Stroke Is an Emergency, Even During a Pandemic

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Stroke is one of the main causes of death and disability all over the world, and the epidemiologic data are coherent with the decision of the World Health Organization to include it within the noncommunicable diseases to define and share strategies for prevention on a health policy level in all countries. Of course, the statement about stroke as a preventable disease is not an absolute truth, and the known global data on its prevalence and incidence are hard to invert both in high-income countries and in middle- and low-income countries. Otherwise, of all noncommunicable disease deaths, 77% are in low- and middle-income countries. The Global Stroke Burden Initiative¹ released the following data for 2019: Among 12.2 million incident strokes (95% uncertainty interval [UI], 11.0-13.6) and 101 million prevalent strokes (95% UI, 93.2-111) with 6.55 million deaths from stroke (95% UI, 6.00-7.02), 86.0% of all stroke-related deaths (95% UI, 85.9-86.9) occurred in lower income, lower-middle income, and upper-middle income countries. In particular, in Brazil, the incidence of stroke in 2019 was 295,510 (95% UI, 264,161-331,954); the prevalence was 2,985,012 (95% UI, 2,716,617-3,280,844), and the stroke-related deaths were 131,007 (95% UI, 119,135-139,018).¹

Another issue is that stroke is a potentially treatable disease; this statement applies not only to the hyperacute stroke pathways but also to care after an acute stroke. The pathways of care of hyperacute stroke and particularly of severe stroke, irrespectively from the acute revascularization treatment (intravenous thrombolysis and endovascular therapy [EVT]), often involves an intensive setting of case (NeuroICU or ICU). Also, in Latin America and in particular in Brazil, there is an going strategical change in the design of the stroke care pathway at a political level, according to the international recommendations.² The clinical benefit of EVT in the public health-care setting of an upper middle-income country was confirmed recently by the Endovascular Treatment With Stent-retriever and/or Thromboaspiration vs Best Medical Therapy in Acute Ischemic Stroke (RESILIENT) trial.³

The pandemic represented an unprecedented health emergency that has changed the pathways of treatment of other diseases acutely, including stroke, despite stroke being a time-dependent emergency. This has happened in all countries; the reduction in the number of stroke admissions/hospitalizations is a recurrent issue in all care settings. The ICU setting has been investigated less widely and is probably the one with the greatest impact from the pandemic because the care needs of patients with SARS-CoV2 infection and severe respiratory failure forcibly have involved the ICUs on the front line, with a limitation of beds available for other diseases, including stroke.^{4 , 5} In this setting the patients with stroke who are admitted in ICU have a worse prognosis in comparison with the prepandemic data, as reported by Ranzani et al⁶ with a clear link between the rise in COVID-19 cases and the increased mortality rate. These data interrupted a trend of improvements in survival rates over 10 years, thereby confirming the analysis of hospital metrics in a single Brazilian hospital.⁵ In this issue of CHEST, a retrospective analysis of the first 250,000 hospital admissions for COVID-19 in Brazil showed that overall ICU admissions were 39% of all hospitalized patients with COVID-19, with an ICU mortality rate of 55%, and were 14% of the patients who underwent invasive mechanical ventilation outside the ICU.⁷

If the pandemic represented a stress test for the health systems of high-income countries with greater resources to be used, this impact was even stronger in middle- and low-income countries,⁸ where resources are fewer. In Brazil, which is a middle-income country, the treatment pathways for stroke and, in particular, the access to revascularization treatment (both IV therapy and EVT) underwent enormous growth and implementation in recent years. The inequalities in the performance of health-care access globally exist,⁹ but a great effort has been made to overcome them in acute stroke care. In Latin America, in the years preceding the pandemic, there was a 35% increase in the number of stroke centers; Brazil was responsible for the greatest percentage because of the National Stroke Programme, which includes financial incentives for hospitals with Stroke Units implemented.¹⁰

The data provided by the authors on a significant reduction in ICU hospitalizations for stroke in relation to the pandemic waves and increased mortality rates of ICU-admitted stroke patients are therefore fundamental also in this context.⁷ The reduced hospitalization rate does not correspond to a parallel reduction in the incidence of cerebrovascular disease. The worst prognosis of patients with stroke who were admitted in the ICU was justified only partially by the increased severity of stroke at admission, particularly in the first wave because of the fear to access the hospital and the isolation measures. Maintaining organized care pathways for stroke, even in emergency situations, is a strategic priority in health policy. This issue is valid both in terms of access to hyperacute treatment with a timing suited to being a time-dependent disease and in all phases of the patient's hospital treatment to ensure the best prognosis. If the first point, albeit with local, regional, and national differences, generally seems to have been guaranteed,¹¹ the second point was challenging even in high-income countries because of the need to cope with a dramatic and sudden reallocation of resources with the rising tide of patients affected by SARS-CoV2 infection and, in particular, by its most severe forms, which required an intensive care setting. ¹² These data should represent an issue of rethinking the organization of stroke pathways to guarantee the proper care for stroke patients in each situation and in each country.

Financial/Nonfinancial Disclosures

None declared.