Impact of COVID-19 pandemic on acute stroke care: facing an epidemiological paradox with a paradigm shift

Abstract

Background: During the coronavirus disease 2019 (COVID-19) outbreak, a decrease of stroke's hospital admissions and reperfusion therapy has been reported worldwide. This retrospective observational study assessed the volume of stroke cases managed in the Emergency Department (ED) and reperfusion therapies in an Italian stroke network with a high incidence of COVID-19, particularly to evaluate if the in-hospital rerouting and the switch from a drip-and-ship to a mothership model could assure an adequate volume of acute treatments.

Methods: We compared data from March 2020 with those from previous years and formulated five PICO questions regarding (1) incidence of stroke cases in the ED; (2) relation between stroke cases and COVID-19; (3) differences in the number of reperfusion therapies, (4) in the call-to-needle and door-to-needle times for intravenous thrombolysis, and (5) in the call-to-groin and door-to-groin times for thrombectomy.

Results: We found (1) a 28% decreased of confirmed stroke cases managed in the ED, (2) a negative correlation between stroke cases in ED and COVID-19 progression (r_s = - .390, p = .030), and (3) a similar number of treatments in March 2020 and March 2019. The adoption of the mothership model (4) did not delay alteplase infusion (median call-to-needle p = .126, median door-to-needle p = .142) but led to (5) a significant reduction in median call-to-groin (p = .018) and door-to-groin times (p = .010).

Conclusion: The "hospital avoidance" of stroke patients during the "stay-at-home" appeals needs to be considered for future public health campaigns. A prompt reorganization of the stroke network can guarantee optimal performances at times of crisis.

Keywords: COVID-19; SARS-CoV-2; Stroke incidence; Thrombectomy; Thrombolysis.

Fig. 1.

Forlì-Cesena (FC—yellow) and Rimini (RN—red) provinces. “Morgagni-Pierantoni” hospital in Forlì and “Infermi” hospital in Rimini are the main Primary Stroke Centers (spokes) of the network; “M. Bufalini” hospital in Cesena is the Comprehensive Stroke Center (hub) of the stroke network. Green arrows: drip-and-ship model (light green arrows: primary transport to the spokes; dark green arrows: secondary transport to the hub). Blue arrows: mothership model (direct transportation to the hub), applied in the province of Rimini

Fig. 2.

a Cumulative incidence of suspected stroke cases during March 2020 (blue) and March 2019 (orange) and cumulative incidence of COVID-19 cases in March 2020 (red dots). b Daily cases of suspected stroke cases during March 2020 (blue) and March 2019 (orange) and cumulative incidence of COVID-19 cases in March 2020 (red dots)

Fig. 3

Volumes of reperfusion therapies in March 2018, 2019, and 2020 in the stroke network

Fig. 4

Door-to-needle (DTN), call-to-needle (CTN), door-to-groin (DTG), and call-to-groin times in RN provinces. Red and blue bars represent drip-and-ship (D-a-S) treatments in, respectively, March 2019 and the first part of March 2020; yellow bars represent mothership (MS) treatments in March 2020.