnoid hemorrhage.

ONT, min Mean ± SD,

Written informed consent was waived due to the retrospective

150.4 ± 63.0, 130.0

148.4 ± 58.8, 140.0
142.3 ± 64.0, 130.0
character of the investigation. As the national stroke register allows
only monthly reports to be extracted, March and April 2020 (pe-

(106–188)
(100–195)
median (IQR)

(92–180)
riod 1) were defined as the months when the COVID-19 pandemic
began to impact public life in Slovakia as well as the rest of Europe.
The data were compared with the same time period (March and
April) in 2019 (period 2) and also with January and February in 2020
(period 3) to take into account the annual effort to improve stroke

DNT, min Mean± SD,

management.

38.62 ± 24.8, 35.0

37.62 ± 25.7, 30.0
37.82 ± 30.78, 30

(20.0–50.0)
(20.0–50.0)
(16.0–45.0)
Summary information on the number of patients admitted with a

median (IQR)
final diagnosis of stroke, with ischemic stroke and with TIA, the num-
ber of patients treated with intravenous thrombolysis (IVT) and me-
chanical thrombectomy (MT), and the average door-to-needle time
(DNT) and average onset-to-needle time (ONT) was extracted for
each hospital and for each evaluated time period. DNT represents

154/10.7
109/10.2

172/13.1
MT, n/%

the time from arrival at the hospital to time of reperfusion therapy,

and ONT is the time from first symptoms to reperfusion therapy.
The severity of stroke was measured using the National Institutes of
TA B L E 1  Main clinical characteristics of the sample in the three time periods

Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS)
346/20.08

393/21.43
276/22.39

score at discharge from hospital.

IVT, n/%

Stroke Scale; ONT, onset-to-needle time; TIA, transient ischemic attack.

Statistical analysis
TIA,

298
189

271
n

Clinical variables of interest were described separately for each time

period. Continuous variables were assessed for normality with visual
Ischemic
stroke, n

inspection of histograms, and were described using mean, standard

1683
1332

1792

deviation and median with interquartile range (IQR), as appropriate.

Categorical variables were summarized using frequencies.
An independent sample t-test was used to compare the means
Ischemic stroke

of normally distributed data. Non-normally distributed data were

and TIA, n

compared using the Wilcoxon–Mann–Whitney two-sample rank-

sum test.
2090

1954
1521
March–April 2020

January–February
March–April 2019

R E S U LT S
2020

The total number of patients admitted with stroke (ischemic

stroke, intracerebral or subarachnoid haemorrhage) decreased in
period 1 (March–April 2020) compared to periods 2 (March–April
IMPACT OF THE COVID-19 OUTBREAK ON ACUTE STROKE CARE IN SLOVAKIA
2019) and 3 (January–February 2020; 1673 vs. 2328 vs. 2155).
The numbers of patients with ischemic stroke and TIA are shown
in Table 1. The independent t-test showed that the proportion of
patients with ischemic stroke (from the overall number of patients
with ischemic stroke and TIA) did not differ (t = 0.68, df = 81.5, p
= 0.50) between period 1 (mean: 78.8 ± 7.6%) and period 2 (mean:
77.5 ± 9.0%), nor was it significantly different (t = −0.05, df = 81.6,
p = 0.96) in period 1 (mean: 78.7 ± 7.6%) in comparison with period
3 (mean: 78.9 ± 8.2%).
As the proportions of patients with TIA across all 43 hospitals
in the selected time periods were not normally distributed, the
Wilcoxon–Mann–Whitney two-sample rank-sum test was run on the
data. No difference was found in the proportions of patients admit-
ted with TIA between period 1 (median [IQR] 9.68 [ 6.9–16.3]%) and
period 2 (median [IQR] 11.70 [5.23–14.55]%; p = 0.95) and between
period 1 (median [IQR] 9.68 [6.9–16.3]%) and period 3 (median [IQR]
11.83 [6.29–17.80]%; p = 0.87).
The proportion of patients treated with IVT in period 1 (median
[IQR] 22.39 [12.20–31.25]%) did not differ significantly from pe-
riod 2 (median [IQR] 20.08 [12.15–27.07]%; p = 0.43). Similar results
were found when comparing period 1 (median [IQR] 22.39 [12.20–
31.255]%) with period 3 (median [IQR] 21.43 [15.56–35.71]%). In
addition, no difference was found in the rate of MT between the
COVID-19 period (10.2%) and the same period in 2019 (10.7%) and
January to February 2020 (13.1%; Table 1).
We found no difference in NIHSS score at discharge from hos-
pital between periods 1 and 2 (W = 52504, p = 0.28) or between
periods 2 and 3 (W = 63816, p = 0.54). The mRS score at discharge
did not significantly change in periods 1 and 2 (W = 83841, p = 0.32)
or in periods 1 and 3 (W = 56778, p = 0.41; Table 1).
A Mann–Whitney U-test showed that there was no significant
difference (W = 33222, p  =  0.06) between the DNT in period 1
(median [IQR] 30 [16–45] min) and that in period 2 (median [IQR]
35 [20–50] min).
The DNT of patients treated with IVT in period 1 (median
[IQR] 30  [16–45]  min) did not significantly differ from the DNT
of patients in period 3 (median [IQR] 30 [20–50] min; W = 40126,
p = 0.27).
For ONT there was no significant difference (W = 36432,
p = 0.13) between the ONT in patients receiving IVT in period 1 (me-
dian [IQR] 130 [100–195] min) in comparison with that in patients
treated in period 2 (median [IQR] 130 [95–180] min).
For ONT there was also no significant difference (W = 40034,
p  =  0.86) between the ONT in patients receiving IVT in period 1
(median [IQR] 130 [100–195] min) compared with that in patients
treated in period 3 (median [IQR] 140 [106–188] min).
DISCUSSION
In this national, multicentre study we observed that the overall num-
ber of patients with stroke admitted to hospitals in Slovakia dur-
ing the COVID-19 outbreak (March–April 2020) was 28% lower in
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comparison with the same period in 2019 and 7% lower in compari-
son with January to February 2020. The proportion of patients with
ischemic stroke or TIA and the proportion of patients treated with
IVT were not significantly different over the selected periods.
Slovakia is a country with a low incidence of COVID-19-positive
patients. In the population of 5.458 million, the first positive patient
was registered on 6 March and by the end of April (the study period),
1396 patients had tested positive and 23 had died. The decrease
in the number of patients admitted with stroke was comparable
to the decrease in the Amsterdam area of the Netherlands – 24%,
and slightly lower than in the Akershus region of Norway – 32%,
while in the Alsace region of France the decrease in patients admit-
ted was more severe at 39.6% [3,4,6]. Some studies have indicated
that the reduced number of patients with stroke during the COVID-
19 pandemic may be explained by a lower number of patients with
TIAs avoiding accessing hospitals because of fear of infection with
SARS-CoV-2 [1–3,8]. A decreased number of patients with TIA were
reported in Germany and the Veneto region of Italy, while studies
from other countries did not specifically evaluate the number of pa-
tients with TIA [1,2,6]. We found no difference in the proportion of
patients with TIA during the pandemic period when compared to the
periods March to April 2019 and January to February 2020.
There are several explanations as to why our results are not
consistent with those reported in Germany, France and Italy [2,4].
First, the lower number of patients with stroke, although not sig-
nificant, can nevertheless be explained by the concerns of some
patients about the possibility of infection in the hospital. We hy-
pothesize that this may apply to patients with TIA rather than stroke,
but this assumption has not been confirmed in Slovakia. Second, a
“do not stay at home with stroke” campaign started very quickly in
Slovakia, and patients and conditions were created for the admis-
sion of patients with suspected stroke after prehospital triage. Third,
the incidence of COVID-19 positive patients was lower than in other
countries [1,2,4]; therefore, hospitals were not filled with patients
with COVID-19 and could more readily treat stroke patients.
We did not find any difference in the proportions of patients
treated with IVT in Slovakia during the pandemic period in compar-
ison with the periods March to April 2019 and January to February
2020. Our results are not in line with data from France (Alsace
region), where they registered a marked reduction in stroke alerts,
IVT and MT [4], from Italy (Veneto region), where the number of
patients treated with IVT or bridging therapy declined [1], or from
Germany [2]. A significant decrease in the number of patients with
stroke who received reperfusion therapy was also registered in
Spain [5]. Our results are, however, in line with those from Norway
and from the Netherlands (hospitals for the Amsterdam area) [3,6].
Slovakia, as well as Norway, are countries where the COVID-19
pandemic has been fairly well controlled, and both countries, with
almost the same population of 5.4 million inhabitants, had the low-
est reported mortality rate for COVID-19 worldwide in the eval-
uated period (in Slovakia 23 patients had died up until the end of
April, in Norway 228 had died by 12 May) [6]. The variability in
the results may also be driven by the fact that, in countries with a
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4       GDOVINOVÁ et al.
high rate of COVID-19 infection, patients with severe stroke with
suspicion of large vessel occlusion were transported directly to
secondary centres, and in the case of large vessel occlusion they
underwent MT without IVT [1].
In Slovakia, no difference was also found in the rate of MT be-
tween the COVID-19 period and the same period in 2019 (10.7%), and
a very small difference compared to the period January to February
2020. These results are in line with those from the Amsterdam area
and in contrast to those of the Alsace region and Spain [3-5].
Neither DNT nor ONT in patients treated with IVT in Slovakia
increased during the lockdown, similar to results from the Alsace re-
gion and Amsterdam [3,4]. The unchanged DNT is evidence of good
hospital management of acute stroke.
We found no difference in the NIHSS and mRS scores at dis-
charge from hospital between periods 1 and 2 or between periods
2 and 3. We do not currently have data on the long-term functional
outcome of patients and how this may have been influenced by the
COVID-19 pandemic; future studies should address this issue.
Due to the low incidence of COVID-19-positive patients in
Slovakia, there was only a small reorganization of hospitals and, un-
like in Italy, hub or spoke centres were not reduced [9].
One of the strengths of the present study is that it included data
from all hospitals in our country, thanks to mandatory stroke registry
in Slovakia, which to the best of our knowledge makes this the first
published study from a whole country on the management of acute
stroke during the COVID-19 pandemic.
A second strength is that we compared data with data from the
same time period 1 year before and also from a time period closer
to the outbreak; we therefore also took into account the fact that
the ongoing campaign to improve stroke management is increasing
the number of patients treated with reperfusion therapy each year.
A limitation of this study is that data collection was retrospective,
but thanks to the mandatory register, the number of patients with
missing data was low. A second limitation is that the national registry
provides only monthly reports; therefore, we could not analyse data
from the exact date (13 March) when the lockdown started.
In conclusion, since the beginning of the COVID-19 outbreak,
several departments have pointed to a decrease in the number of
patients admitted to hospital with stroke, but exact data have not
been available. The data published so far have come from regions or
areas in different countries. The aim of our work was to find out the
data for the whole country, which was possible thanks to the man-
datory register of strokes in Slovakia. We found a decrease in the
number of stroke patients admitted to hospital during the COVID-19
outbreak in Slovakia, but no evidence of a change in the quality of
acute stroke care. Continuing to provide high- quality acute stroke
care should be our goal in the future.
AC K N OW L E D G M E N T S
The authors wish to acknowledge the colleagues from all 43 depart-
ments who contributed to the register. This article was supported
by the Irene COST Action CA18118 “Implementation Research
Network in Stroke Care Quality”. There was no financial or material
support.
C O N FL I C T O F I N T E R E S T
Zuzana Gdovinová has received honoraria for lectures from
Boehringer-Ingelheim and serves as a member of the European
Academy of Neurology Stroke Management Panel. The remaining
authors do not have a conflict of interest in relation to this article.
AU T H O R C O N T R I B U T I O N S
All authors have made a substantial contribution to all categories by
the ICMJE guidelines on authorship.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on re-
quest from the corresponding author. The data are not publicly avail-
able due to privacy or ethical restrictions.
ORCID
Marianna Vitková  https://orcid.org/0000-0002-6964-6710
REFERENCES
1. Baracchini C, Pieroni A, Viaro F, et al. Acute stroke management
pathway during Coronavirus-19 pandemic. Neurol Sci. 2020;41:
1003-1005.
2. Hoyer C, Ebert A, Huttner AB, et al. Acute stroke in times of the
COVID-19 pandemic. Stroke. 2020;1:2224-2227.
3. Rinkel LA, Prock JCM, Slot RER, et al. Impact of the COVID-19
outbreak on acute stroke care. J Neurol. 2020;20:1-6. https://doi.
org/10.1007/s0041​5-020-10069​-1
4. Pop R, Quenardelle V, Hasiu A, et al. Impact of the COVID-19 out-
break on acute stroke pathways – insights from Alsace region in
France. Eur J Neurol. 2020;27:1783-1787.
5. Meza HT, Lambea A, Saldana AS, et al. Impact of COVID-19 out-
break in reperfusion therapies of acute ischemic stroke in North-
West Spain. https://doi.org/10.1111/ENE.14476
6. Kritoffersen ES, Jahr SH, Thommessen B, Ronning OM. Effect of
COVID-19 pandemic on stroke admission rates in a Norwegian pop-
ulation. Acta Neurol Scand. 2020;1-5.
7. Bersano A, Kraemer M, Touze E, et al. Stroke care during the
COVID-19 pandemic: experience from three large European coun-
tries. Eur J Neurol. 2020;27:1794-1800.
8. Caso V, Federico A. No lockdown for neurological diseases during
COVID 19 pandemic infection. Neurol Sci. 2020;41:999-1001.
9. Zedde M, Pezzella FR, Paciaroni M, et al. Stroke care in Italy: an
overview of strategies to manage acute stroke in COVID-19 time.
Eur Stroke J. 2020;5:222-229.
How to cite this article: Gdovinová Z, Vitková M, Baráková A,
Cvopová A. The impact of the COVID-19 outbreak on acute
stroke care in Slovakia: Data from across the country. Eur J
Neurol. 2020;00:1–4. https://doi.org/10.1111/ene.14640