In this study, based on data from almost 800 patients, we found no changes in workflow time intervals, ET efficacy, and functional outcomes in LVO patients treated with ET during the COVID-19 pandemic in Germany when compared to 2019.
Our study needs to be put into perspective and compared to recent reports on stroke admission numbers and workflow time intervals from other countries and regions. While we found a slight reduction of patients admitted with ischemic stroke and transient ischemic attack but no change in patients treated with ET, reductions in stroke patient numbers during the COVID-19 pandemic were also found in China and Spain when all stroke admissions were analyzed [6, 7], and in France when patients treated with ET were analyzed [8]. Moreover, longer workflow times were found in France [8] but not in Spain [7]. In contrast, in our analysis the majority of workflow times were similar between 2020 and 2019 except for a longer door-to-groin puncture time in patients admitted through interhospital transfer in 2020. This may potentially be related to a higher level of uncertainty regarding the infectious status of patients from other hospitals, although we have no data to support this interpretation. We hypothesize that the differences between these findings and our results are likely related to a combination of epidemiological and health system-related factors, which may include: i) differences in the COVID-19 incidence between regions and countries, ii) different levels of lockdown measures between countries, iii) the pre-pandemic state of these health care systems, and iv) the ability of healthcare providers and policymakers to prepare for the impact of the pandemic. Integrating these data from different countries might inform policymakers and health care providers on how to react adequately to future pandemics, or a potential ‘second wave’ of the current pandemic, while maintaining optimized emergency workflows for patients with acute ischemic diseases. In our cohort, three patients were tested positive for SARS-CoV-2, however, we note that routine testing was not implemented in most hospitals during that time, indicating that the actual number might be higher.
The strengths of our study include the large sample size and multi-center nature of our study, as well the report of functional outcome measures in addition to procedural times. Importantly, our data were collected from both university and municipal hospitals and from regions differently affected by the COVID-19 pandemic. Our study is limited in its observational character, and we thus cannot rule out residual confounding. Moreover, our data were obtained from stroke centers with highly standardized prehospital and intrahospital algorithms, and may thus not be generalizable to lower-volume or non-specialized hospitals.
We conclude that pre- and intrahospital ET workflows, ET efficacy, and functional outcome of LVO patients were not affected during the COVID-19 pandemic in our large German cohort. Close monitoring of workflow intervals remains important to secure optimized care of hyperacute emergencies during the pandemic.
