Stroke management in the COVID-19 era

Stroke epidemiology and care have been deeply affected by the SARS-CoV-2 pandemic. During the last two years, several brand-new issues emerged, which the medical community has gradually addressed. On the one hand, a paradoxical reduction of stroke cases occurred despite growing evidence of the intimate connections between COVID-19 and hypercoagulability disorders (including stroke). On the other hand, stroke networks were unprepared to face the disruption of regular hospital pathways. To face the new pandemic-derived challenges, our stroke network of AUSL Romagna, Italy, shifted from a drip-and-ship to a mothership model with direct transport of acute ischemic stroke patients to the Comprehensive Stroke Center (“M. Bufalini” hospital, Cesena, Italy). Moreover, intrahospital routes for stroke management were redesigned, and the Neurology Unit opened a Short-stay Neurological Observation (SSNO) unit. This PhD project aims at evaluating different aspects of the impact of COVID-19 pandemic on stroke epidemiology and acute care by analyzing data from the stroke network of AUSL Romagna. The project includes four studies: (1) an epidemiological study to confirm the decrease in stroke referral during the first pandemic wave, (2) a whole stroke network performance study to evaluate the volume and promptness of reperfusion therapies during the first COVID-19 pandemic wave (3) a SSNO unit performance study to evaluate the usefulness of a Neurologist-managed observations unit and (4) a comparison of the mothership and drip-and-ship models to assess efficiency and efficacy of the MS model during the pandemic outbreak. Our epidemiological study (1) confirmed a significant 25-28% decrease of confirmed strokes cases managed in the Emergency Department (ED) in March 2020 compared with the same month of the previous two years. (2) Despite the reduction of confirmed stroke cases, the absolute number of treatments performed in the stroke network remained similar to the previous years. (3) The opening of the SSNO was feasible and strategic in managing stroke referrals in a mothership model. (4) The mothership model proved to be more efficient (promptness of reperfusion therapies) than the drip-and-ship model, with a trend to a better efficacy (functional outcome) despite the pandemic emergency. The reduction of stroke cases is probably explained by a reduced seek for help and hospitalization of patients with transient or non-debilitating neurological symptoms. The shift to the mothership model during the COVID-19 pandemic was feasible. The COVID-19 pandemic has been a great stress test for stroke networks. The lesson learned is that stroke networks should be ready to adapt organization models and participate in population awareness.