key: cord-0981003-jp4m6ibe
authors: Naccarato, Marcello; Scali, Ilario; Olivo, Sasha; Ajčević, Milos; Stella, Alex Buoite; Furlanis, Giovanni; Lugnan, Carlo; Caruso, Paola; Peratoner, Alberto; Cominotto, Franco; Manganotti, Paolo
title: Has COVID-19 played an unexpected “stroke” on the chain of survival?
date: 2020-05-06
journal: J Neurol Sci
DOI: 10.1016/j.jns.2020.116889
sha: f61f38726ad0e68770581001126c9ccc25ecd526
doc_id: 981003
cord_uid: jp4m6ibe

BACKGROUND: The COVID-19 pandemics required several changes in stroke management and it may have influenced some clinical or functional characteristics. We aimed to evaluate the effects of the COVID-19 pandemics on stroke management during the first month of Italy lockdown. In addition, we described the emergency structured pathway adopted by an Italian University Hub Stroke Unit in the cross-border Italy-Slovenia area. METHODS: We analyzed admitted patients' clinical features and outcomes between 9th March 2020 and 9th April 2020 (first month of lockdown), and compared them with patients admitted during the same period in 2019. RESULTS: Total admissions experienced a reduction of 45% during the lockdown compared to the same period in 2019 (16 vs 29, respectively), as well as a higher prevalence of severe stroke (NIHSS>10) at admission (n = 8, 50% vs n = 8, 28%). A dramatic prevalence of stroke of unknown symptom onset was observed in 2020 (n = 8, 50% vs n = 3, 10%). During lockdown, worse functional and independence outcomes were found, despite the similar proportion of reperfused patients. Similar ‘symptoms alert-to-admission’ and ‘door-to-treatment’ times were observed. During lockdown hospitalization was shorter and fewer patients completed the stroke work-up. CONCLUSION: In conclusion, the adopted strategies for stroke management during the COVID-19 emergency have suggested being effective, while suffering a reduced and delayed reporting of symptoms. Therefore, we recommend raising awareness among the population against possible stroke symptoms onset. Thus, think F.A.S.T. and do not stay-at-home at all costs.

As a result of the ongoing pandemic of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), about one-third of the world population is currently living in a lockdown modality [1] . The first case in Italy was diagnosed on February 20th 2020 [2] . The infectious disease sp read rapidly throughout northern Italy regions and afterwards the whole country, reaching 143'626 confirmed cases, with 18'279 deaths as of 9th

April, 2020 (http://www.salute.gov.it/portale/home.html). On the same date, Friuli Venezia Giulia (FVG), a crossborder region between Austria and Slovenia, showed 2'299 confirmed SARS-CoV-2 cases and 171 deaths ( Figure   1 ).

On 9th March 2020 the Italian government imposed a national quarantine, restricting the movement of the population except for necessity, work, and health circumstances. In many Italian regions, hospitals have been reorganized to properly manage COVID-19 patients, creating new protected wards for SARS-CoV-2 positive patients both for intensive and sub-intensive care, including reorganizing many Stroke Units [3] . The Giuliano -Isontina area of Friuli-Venezia Giulia region represents a peculiar community determined by a high prevalence of J o u r n a l P r e -p r o o f elderly with polymorbidities [4] , and by an international cooperation program for stroke management between Italy and Slovenia.

To evaluate the effects of the COVID-19 pandemics on stroke management, this report described the emergency structured pathway adopted by an Italian University Hub Stroke Unit in the cross -border Italy-Slovenia area (which serves 373'803 people) (data from Istituto Nazionale di Statistica-ISTAT official report, 30th September 2017, see http://dati.istat.it/), and compared clinical features and outcomes of admitted patients between 9th March 2020 (start of Italy lockdown) and 9th April 2020 with stroke patients admitted during the same period in 2019. Figure 2 .

The study population was composed of consecutive patients of both sexes, above 18 years of age, with acute focal neurological symptoms compatible with acute stroke. We excluded patients with acute and sub -acute stroke admitted to other departments. Intravenous thrombolytic therapy (rtPA) (0.9 mg/kg) and endovascular thrombectomy (EVT) were administered following the international guidelines (AHA 2019), with the support of computed tomography perfusion (CTP) for tissue-based selection. NIHSS evaluation was carried out at the time of presentation at the Stroke Unit by a vascular neurologist trained in performing NIHSS examination [5] . For this report, demographic characteristics, clinical and functional features, pre-hospital and intrahospital management characteristics were included in the analysis. For a complete description, see Table 1 .

The study was conducted according to the principles of the Declaration of Helsinki. Approval for the study was obtained from the local ethics committee (CEUR FVG).

J o u r n a l P r e -p r o o f Subgroup analysis and data presentation was proposed for 2019 and 2020 patients, continuous variables were presented as medians (25th-75th percentile) and non-continuous variables as percentages. Differences between the two groups were tested with the appropriate nonparametric t ests (namely, Mann-Whitney U-test) and chi-square. A level of p < 0.05 was regarded as statistically significant.

During the study period, 16 patients were admitted to the Stroke Unit compared to 29 who were admitted in the same period of 2019 (-45%). All patients admitted to our Stroke Unit performed nasopharyngeal swab. None of the patients was positive to SARS-CoV-2. Among these, no differences were present in terms of demographic characteristics and stroke subtypes. In general, a lower absolute number of 'code stroke' activations (9 vs 17) and rtPA treatments (6 vs 12) was found in 2020 compared to 2019. Despite similar alert -to-admission and door-totreatment times, a higher prevalence of severe stroke (NIHSS>10) was found in 2020 (n=8, 50%) compared to 2019 (n=8, 28%), thus leading to worse functional outcomes. Intrahospital management and complications highlighted a shorter hospitalization with a faster commencement of physiatric consultancy and a higher absolute number of respiratory infections in 2020. A dramatic prevalence of stroke of unknown symptom onset (SUSO) was found in 2020 (n=8, 50%) compared to 2019 (n=3, 10%). A complete summary of these findings is reported in Table 1 .

During the state of emergency, the attention of healthcare providers and health authorities is primarily focused on infected patients and the frontline responders. This had an impact also on other units dedicated to highly invalidant pathologies such as a stroke, which still is one of the leading causes of death and disability worldwide. In conclusion, the adopted strategies for stroke management during the COVID-19 emergency have suggested being effective, while suffering a reduced and delayed reporting of symptoms. Therefore, we recommend raising awareness among the population against possible stroke symptoms onset. were admitted to a specific protected 'dirty ED area' (separated from the 'clean ED area', for non -suspected COVID-19 patients) where neurological examination and urgent hematological tests were performed. In "code stroke" patients, Multimodal CT (including Non-enhanced CT, CT angiography of the supra-aortic and intracranial arteries, and -in the cases of ischemic strokes -whole brain volume CT Perfusion) was performed as usual. After neuroradiological examination in suspected COVID-19 positive patients, the CT-room and equipment were properly sanitized. Patients with diagnosis of definite or probable acute cerebrovascular disease were hospitalized in Stroke Unit where, similarly to the ED, 'dirty' and 'clean' areas were arranged.

In both areas, patients were treated with the usual standardized protocols. All patients admitted to ED with stroke symptoms performed nasopharyngeal swab during the assessment process. The median time from swab collection to examination results was 4 h. If COVID-19 diagnosis was confirmed, the patient was transferred to a protected intensive care unit (ICU) or other wards dedicated to COVID-19 for sub-acute care. 

No lockdown for neurological diseases during COVID19 pandemic infection

Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response

On being a neurologist in Italy at the time of t he COVID-19 outbreak

4 (25%) 2 (12%) 4 (27%) 9 (60%) 0 2 (13%) 1 (6%) 0 7 (47%%) 7 (47%) 0 15 (94%) 6 (37%) 10 (62%) 7 (44%) 2 (12%) 5 (33%) 3 (19%) 5 (31%) 13 (12-16) 7 (44%) 3 (2-5) 1 (1-2) 5 (31% ) 6 (43%) 2 (15%) 5 (35%) 1 (7%) 10 (35%) 2 (7%) 1 (3%) 91 (46-165) 57 (40-109) 83 (70-99) 10 (9-10) 7 (24%) 6 (3-11) 8 (28% ) 1 (0-6) 90 (18-100) 95 (30-100) 29 (100%) 14 (48%) 3 (10%) 5 (19%) 13 (48%) 4 (15%) 5 (18%) 3 (11%) 4 (15%) 9 (33%) 10 (37%) 1 (4%) 22 (76%) 8 (28%) 18 (62%) 10 (34%) 6 (21%) 3 (10%) 2 (7%) 4 (14%) 18 (11-24) 15 (52%) 4 (2-4) 3 (2-3) 20 (69% ) 12 (46%) 4 (15%) 2 (8%) 8 (31%))