Updates and perspectives on stroke care and the COVID19 pandemic.
Updates and perspectives on stroke care and the COVID19 pandemic.
Around the globe we find ourselves adapting to a new reality. This is a big personal and professional challenge. Firstly, we have to bring our spouses and families into a safe situation and take care of our children in every imaginable way. Secondly, we have to make gross and unforeseen changes to our professional life. There, we have to consider our patients first.
From many sides I hear that to be a stroke patient has become more and more difficult. Resources are being cut, departments and stroke units moved to smaller and less capable locations, the armarium of therapeutic possibilities is being cut by new priorities and our intensive care beds are being kept open for COVID19 patients. Our hours of duties on the wards are in danger of being redirected to the COVID19 management. Department heads and stroke unit managers have to spend many hours in administrative meetings in order to adapt to the new directives and lead their teams to new hospital entry pathways and management guidelines. At best we are losing time when our patients enter the hospitals, where we have unforeseen delays in initiating emergency treatments, at the worst we are missing the therapeutic window altogether due to delays in hospital admission or referrals, or patients preferring not to enter the hospital at all.
All these adaptations are necessary and we fully support all priority measures to treat COVID19 patients as needed. But we also have to look at the fate of the many patients with other diseases. I even receive messages that the number of stroke admissions are decreasing in some regions. Many of you have created some Whattsapp or Wechat groups among your professional contacts and I am asking you to make these experiences available here on our website and on our social media channels.
it would be a timely help for our international organization to see how we make adaptations in our countries, regions or even hospitals. I think that examples from hospitals or regions are most valuable. I urge you to send us some of your experiences in order to show the world how you are coping with the new requirements imposed upon our profession as stroke physicians, neurologists, nurses, medical personel or therapists.We can then see how things are going from Timbuktu to Los Angeles, from Lagos to Oslo, or from Madrid to Tehran. It would be helpful to recieve reports from countries most severely affected by the COVID19 pandemic.
Michael Brainin, MD President,WSO
March 20, 2020
Dr Rufus Akinyemi, Founding Chair, Steering Committee, African Stroke Organization (ASO)
Prof Mayowa Owolabi, Co – Chair, Steering Committee, African Stroke Organization (ASO)
Mr Ad Adams Ebenezer, Secretary, Steering Committee, African Stroke Organization (ASO)
31st March 2020
The Corona virus disease (COVID- 19) situation in Africa is rapidly expanding. From the first reported case in Africa reported from Egypt on 15th February, 2020 to the first case from sub – Saharan Africa reported from Nigeria on 27thFebruary, 2020, a cumulative total of 3,544 confirmed cases have now been reported from across 39 African countries with 78 deaths as at 2.00pm GMT on 31st March, 2020. Further escalation is anticipated in the weeks ahead.
Although direct clear cut relationships between stroke and COVID – 19 are yet to be described, reports emanating from Europe and North America suggest that the COVID – 19 pandemic is heavily impacting different aspects of stroke care, research and education. Individuals living with stroke have a higher risk of mortality from the corona virus disease. Therefore, it is imperative to particularly support them at this time with innovative solutions to the challenges of access to medications and rehabilitative care in addition to efforts to protect them from contracting the virus.
Seeking information about travel/contact history and respiratory symptoms is fast becoming a component of acute stroke management protocols. COVID – 19 positivity in an acute stroke patient significantly alters the care pathway with significant process delays and utilization of more resources (including designation of special infrastructures for managing cases). Dedicated beds in stroke units and neurointensive care units are being taken up for caring for COVID – 19 patients and medical personnel including stroke physicians are being drafted to the frontline of COVID- 19 care.
Closure of outpatient stroke clinics and the ‘stay at home’ order on the populace has shifted the interaction of the stroke patient and his doctor to telestroke platforms including mobile phone, WhatsApp©, Skype and Zoom, especially in centres where the system had been well developed before the COVID -19 era. Creative ideas to deliver stroke rehabilitation electronically are also being developed.
Research requiring face – to - face interaction with stroke patients and/or their family/caregivers is also affected globally. Recruitment is being suspended for many such studies, while other studies are re-focusing their energies on data curation, cleaning, analysis and manuscript writing. Face -to - face stroke education delivery to medical students, residents and other trainees in stroke medicine is innovatively being moved to online platforms with remote connections to passionate teachers where possible. However, we don’t have much information on the current situation of COVID- 19 and stroke in Africa.
The African Stroke Organization (ASO) would love to hear from you.
Kindly provide brief answers to the following questions:
1. What is your current working situation?
2. How has stroke care been affected in your hospital?
- Acute care services
- Stroke rehabilitation services
- Stroke outpatient clinic
3. How has stroke research and training been affected in your centre?
4. Do you have access to personal protective equipment (PPE) in your practice?
5. Have you seen a stroke patient with COVID – 19 infection (before or after the stroke)?
6. Do you have any suggestion on ASO initiatives that could be useful to support stroke patients and teams facing challenges at this time?
7. Is there a message / experience / learning you would like to share with the ASO and the global stroke community?
We will love to have your contact details.
E mail contact:
Please send your feedbacks to any of the following e mail addresses.
Your comments will be also be collated and forwarded to the World Stroke Organization (WSO).
Adolfo Savia, MD Chief of Emergency Medicine – Anchorena’s Hospital, Buenos Aires
1st April 2020
We are in full quarantine ordered by the Government trying to flatten the curve. Now as the confirmed cases of COVID-19 in our country are on the rise (at this moment 820 cases, 20deaths) our entire healthcare system is preparing for what's coming (in volume and complexity) in the next few weeks.
Our Stroke unit is led by a Vascular Neurology Team and based on the Emergency Department of a General Hospital, so we are used to treat at same time acute stroke patients with acute myocardial infarction, sepsis or trauma. However, this moment is different because we are facing a new disease with a day-by-day evolution, which represents a threat to patients and even to us. Furthermore, it is a historical moment, this is the moment when all our training, our planification, our logistics, our capacity to work in coordination with other services (like EMS) and other specialities (like Critical Care, infectious diseases…) is going to be put at the maximum test. Our system and our will to help is going to be challenged at maximum;but the good news is that this situation is not new for Stroke providers. During the last few years, we learned to strengthen the system and to make every minute and every resource count. So it is important, even in crisis moments, not to forget what we are, what we do, difficult times calls for difficult decisions: triage, resources allocation, etc., but trust your team and work with the system you helped strengthen the last years! All stroke patients we helped, have helped us too to optimize the system, to train you to act faster, to do the right thing at the right moment, so we thank them for the opportunity to make us better. We have done some changes in our protocols, to have an early hospital discharge. One week after the discharge, we appoint a medical control in the doctor's office outside the hospital to minimize the chance of contagion and continue the aetiologycal study.
Finally, our patients do not choose when to have an emergency (like a Stroke), or event they undertook the preventive measures to avoid COVID-19´s contagions it may occur… so the emergency care of all emergencies must continue. I remember to myself every day, “people don't choose to be ill but we choose to face illness everyday”, so we must technically, physically and emotionally be up to the challenge.
PS, I share you all a very short video… it’s Stroke care in time of Coronavirus. Hope it inspires you.
Be safe and thank you all for your commitment with your communities.
On behalf of all the Stroke, Neurology and Emergency Room Team, Anchorena’s Hospital. Buenos Aires. Argentina.
As COVID-19 ramps up here in Australia, the Government has enacted significant social distancing policies and hospitals have been preparing for some weeks. Non-essential businesses are closed and this includes our research institute here at The Florey. Working from home is challenging for some, they need support. SLACK, What's App, ZOOM and other tools are helping, lunch 'catch-ups' and maintaining social connection are critical at this time. Scientists and clinicians should be the 'truth-tellers' for the community, so we are working to keep people credibly informed about the virus. Clinical trials requiring face to face contact are now on hold. Our Stroke Foundation is communicating strongly with stroke survivors, maintaining the FAST message, reassuring patients that drugs are not in short supply. Rehabilitation centers are now closing, so ongoing support for patients who have left the hospital early needs attention. We are looking to this now and welcome innovative solutions - online 'classes', ZOOM supported training, online platforms like ENABLEme (Stroke Foundation) will all help.
Susanna M. Zuurbier, NeuroVascular Center and Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Belgium
6th April, 2020
The scope and scale of events related to the COVID-19 pandemic are almost inconceivable. Efforts to organize optimal care for a large number of COVID-19 patients requires a huge amount of planning, decision-making, and understanding by everyone.
Our neurology ward and neurovascular stroke unit in Antwerp has been reallocated to another part of the hospital, as our ward is currently being used to admit patients with severe COVID 19 infection. A team of stroke neurologists and trained nurses has moved together with the stroke unit to the new location. To prevent unnecessary transportation from primary stroke centers secondary referrals of patients prevent futile transports for endovascular treatments for acute strokes in our hospital.
As many other centers, we have noticed a sharp reduction in the admission of acute stroke patients since the start of the COVID-19 outbreak, especially for minor strokes and TIA’s. The outpatient stroke clinic is closed, only patients requiring urgent medical follow-up are allowed to come in for policlinic assessment. All regular follow-up has been replaced by telephone consultations. Outpatient rehabilitation is currently a problem because many outpatient rehabilitation facilities are closed, or have reduced their capacity. Many of us are leaving their medical (sub) specialities to support the emergency department, the intensive care unit or wards admitting COVID-19 patients. The flexibility and solidarity across the teams is amazing.
Sharing best practices through social media by newsletters and blogs (e.g. World Stroke Organization and the European Stroke Organization) is very important. My colleagues and friends from the European Master in Stroke Medicine are of such great value in these times. I am truly grateful that I have received the opportunity to take part in this training program. Having international colleagues and friends all around the world is helpful for sharing emotions, feelings, and experiences. Also, to support each other. To read about their experiences every day in the hospital and what they are going through. One of our colleagues’ training program director during his specialist training, unfortunately, died due to COVID-19.
During these times, I realize how important it is to be grateful to everything we have, like an amazing family and how beautiful some small things are in our life. I hope that you and your loved ones will be safe through these difficult times. Take care.
Dr. Sheila Martins, Hospital de Clínicas de Porto Alegre, Porto Alegre
In Brazil, in times of coronavirus, we have 2433 cases, 57 deaths (March 25). The city with the highest number of cases is São Paulo, but we are preparing the whole country. In some places, neurological ICUs became ICUs for COVID 19 and stroke units that were to be opened this week became useful for these cases. Stroke patients have been seen at stroke centers normally. We have been trying to shorten the hospitalization time for mild cases, performing etiological after discharge. Volunteer neurologists are also being trained to deal with COVID cases. Most people are at home, as recommended by the Minister do Health. Watch the video of the city of Porto Alegre.
Rodrigo Guerrero MD, Pablo Lavados MD MPH
April 2nd 2020
It's been practically a month since the Ministry of Health confirmed the first case of Covid-19 in Chile.
For some time, we had been feeling distant, incredulous, fearful and somewhat insecure regarding the news coming from mainland China, Korea, Italy and Spain. We dedicated ourselves to compare these different countries´ strategies, as we observed their daily case and death curves, all rising steeply.
While the discussions regarding the Ministerial measures continued (as it still does today), Chilean Neurologists, and many other specialties, have been forced to change their usual way of functioning.
Changes have been experienced in different aspects of the usual neurological clinical tasks. Firstly, in our patients´ care. The country's efforts have been directed towards reducing the pandemic impact, as they should be, with quarantine, lockdowns, curfews, and health security corridors around some cities. Nevertheless, at the expense of the reduction of the regular evaluations of acute pathologies, such as acute stroke in the emergency departments (ER), in the neurology ward and in the outpatient clinic follow-up, as well as their timely access to pharmacological therapies and rehabilitation facilities.
As many of our colleagues worldwide, we have seen a decrease in stroke related consultations. Maybe it's because of our patients´ fear of going out of their homes, or maybe because of an extreme abidance to their city's-imposed quarantine.
We have had to work in teams and optimize (or in some hospitals create from scratch) strategies, such as telemedicine in the evaluation of acute strokes and follow-ups. The few teams across the country that can provide endovascular therapy have revised and created their own protocols to diminish the exposure time to the virus, assessing and reassessing, for example, the use of personal protection equipment (PPE) inside the angio-suite.
We have had to re-think of ways to re-organize our rotations and shifts for the neurology wards, that way minimizing contagion risks to neurologists and the rest of the healthcare team, since in some hospitals and regions it would be devastating to leave a service unattended if one of them got sick. We have tried to simplify, optimize and advance as fast as possible regarding the stroke source studies, avoiding the over-extension of hospitalizations, and procuring social distancing.
Our Health Ministry has made the timing of guaranteed care of certain pathologies more flexible, among those some related to patients with acute ischaemic stroke. The Assessing Neurology Group of the Sub Secretary of Health , and the Neurologic Assessor in the Direction of Chronic Non-Communicable Diseases, are preparing a document that will contain the guidelines for the management of patients with acute stroke, in their pre-hospital care, urgent care, hospitalization, follow-ups and rehabilitation, which has been reviewed by the stroke network, stroke leaders and the national neurological society. This document's main objective is to minimize the patient and medical staff exposure to infection, nevertheless maintaining the standards of care, and it should be ready and available to the public within one week. It suggests, among other things: the use of tenecteplase in intravenous thrombolysis, the extensive use of tele-assistance, the change and optimization of neuroimaging modalities, the maintenance of usual hypotensors and the preferred use of DOACs in comparison to other anticoagulants.
The Hospital Neurology and Cerebrovascular Diseases Working Group from the Chilean Neurology, Psychiatry and Neurosurgery Society (SONEPSYN), has worked with the outpatient rehabilitation teams of different institutions, in order to share realities, projects, successes and difficulties of those who have been affected by the pandemic, and therefore to prepare guidelines and stay focused in outpatients, who still need timely intra-hospital and ambulatory rehabilitation.
Medical Academic Teaching centers and Universities have had to look for new ways of training e without patient bedside teaching, not only to our neurology residents but also our medical students, who have just started to have contact with clinical neurology.
Clinical trials in stroke have also taken the toll either stopping recruitment or reducing it to minimum according to, regulatory agencies, IRBs, ethics committees and sponsors recommendations. Registries have also seen their work force reduced.
Already we have had to evaluate COVID -19(+) patients, wearing advanced PPE, and approaching patients who have put their entire trust in us, to offer our expertise in that moment when they feel most vulnerable and exposed. We have already thrombolysed patients with acute strokes hospitalized with multilobar pneumonia.
We are neurologists, but first and foremost we are persons and citizens, we feel empathy, we have loved ones, for whom we care about, and we are trying our best. We are aware of the need in putting ourselves at the disposition of our health authorities, in case they need us to learn new expertise, such as the management of a ventilator or the treatment of a patient with acute respiratory distress syndrome (ARDS), as have our colleagues in other countries.
We choose to help and care for our patients, and we are available if we are needed to face this pandemic in the front lines, worried not to leave uncared for all those patients with acute strokes and other neurological disease.
Prof. Craig Anderson, Yi Sui PhD, Shenyang Brain Hospital, Shenyang
Adaption of acute ischemic stroke management in facing of COVID-19: the Chinese experience
The treatment of acute stroke patients is highly time-dependent. Covid-19 has caused a global pandemic since December 2019, currently causing up to 339,259 infections and 14,706 deaths (https://coronavirus.jhu.edu/map.html, assessed at 14:00 23/03/2020). In the treatment of acute stroke patients, screening for novel coronavirus infection is extremely important, both to prevent the spread of the virus in patients and medical institutions and to avoid Door-to-Needle Time delay as much as possible.
The global pandemic of this outbreak is unprecedented, and we still have a lot to learn about this virus, including how it is transmitted and how it can be prevented. As such, frontline experience and expert opinions are more likely to be the first line of action. In the past three months, China has summarized the problems and experiences in the treatment of acute ischemic stroke in epidemic situations, which we believe may be worthy of reference by international counterparts.
When a suspected acute stroke is first contacted at ER,
1. Epidemiological contact history, body temperature and possible respiratory symptoms should be first collected.
2. The initial excluded infected patients will be treated according to thrombolysis or mechanical thrombolysis procedures, accompanied by blood examination routine, head and lung CT.
3. Dispatch those who cannot be excluded from a fever clinic/isolation ward for the same examination. It is recommended to apply designated CT scanner and conditional nucleic acid detection in this instance.
4. During and following the treatment, any necessary consultation with the established hospital COVID-19 expert committee should be requested timely.
5 For suspected infected patients, thrombolysis will be applied in a single cell, and mechanical thrombolysis applied in negative pressure or designated DSA suite.
6 Personal protective equipment should be strictly worn by health care workers who come into contact with patients to minimize their infection.
7 Telestroke and phone consultations are encouraged to apply across medical institutions, in assessing the eligibility of thrombolysis and thrombectomy and to guide treatment.
The above measures require prior deployment of personnel, equipment and space facilities, thus experience borrowed from China may warn other countries against collateral damage of acute stroke patients. Preparedness in advance is vital in containing and mitigating this outbreak.
Prof. Werner Hacke, University of Heidelberg, Heidelberg
In times dominated by panic and and contradicting numbers a few facts from our country...
We are approaching 40,000 positive cases, but the mortality in Germany remains very low: just over 200, and most of them are over 80 years old and multi-morbid.
High numbers and low mortality are probably due to wide screening also catching many mild and asymptomatic pstients.
Currently we have 28,000 ICU beds for 83 Million inhabitants ((35 per million) in Germany, which is much higher than in heavily affected countries (Italy, Spain, France 6-8/million), I do not know the UK numbers, for New York state the number is roughly 12.000 ICU beds for 20 million inhabitants.
In addition, IMC beds are being upgraded, many additional ventilators have been ordered by the government.
In Heidelberg we had 10 COVID19 patients on IMC/ ICU! Four on ventilators, some of them transferred from the neighbouring provinces of France.
Of the over 100 ICU beds at Heidelberg, several are emptied and wait for cases.
SU and Neuro ICU not involved yet. The ICU beds for COVID-19 patients are from surgery, anesthesiology, gastro, thoracic, where elective procedures are cancelled / reduced.
Our state has 10 french patients on ventilators, other states are getting patients from Italy.
We currently can take >5 times more ICU patients before reaching saturation and the need of providing more ICU beds, and then there is still the number of upgraded IMC beds and several rehab hospitals with weaning facilities.
The real limiting factor however is manpower. Like everywhere, medical personell is understaffed and there are increasing numbers of infections among them.
Simon Nagel, MD, Peter A. Ringleb, MD for the Heidelberg Stroke Team
Hospitals in Germany, as elsewhere in world, are preparing for a surge of severely affected patients with the new Sars-Cov2 Virus (nCoV) in need of intensive care and ventilation. Luckily, and in contrast to many regions worldwide, which have been overrun with Covid- 19 patients, the situation within the Heidelberg University Hospital (UKHD) catchment area is still manageable. The basic principles and treatment concepts for our acute stroke patients have so far been unaffected by the nCoV pandemic. Admissions to our stroke unit within the past 30 days (as of 26th March 2020) have only decreased by 8% as compared to the same period of last year. Imaging and interventional acute treatment (i.e. mechanical thrombectomy) services remain available 24/7 in the same capacity, but our neuroinventionalists have formed small teams that rotate temporarily in order to maintain unaffected by the virus. Elective neurointerventional treatments, like aneurysm repair or embolisations of arterio-venous malformations have been postponed whenever medically indicated. Since the german health authorities, as of last week, have requested to keep intensive care capacities available, our neurointensive care unit was reduced to 50% capacity. A dedicated task force within the UKHD has developed a step wise escalation plan on how ICU beds will be allocated when more Covid-19 patients arrive at UKHD. If that happens our stroke unit will gradually be modified and upgraded to an intermediate care / ICU / stroke unit with the possibility of offering ventilation to non-Covid-19 patients. Consequently further beds on other wards will allocated for stroke patients. In case admissions further rise the stroke unit team will also send nurses and physicians to the dedicated Covid-19 wards. We then also expect a reduction in drip&ship patients if transport capacities become scarce as the epidemic surges.
We sincerely hope that we are not hit as badly as many of your colleagues and we wish to express our sincere respect and appreciation for those who currently treat patients that suffer directly or indirectly from the massive impact of the nCoV pandemic on healthcare worldwide.
Dr Jeyaraj Durai Pandian, Christian Medical College, Ludhiana, Punjab
I returned back from Rio de Janeiro Global Stroke Alliance, Latin American Meeting on March 15th. As per Indian regulations I had to be on self-quarantine for 14 days. This was initially difficult, however, I made my own adjustments to the work schedule. I started seeing patients through video calls in the outpatient clinic. I started a virtual ward round with my team using video calls. It was a new experience for patients as well. The faculty participates in departmental teaching program by Zoom. On the other hand, I was able to complete a few research grants and papers by working from home. As a Dean of the medical school I had to make crucial decisions about the teaching program of the medical students. Finally, the University gave permission for me to close the college. We are going to start online teaching for the students if the situation continues beyond March.
Prabin Bastola, Physiotherapist
Woodlands Hospital, Kolkata, India
31st March 2020
In India, COVID !9 entered little late, but the early lock down, social distancing and fear for patients has severely affected our acute as well as chronic rehabilitation. Patients are not able to attend their rehab session, nor are we physical therapist able to visit their places and provide them rehab sessions.
Similarly, the squeezed departmental space and decreased hospital stay of in patients has also impacted the proper acute rehabilitation. So, I can say that due to the COVID 19 both the acute and chronic rehabilitation has been impaired and of course the mental health of stroke survivors too.
Theodoros Karapanayiotides MD, PhD, FESO, Associate Professor of Neurology, Aristotle University of Thessaloniki,
2nd Department of Neurology AHEPA University Hospital-Thessaloniki-GREECE
Treasurer, Hellenic Society of Cerebrovascular Diseases
29th March 2020
Following your newsletter, please receive a short report concerning the impact of COVID-19 pandemic in stroke care in Greece. For the past 5 years the Hellenic Society of Cerebrovascular Diseases, member of WSO, has been working intensively on implementing acute stroke pathways with emphasis on thrombolysis and thrombectomy networks and we used to take pride in creating a success story for the benefit of our patients and for Greek vascular Neurology. Out of the blue, SARS-CoV-2 invaded our lives and changed dramatically the scenery. My hospital, the largest academic hospital in Northern Greece, became a virus-referral hospital. For the time being, COVID-19 cases in Greece are (hopefully) modest in number and the situation is under control but the health system has been prepared for the worst. As a consequence, the entire neurosciences building has been converted to a “corona” building and the ICU turned into a COVID-19 dedicated ICU. Two neurology departments and one ENT department have been clustered to a single wing and my neurosonology lab is no longer accessible. Stroke dedicated beds no longer exist and stroke admissions have dropped down by 80%, meaning that not only minor strokes and TIAs but also moderate-to-severe strokes are lost in the viral black hole that consumes all medical emergencies but COVID-19. In-hospital stroke pathway is a matter of improvisation depending on the availability/reallocation of spaces and facilities that are subject to constant change and to the patients’ true (or presumed) viral status. One year ago, we implemented an effective EVT pathway, which seems unsafe to carry on under the circumstances (to be honest, even iv. thrombolysis may not be safe under the circumstances). Bottom line, the virus has definitely halted the efforts of the Greek vascular Neurology community and I am afraid that even after the end of this plague we will have to work twice as hard to catch up with the pre-virus level of acute stroke care.
Prof. Valeria Caso, Stroke Unit , Perugia University Hospital, Perugia
Each and everyone of us is having to face her/his personal challenges brought on by the COVID- 19 pandemic. I would like to share with you what I find to be most striking. I am writing to you from Italy, where since the outbreak, everything has changed in our healthcare system, and not only. Since early February, there have been more than 50,000 recorded cases and more than 4,000 deaths. With every passing hour, our hospital is being transformed into a COVID-19 hospital. It is almost impossible to plan any projects for the future.
The daily lives of all Italians now center around the 6:00 pm report from the "Instituto Superiore di Sanità" (ISS). This national health institute communicates the statistics regarding the propagation of the virus throughout the nation.
On March 20th, they reported the analysis of the first 3,200 deceased patients. Based on the presence of other comorbidities, patients were divided into those who had died with, and those who had died due to COVID-19. Only three deaths were classified as being due to COVID, while the remaining were classified as deaths with COVID-19. The mean age was 78,5 (median: 80, Range 31-103, Range InterQuartile - IQR 73-85), whereas 30% had ischemic heart disease, 22% AF, 73,8 Hypertension, and 33% Diabetes Mellitus. When I saw these data, I realized that these are my patients, the ones who I treat with thrombectomy, thrombolysis, and Stroke Unit Care. For these patients, I have dedicated the last twenty-five years, done research, and traveled the world attending conferences to convince stakeholders to invest more seriously in stroke treatment and prevention. We have greatly improved the prognosis of these patients with dedicated stroke treatment, giving many of them a second chance at life. It is totally misleading to claim that these patients died with, and not due to COVID-19. COVID-19 cut short their life-expectancy dramatically and pushed all our efforts back before dedicated stroke care was set up.
Another aspect that came to my attention was the fact that in Italy, 3,654 health professionals have been infected to date, with 2 out of 3 being females having a mean age of 49y. Over the past few weeks, I have witnessed how many female Internal Medicine specialists spontaneously volunteered to work in the newly created COVID-19 wards, selflessly, and courageously volunteering to tackle the treacherous day and night shifts.
However, as always, the experts that are interviewed on TV and radio programs or find a voice in newspapers are principally members of the grey male eminence while the women are silently laboring in the trenches.
We will need to take time out when this Covid-19 pandemic is behind us to formally and publicly recognize these female professionals for their contribution.
I would like to finish by wishing that you and your families remain healthy.
We will meet again soon.
Valentina Saia, MD, PhD
Neurology and Stroke Unit,Santa Corona Hospital, Pietra Ligure
28th March 2020
In Italy, the first two cases of COVID-19 was identified in late January, while secondary transmissions were recorded from mid-February, so that severe restrictive measures have been introduced in the attempt to limit the outbreak. Due to the steep increase in cases over the coming weeks, many hospitals have been reconverted into COVID-19 centres, where routine activity is no longer available, not even for emergency. In this scenario, our hospital has been spared from becoming a COVID one, as it serves as a Hub centre for Stroke treatment. Therefore, we expected to collect many cases of stroke from nearby areas. However, the number of patients admitted to the ED for cerebrovascular diseases in the last month was well under our expectations and we have to face the truth: people are not coming to the hospital as they are scared! We share this concern with Cardiologists, as the same is happening for myocardial infarction. As we routinely collect endovascular treatments on national basis in our “Italian Registry for Endovascular Treatment in Acute Stroke”, we notice an unusual decline in the number of cases recorded in March 2020, as compared to March 2019, meaning that we’re probably missing even severe stroke cases.
Still, there are many other ways in which this epidemic is affecting stroke care. As other Colleagues already pointed out, we’re facing troubles in staying into the time window for acute phase treatments in these days, as patients coming to the ED are first of all screened for Corona virus infection, even if not symptomatic. Diagnostic neuroimaging and endovascular treatment also take time, as the suites have to be decontaminated if a suspected case has been examined/treated before. Moreover, in case of co-occurrence of stroke and COVID-19, patients have to be isolated in dedicated areas where Neurological management can be difficult. During their hospital stay, patients are not in contact with their families and sometimes they die in isolation. Secondary prevention is also affected as outpatient services are closed, in order to limit the outbreak, so that non-urgent diagnostic tests are delayed or not performed at all.
To conclude, I have to report the lack of appropriate PPE for health workers, so that many of them are unfortunately infected.
I wish we’ll be able to discuss further on this topic, in presence, at the next WSO Congress!
Haruko Yamamoto, Japan
30th March 2020
The number of deaths due to COVID-19 remains low, under 100.
Fortunately, it seems that the stroke departments and units work as usual.
Bad news is that the number of new Covirus patients increases every day.
Good news is that this number still remains low, 140 new patients yesterday.
Another good news is that people including mass media are now understanding that we are on the edge of “infection overshooting", which will lead collapse of medical system.
The government leaders and the health professionals are sending strong message,
"Good infection control practices of each Japanese citizens are strongly expected"
Now we see no people under the cherry trees in full bloom.
Few people are walking in the famous scramble crossing in Shibuya, Tokyo.
Although no one knows whether we will have the overshooting tomorrow or not, we are trying hard to not let the nightmare come true.
Dr. Wan Asyraf Wan Zaid, Consultant Neurologist (Stroke)
Hospital Canselor Tuanku Muhriz Pusat Perubatan Universiti Kebangsaan
We are currently in lockdown since 18 of March 2020 and the government has decided to extend the lockdown period till 14th of April 2020.
I would like to share our experience, as my center is one of the public university hospitals that provide stroke service. Total COVID19 cases as for today has escalated to 2161 cases with 26 patients succumbed due to this nasty virus. At the moment, our stroke services are still functioning as usual but all clinical trials recruitment are suspended. Like any other developing countries we are having limited resources to support the increasing number of SARI and COVID19. The subspecialized intensive care units are now being occupied with ill general medical cases and SARI. Stroke intervention that may require general anesthesia or intensive care back up may need to be discontinued. This raised a huge concerned as stroke and other medical emergencies still arrived to our door and the usual standard of care maybe compromised due this pandemic and at the same time we should protect the healthcare processionals . Nevertheless, innovative approach to help our patients via email, hotlines and Zoom has been use. Similarly with our undergraduates and postgraduates teaching mostly done via Zoom.
It is definitely a tough period, I hope through WSO we are united to face this pandemic with our colleagues around the world to help stroke patients, COVID19 and non-COVID19 patients.
I wish all of us to be safe and remain healthy.
Pamela Naidoo, CEO, Heart and Stroke Foundation, South Africa
31st March 2020
It was only a matter of time that COVID-19 hit South African shores. This is a very difficult time indeed. The country has been in lock-down since 27th March 2020 and will last, at this point, until 16th April 2020. On 31st March the Minister of Health in South Africa announced that there were at least 1 353 people who tested positive for COVID-19 and five deaths. The age group of those that died were a mixture of males and females who were middle to older adults ranging from 48 years to 85 years. At least three of the five people who died in South Africa had underlying co-morbid conditions, such as hypertension, asthma and other respiratory disorders. It is unclear what the health status of the COVID-19 positive cases are, especially with respect to accompanying NCDs such as stroke and heart diseases.
What implications does the coronavirus pandemic have for stroke care and CVD care in general? In South Africa, similar to many other countries in the world battling with the crisis, much of the health care resources are now being directed to COVID-19 detection, as well as treatment of extreme cases admitted to high care and ICUs. It was announced by our President on the 30thMarch 2020 that there will be a massive testing initiative which will hopefully provide a more accurate estimate of the number of cases. It is too soon to comment on the actual impact of COVID-19 on the treatment and continued care of stroke patients.
Prof Keun-Hwa Jung, MD, Seoul National University Hospital, Seoul
We find ourselves feeling trapped in the endless loop of a brand new virus. In Korea, spaces from ER, ICU and general wards are being converted to care patients contracting COVID-19, and protocols are changing every single day. We can’t agree more that the management for coronavirus should be our top priority for public health. But we also have to consider the aftermath of the significant constraints posed by the COVID-19 pandemic.
Indeed, we are faced with quite a bit of trouble that some of code strokes are COVID-19 suspected and swab results pending. As the test takes a couple of hours, we are limited to making informed decisions due to the restriction of imaging and procedure. If the case is confirmed positive, we should abandon the EVT. Even if the case is negative, time delay would preclude the EVT. In many of hospitals, we are just doing CT and intravenous tPA. We are stratifying patients’ risk based on exposure history and respiratory symptoms/signs and applying different levels of protection gear to the patients and workers during the transportation and procedure.
This situation may last longer than any of us expected and the similar ones may continue to follow. We are planning on preparing interventional radiology suite maintained at negative air pressure to protect the worker and the environment. We find it challenging, but it is doable.
We don’t yet have any solid guidance for the conduct of emergent treatment and thrombolysis in suspected cases. Boards and members from Korean stroke society are discussing about the range of investigation, legal document to defense the potential delay for EVT, and referral and transportation policy. The situation is quite fluid with circumstances changing daily and the guidance should be coordinated following the government’s regulations. The opinions of internationally trustworthy organization, such as WSO are likely to help create guidance in each country. We obviously need collaborative work based on experiences of each country and region.
Local and international meetings are being cancelled or postponed. The last thing I would like to mention is Asia Pacific Stroke Conference (APSC) 2020 conjoined with WSO is postponed to 7-9 December 2020, and the new venue will be in Busan, Korea. We hope we can make it safely.
Dr. Deidre de Silva, Singapore General Hospital
Singapore was one of the first countries outside China to be significantly affected by the COVID-19 pandemic. Due to the well-strategised and executed measures, we have managed to keep our case numbers down. However, we are now seeing a second wave of cases due to the spread to many other parts of the world.
For clinical practice of hyperacute stroke in Singapore, there has been minimal disruption. Our ambulance service still dispatches patients to stroke designated hospitals. Thrombolysis and endovascular clot retrieval are being utilized for patients with no change in indication, including use of MRI for stroke of unknown onset, extended time window ECR using the DEFUSE 3 or DAWN criteria. Respiratory symptoms, contact and travel history are now more emphasized and if positive there may be some delay in getting brain imaging, preparing for ECR, finding an appropriate inpatient bed with appropriate isolation precautions yet ability for post-reperfusion monitoring, and for secondary transfer for ECR where needed. Multidisciplinary stroke huddles are curtailed in order to maintain appropriate distancing between staff. Transfers to inpatient rehabilitation facilities are slightly delayed due to various reasons related to COVID-19. Outpatient rehabilitation has taken a particular hit, with most outpatient facilities being closed. Contingency plans for the management of stroke should the situation worsens are being discussed.
Education amongst stroke professionals is now minimal unfortunately. This is due to manpower shortage as well as avoidance of large groups meeting. For example, we have not held our routine multidisciplinary thrombolysis audits since the COVID-19 crisis started. Small group teaching sessions have continued, mainly for training of our residents. Web-based teaching sessions have started. We have started developing a series of infographics discussing recent stroke publications, as part of our stroke interprofessional education (STRIPE) programme. These will be sent via email as an interim measure to allow the stroke healthcare community keep up with the literature.
On the research front, all recruitment has ceased. Trials involving critical treatment can apply for exemption from this and I am aware of at least 1 thrombolytic trial which has successful received this exemption. Whilst, recruitment of patients is halted, I have noticed that many clinicians are catching up on their data analyses and manuscript writing during this period. I think this is because whilst many healthcare workers are busy, they miss the academic interactions which have been curtailed by COVID-19.
Finally, I am particularly concerned about how COVID-19 is affecting stroke survivor support and advocacy. All stroke support group activities have been cancelled to minimize spread. Social media and initiatives which are not face-to-face, have been started including telephone befriending, notices on social media and members posting message on how they are coping. I am aware of the ongoing development by local therapists of an exercise video series which will hopefully be out soon.
Prof. Patrik Michel, Neurology Service, Centre Universitaire de Lausanne (CHUV), Lausanne
Our stroke center has decided to fully maintain all acute stroke and TIA assessments and clinics, including the TIA day clinic. The hospital management understands that doing otherwise would put more strain than gain on the entire system, would reduce patient flow and overload the system further with unnecessary handicaps and care. We have also opened our doors for acute stroke assessment and treatment for a neighboring stroke unit which was requisitioned to treat COVID patients.
On the other hand, a first cerebrovascular patient in the stroke unit turned COVID-positive (likely prehospital infection), requiring the patient to go to a medical COVID-bed outside the stroke unit. Similarly, acute stroke patients with “unexplained fever” (which is most frequently acute aspiration pneumonia) may have to transit initially through these COVID-beds till tested negative for the virus, making a neurovascular assessment and proper stroke unit care much more difficult.
Several of our clinical and neuroradiological stroke physicians have been infected by the virus (luckily with minor symptoms for now) despite applying the recommended in and out of hospital measures, putting them in quarantine for 10-14 days. For this and staffing reasons, the in and outpatient patient educational programs had to be put on hold.
The outpatient stroke clinic is mostly performed telephone consultations. While doing so, we still take sufficient time to discuss stroke sequelae, stroke symptoms, and psychological questions; we also review all medications thoroughly and encourage patients to stick to secondary preventive measures.
Juliet Bouverie OBE Chief Executive Officer, UK Stroke Association.
Impact on people affected by stroke
The Stroke Association, with support from NHS clinicians, is maintaining up-to-date information for stroke survivors and their families on our website https://www.stroke.org.uk/news/coronavirus-covid-19-information-people-affected-stroke. Stroke survivors have been classified as ‘vulnerable’ due to having a chronic neurological condition.
Impact on stroke services
New guidance on the management of stroke patients in England affected by COVID has been published today on NHS England’s website
Stroke clinicians are concerned that stroke-related deaths may increase due to stroke unit beds and stroke clinicians’ time being redirected to COVID-19. We are also seeing evidence of people not phoning 999 for TIAs – the Stroke Association will be running a campaign on this in due course – a reduction in provision of mechanical thrombectomy, and stroke patients being discharged from hospital into the community earlier with increased disability. Stroke clinicians are also concerned that, not only will we lose momentum on stroke services during the crisis, but it may also be more difficult to get stroke back onto the clinical priority list post-COVID.
Impact on stroke research
The National Institute for Health Research has asked for studies not relating to COVID-19 to be suspended. Clinical audits, including those for stroke in all four countries of the UK, have also been suspended,
Support from the Stroke Association
We have moved all of our face-to-face services for stroke survivors and their carers to telephone and digital. We are planning to enhance our offer which is likely to include stroke information and a phone call for newly diagnosed stroke survivors, emotional support, peer support / telephone befriending, low-level virtual rehabilitation, and 6-month reviews. The offer will be finalised shortly. We have asked for volunteers and staff to be trained for new roles.
Prof. David S. Liebeskind, UCLA Comprehensive Stroke Center, Los Angeles
An updated, almost real-time summary of the last 48 hours:
Tuesday 24 March: At UCLA we are spending the entire day, every day either on Zoom in social isolation, organizing and coordinating healthcare approaches for the expected onslaught. In parallel, we are adapting our stroke care and neurocritical care decisions to minimize exposure and maximize resources, such as personal protective equipment (PPE).
Wednesday 25 March: After weeks of discussion regarding the theoretical aspects of managing acute stroke and endovascular therapy during the current COVID crisis, it was prime time. Earlier today we had the real world experience of managing acute ischemic stroke in confirmed COVID positive patients in the ICU, evaluating, imaging and triaging for endovascular therapy. We have now been in contact with several positive patients, many who are critically ill. There were many lessons learned, including the simplest conclusion, that any protocol will not work in all cases.
I underscore the key principles of minimizing exposure and maximizing resources. We exercised all the care possible with PPE, when available. Interesting scenarios were encountered, such as 20 foot long IV lines placed down the hallway. During transport, there is considerable time spent in the hallway, increasing potential exposure. A CT and even an MRI, when available, needs to be designated as the COVID scanner. CT may seem simple, yet not really helpful in a complex ICU patient with unclear time of onset. COVID causes renal failure, limiting contrast use for diagnostic imaging such as CTA/CTP/MRI with Gad for MRA or PWI. There are no negative pressure angio suites. Decontaminating and cleaning the scanners and suites is not so simple. Surgical masks for all healthcare workers are not sufficient as at least N95 must be provided for everyone. Regarding intubation, there is a significant shortage and resource allocation must be considered, across the hospital. As mentioned, re-intubating someone for the procedure or planning short term intubation is a nice plan, but all decisions must be realized in sequential decision making. In an ideal world, where all resources of every kind are available, one can issue a simple protocol, including the ideal method of anesthesia or support. However, that is not the real world. Finally, it is ludicrous to think that these complexities and difficulties will not impart delays in our usual efficient stroke care. Workflow and timing will not be the same.
I anticipate that this left MCA occlusion case is just the beginning of a prolonged exposure to stroke and COVID-19.
Christian Emmanuel T Lim, Head, Acute Stroke Unit, Gov. Celestino Gallares Memorial Hospital Tagbilaran City, Bohol, Philippines
30th March 2020
We at Gov. Celestino Gallares Memorial Hospital, a tertiary hospital in the province of Bohol, have given up our seven bed stroke unit to be utilized as a COVID ICU, we were given a 2 bed unit with telemetry to continue with the stroke service. The delivery of thrombolysis medications have been stalled since the island is already on lockdown. We continue to cater to stroke patients despite the new limitations imposed by this CoVid Pandemic. Our enthusiasm to continue to improve stroke care in the province continues despite major setbacks brought by the pandemic. We continue our activities: patient and family education, rehabilitation, and policy improvement as we also extend help the rest of the hospital battle this illness. With our collective prayers, we will succeed.
In the last couple of weeks, the COVID-19 pandemy is changing all our daily lives. What we are hearing from countries where thousands of people are already infected and far too much are dying is heart breaking. Of course, we are absolutely aware that you and your colleagues in the hospitals have the biggest challenges, workload and risk by far. So many doctors and nurses are already infected.
However we also see a lot of wonderful examples how doctors, nurses, but also ordinary people, neighbors are helping, caring and supporting in a very creative manner, which give us hope that we will overcome this horrible crisis and that we learn the lessons.
Please don’t forget, we as Angels will continue to support you whatever it takes. We and our Angels Consultants will continue to communicate with you by appropriate channels to help you in the current situation, to deal with the challenges, to find ways to treat stroke patient in a new environment and if possible to continue with the work that has started before. Please do not hesitate also to contact us, if you think this can help you and your patients.
We are well aware that there are huge differences in the different countries, regions and hospitals due to the level of outbreak and the health care infrastructure. Some hospitals in heavily affected region are transformed to “virus-clinics”, stroke units are closed or transferred to normal stations. A lot of you and colleagues are overloaded with work and others - as we - must work remotely from our home.
Please try not to stop sharing your experience, the situation that we are facing is totally unprecedented, so we can learn a lot from each other. To facilitate this, we created an Angels Initiative closed Facebook group. In other words, only people registered on the Angels website will be accepted in this community. We want to make this platform available for you to support each other, encourage each other and connect information that could save lives.
Please join us here: https://www.facebook.com/groups/AngelsInitiative/
The pharmaceutical industry and their logistics partners play an important role during the ongoing COVID-crisis as the lives of patients worldwide depend also on open borders, on established logistics processes, on airplanes being able to land when transporting essential medications. While politicians worldwide have promised their citizens that the exchange of goods can continue, our industry and related stakeholders in the medical community are faced with the reality that these routine processes have been seriously disturbed by the Corona-pandemic.
Out-of-stock situations of life-saving drugs or medical devices may happen due to circumstances out of our control and I would like to send this message on behalf of many frustrated colleagues in my industry who wish to help more than ever but are faced with these unfortunate realities. Please contact the companies directly when these situations happen, we work for you and your patients and feel very responsible to support you in difficult times.
I would also like to send a message to all our friends and partners in the medical community who are nowadays not only treating stroke patients but additionally support their colleagues in the ER, increasing their own risks to become infected by becoming first line responders during this pandemic and I would like to say thank you to every medical worker who takes on this enormous task right now.
EVER pharma is not a huge global player but we have been trying our best to support stroke education projects since 2006, the year the WSO was established. These projects will also come to a complete stop right now but we promise to be back at your side when all our lives normalize again.
Guidance and action on COVID19 is constantly evolving, the media and social media channels are full of information. We recommend that you use and share trusted, evidence-based sources information sources to keep you, your family and community safe. Please refer to WHO information and guidance and official guidance from your national public health systems.
WHO COVID19 Public Information Resources – have been designed to help you raise awareness of key public health messages on symptoms, public safety and treatment.
Many stroke survivors and caregivers will be unable to access healthcare appointments, rehabilitation or social support groups. Some may be advised against allowing any visitors other than people providing essential care into their homes. Follow your local guidelines, contact your local health and social care services for information and contact your local stroke support organization for advice.
Stroke Association in the UK – Have an online tool, My Stroke Guide, which provides access to trusted advice, information and support and connects you to stroke survivors and caregivers online.
MyTherAppy provides curated access to mobile apps that support stroke self managed rehabilitiation. Apps have been reviewed and tested by clinicians and patients in the UK.
In light of the serious challenges posed by COVID-19. WSO is now providng open access to ALL CME content on the World Stroke Academy.
The WSO Education Committee is developing a series of free webinars, open to all, irrespective of WSO membership. The first, on the 24th March, was very well attended with 170 registrations presented by Alex Pollock: ‘How to do a systematic review’. The next webinar will be on 31st March presented by Julie Bernhardt: ‘How to develop studies in stroke rehabilitation’.
We are developing webinars on such topics as ‘How to run your stroke service during the pandemic’, ‘How to make best use of limited imaging during the pandemic’ and ‘How to maintain stroke clinical trials during the pandemic’, follow our social channels to keep in touch. @WorldStrokeEd
Achieving our vision of a life free from stroke is a task that WSO cannot achieve alone. We are committed to building our partnerships at the global, regional and national level to scale up and deliver improvements in prevention, treatment and support to reduce the burden of stroke.