Maintenance of Acute Stroke Care Service During the COVID-19 Pandemic Lockdown

Abstract

Background and Purpose: Timely reperfusion is an important goal in treatment of eligible patients with acute ischemic stroke. However, during the coronavirus disease 2019 (COVID-19) pandemic, prehospital and in-hospital emergency procedures faced unprecedented challenges, which might have caused a decline in the number of acute reperfusion therapy applied and led to a worsening of key quality measures for this treatment during lockdown. Methods: This prospective multicenter cohort study used data from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry of patients with acute ischemic stroke treated with reperfusion therapies, that is, intravenous thrombolysis or endovascular therapy. We compared prehospital and in-hospital time-based performance measures (stroke-onset-to-admission, admission-to-treatment, admission-to-image, and image-to-treatment time) during the first 6 weeks after announcement of lockdown (lockdown period) with the same period in 2019 (reference period). Secondary outcomes included stroke severity (National Institutes of Health Stroke Scale) after 24 hours and occurrence of symptomatic intracranial hemorrhage (following the ECASS [European-Australasian Acute Stroke Study]-II criteria). Results: Across 20 stroke centers, 540 patients were treated with intravenous thrombolysis/endovascular therapy during lockdown period compared with 578 patients during reference period (−7% [95% CI, 5%–9%]). Performance measures did not change significantly during the lockdown period (2020/2019 minutes median: onset-to-admission 133/145; admission-to-treatment 51/48). Same was true for admission-to-image (20/19) and image-to-treatment (31/30) time in patients with available time of first image (n=871, 77.9%). Median National Institutes of Health Stroke Scale on admission (2020/2019: 11/11) and after 24 hours (2020/2019: 6/5) and percentage of symptomatic intracranial hemorrhage (2020/2019: 6.2/5.7) did not differ significantly between both periods. Conclusions: The COVID-19 pandemic lockdown resulted in a mild decline in the number of patients with stroke treated with acute reperfusion therapies. More importantly, the solid stability of key quality performance measures between the 2020 and 2019 period may indicate resilience of acute stroke care service during the lockdown, at least in well-established European stroke centers.

Characteristics, Management, and Case-Fatality of Patients Hospitalized for Stroke with a Diagnosis of COVID-19 in France

“…We observed twice higher inhospital and 3-month mortality in patients hospitalized for stroke with a primary diagnosis of COVID-19 (group B). This result might highlight the difficulty to manage patients with both acute stroke and severe COVID-19 in terms of care pathway organization including prehospital management, emergency department regulation, interhospital transfers, and endovascular procedures as found in previous studies [8, 9] from France [10], the stroke care network of Madrid [11], in Germany [4], in Lombardy and Italy [12]. These difficulties led to the publication of a guidance statement based on shared best practices in May 2020 [13].…”

Evaluation of Workflow Delays in Stroke Reperfusion Therapy: A Comparison between the Year-Long Pre-COVID-19 Period and the with-COVID-19 Period

“…Ventilation of CT rooms is much easier. This change in the first-used thirds in Western countries 8,13,27) . Although the number of overall patients with AIS decreased somewhat early on in the with-COVID-19 period, the total number of patients undergoing reperfusion therapy per year did not change between the pre-COVID-19 and with-COVID-19 periods.…”

“…In the present study, OTD time was a median of 29 minutes longer in the with-COVID-19 period compared with the pre-COVID-19 period, although this difference was not statistically significant. Other studies reported an increase in OTD time after the COVID-19 pandemic 13,26,27) . The causes of a delay in in-hospital care in the with-COVID-19 period include 1) the time required for the standard personal protective equipment, 2) the time taken to perform a COVID-19 antigen test if needed, 3) the time taken to secure the delivery flow-line from the emergency room to the imaging room/angiography suite and to prepare the angiography suite to avoid contact between patients with suspected COVID-19 and other patients or medical staff, and 4) potential fear of medical staff of contracting COVID-19.…”

Clinical profile and outcome of non-COVID strokes during pandemic and the pre pandemic period: COVID-Stroke Study Group (CSSG) India

“…Interestingly, contrary to what was perceived and has been observed previously, the overall rate of thrombolysis was not changed during the pandemic period [ 17 ]. However, as mentioned above, the sharp decline in thrombolysis in April 2020 correlates well with the reduction of stroke admissions during the sudden surge of COVID-19 cases, lockdowns and overwhelmed health care facilities [ 18 ]. As most of the sites in the present study are established stroke centres, it is likely that acute stroke management remained a priority and reorganization of care pathways during the pandemic stabilized the rate of stroke admissions and thrombolysis [ 19 ].…”