Anna Bersano and Natan Bornstein on behalf of EAN Stroke Management Panel
According to the WHO, the spread of coronavirus disease 2019 (COVID-19) has already reached pandemic proportion, affecting at present more than 2.034.000 patients worldwide. Although the majority of cases were first reported in China, the USA and Europe are now experiencing the biggest disease outbreaks with Spain and Italy leading the total number of COVID-19 cases followed by other countries like France Germany, and the UK. Health care systems, health professionals and resources are completely devoted to the fight against COVID-19. How is stroke care considered within this scenario? On one hand, stroke patients are advised to protect themselves from contagion, given they are at increased risk for complications if they get COVID-19. Moreover, based on current information, it appears that elderly people with coronary heart disease or hypertension are more likely to present with more severe symptoms. People affected by infectious diseases as COVID-19 are also at increased risk of ischaemic and haemorrhagic cerebrovascular complications. For this reason, an increased number of strokes could be forecast. However, an unexpected reduction of stroke patients in the emergency room throughout Europe has been observed. It is reasonable to assume that patients with acute mild stroke or TIA remain at home, because they are asked to stay at home, limit emergency room visits, and minimise travel. The patients may be prioritising avoiding contagion. Another issue is that stroke care organization and pathways within hospitals are currently adapted to cover the requirements of dealing with COVID-19. Several stroke units have been reorganized, staff reallocated and many neurologists have to deal with patients affected by COVID-19. In some countries, stroke care pathways are being modified by centralizing all activities to a hub or comprehensive stroke centres and stroke units are sharing their staff. These circumstances could limit stroke patients’ access to recanalization therapies, that must be initiated within a short time window, and act as a barrier to implementation of secondary stroke prevention measures, leading to a higher risk of recurrence and long term disability. Lastly, periodic follow-up visits and rehabilitation activities have been cut down in order to target resources to emergency management of COVID-19, which may lead to increased complications, disability and psychological consequences. This situation is likely to be even worse in developing countries where resources are already scarce. Telemedicine platforms are being implemented to allow patient visits without face-to-face contacts and may partially overcome these limitations. Meanwhile, stroke neurologists are required to protect acute stroke pathways to ensure the best possible stroke care continues, to protect stroke patients from contagion as far as possible and verify that recommendations on risk factor control or therapies are maintained. Patients with a sudden onset of neurological symptoms that could indicate stroke (i.e FAST) should still be aware about the importance of presentation to an emergency room as soon as possible to implement potentially life-saving and time-limited treatment, in spite of the current challenges. Finally, we must remember our colleagues and friends, who were infected and died while being in the front-line in the fight against COVID 19.
