Low stroke incidence in the TEMPiS telestroke network during COVID-19 pandemic – effect of lockdown on thrombolysis and thrombectomy

Background During the COVID-19 pandemic emergency departments have noted a significant decrease in stroke patients. We performed a timely analysis of the Bavarian telestroke TEMPiS “working diagnosis” database. Methods Twelve hospitals from the TEMPiS network were selected. Data collected for January through April in years 2017 through 2020 were extracted and analyzed for presumed and definite ischemic stroke (IS), amongst other disorders. In addition, recommendations for intravenous thrombolysis (rtPA) and endovascular thrombectomy (EVT) were noted and mobility data of the region analyzed. If statistically valid, group-comparison was tested with Fisher’s exact test considering unpaired observations and ap-value < 0.05 was considered significant. Results Upon lockdown in mid-March 2020, we observed a significant reduction in recommendations for rtPA compared to the preceding three years (14.7% [2017–2019] vs. 9.2% [2020], p = 0.0232). Recommendations for EVT were significantly higher in January to mid-March 2020 compared to 2017–2019 (5.4% [2017–2019] vs. 9.3% [2020], p = 0.0013) reflecting its increasing importance. Following the COVID-19 lockdown mid-March 2020 the number of EVT decreased back to levels in 2017–2019 (7.4% [2017–2019] vs. 7.6% [2020], p = 0.1719). Absolute numbers of IS decreased in parallel to mobility data. Conclusions The reduced stroke incidence during the COVID-19 pandemic may in part be explained by patient avoidance to seek emergency stroke care and may have an association to population mobility. Increasing mobility may induce a rebound effect and may conflict with a potential second COVID-19 wave. Telemedical networks may be ideal databases to study such effects in near-real time.

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Estimating the number of UK stroke patients eligible for endovascular thrombectomy

European Stroke Journal ◽

10.1177/2396987317733343 ◽

2017 ◽

Vol 2 (4) ◽

pp. 319-326 ◽

Cited By ~ 46

Author(s):

Peter McMeekin ◽

Philip White ◽

Martin A James ◽

Christopher I Price ◽

Darren Flynn ◽

...

Keyword(s):

Arterial Occlusion ◽

Intravenous Thrombolysis ◽

Sensitivity Analyses ◽

Stroke Patients ◽

Advanced Imaging ◽

Stroke Incidence ◽

Endovascular Thrombectomy ◽

Decision Points ◽

Published Evidence ◽

Randomised Control Trials

Introduction Endovascular thrombectomy is a highly effective treatment for acute ischemic stroke due to large arterial occlusion. Routine provision will require major changes in service configuration and workforce. An important first step is to quantify the population of stroke patients that could benefit. We estimated the annual UK population suitable for endovascular thrombectomy using standard or advanced imaging for patient selection. Patients and methods Evidence from randomised control trials and national registries was combined to estimate UK stroke incidence and define a decision-tree describing the endovascular thrombectomy eligible population. Results Between 9620 and 10,920 UK stroke patients (approximately 10% of stroke admissions) would be eligible for endovascular thrombectomy annually. The majority (9140–9620) would present within 4 h of onset and be suitable for intravenous thrombolysis. Advanced imaging would exclude 500 patients presenting within 4 h, but identify an additional 1310 patients as eligible who present later. Discussion Information from randomised control trials and large registry data provided the evidence criterion for 9 of the 12 decision points. The best available evidence was used for two decision points with sensitivity analyses to determine how key branches of the tree affected estimates. Using the mid-point estimate for eligibility (9.6% of admissions) and assuming national endovascular thrombectomy coverage, 4280 patients would have reduced disability. Conclusion A model combining published trials and register data suggests approximately 10% of all stroke admissions in the UK are eligible for endovascular thrombectomy. The use of advanced imaging based on current published evidence did not have a major impact on overall numbers but could alter eligibility status for 16% of cases.

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Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital

Frontiers in Neurology ◽

10.3389/fneur.2021.655434 ◽

2021 ◽

Vol 12 ◽

Author(s):

Piotr Sobolewski ◽

Wiktor Szczuchniak ◽

Danuta Grzesiak-Witek ◽

Jacek Wilczyński ◽

Karol Paciura ◽

...

Keyword(s):

Retrospective Study ◽

Stroke Unit ◽

Community Hospital ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Staff Members ◽

Second Wave

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area.Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 (“first wave”), and between September 15 and November 30, 2020 (“second wave”). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19.Results: During the “first wave,” 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the “second wave” were infected with SARS-CoV-2 (p < 0.001). During the “second wave,” more SU staff members were infected with COVID-19 than during the “first wave” (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60–47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04–34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed.Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the “second wave” of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

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Intravenous Thrombolysis Is Associated with Less Disabling Stroke and Lower Mortality in Multiple-Pass Endovascular Thrombectomy

Cerebrovascular Diseases ◽

10.1159/000512105 ◽

2021 ◽

pp. 1-6

Author(s):

Christopher Blair ◽

Leon Edwards ◽

Cecilia Cappelen-Smith ◽

Dennis Cordato ◽

Andrew Cheung ◽

...

Keyword(s):

Multivariate Analysis ◽

Acute Ischaemic Stroke ◽

Intravenous Thrombolysis ◽

Additional Benefit ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Multiple Pass ◽

First Pass

Background and Purpose: The benefit of bridging intravenous thrombolysis (IVT) in acute ischaemic stroke patients eligible for endovascular thrombectomy (EVT) is unclear. This may be particularly relevant where reperfusion is achieved with multiple thrombectomy passes. We aimed to determine the benefit of bridging IVT in first and multiple-pass patients undergoing EVT ≤6 h from stroke onset to groin puncture. Methods: We compared 90-day modified Rankin Scale (mRS) outcomes in 187 consecutive patients with large vessel occlusions (LVOs) of the anterior cerebral circulation who underwent EVT ≤6 h from symptom onset and who achieved modified thrombolysis in cerebral ischaemia (mTICI) 2c/3 reperfusion with the first pass to those patients who required multiple passes to achieve reperfusion. The effect of bridging IVT on outcomes was examined. Results: Significantly more first-pass patients had favourable (mRS 0–2) 90-day outcomes (68 vs. 42%, p = 0.001). Multivariate analysis showed an association between first-pass reperfusion and favourable outcomes (OR 2.25; 95% CI 1.08–4.68; p = 0.03). IVT provided no additional benefit in first-pass patients (OR 1.17; CI 0.42–3.20; p = 0.76); however, in multiple-pass patients, it reduced the risk of disabling stroke (mRS ≥4) (OR 0.30; CI 0.10–0.88; p = 0.02) and mortality (OR 0.07; CI 0.01–0.36; p = 0.002) at 90 days. Conclusion: Bridging IVT may benefit patients with anterior circulation stroke with LVO who qualify for EVT and who require multiple passes to achieve reperfusion.

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Early NT-ProBNP (N-Terminal Probrain Natriuretic Peptide) Elevation Predicts Malignant Edema and Death After Reperfusion Therapy in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/strokeaha.120.029593 ◽

2021 ◽

Author(s):

Xuting Zhang ◽

Shenqiang Yan ◽

Wansi Zhong ◽

Yannan Yu ◽

Min Lou

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Natriuretic Peptide ◽

Odds Ratio ◽

Intravenous Thrombolysis ◽

Reperfusion Therapy ◽

Stroke Patients ◽

Endovascular Thrombectomy ◽

Median Serum ◽

The Relationship

Background and Purpose: We aimed to investigate the relationship between early NT-proBNP (N-terminal probrain natriuretic peptide) and all-cause death in patients receiving reperfusion therapy, including intravenous thrombolysis and endovascular thrombectomy (EVT). Methods: This study included 1039 acute ischemic stroke patients with early NT-proBNP data at 2 hours after the beginning of alteplase infusion for those with intravenous thrombolysis only or immediately at the end of EVT for those with EVT. We performed natural log transformation for NT-proBNP (Ln(NT-proBNP)). Malignant brain edema was ascertained by using the SITS-MOST (Safe Implementation of Thrombolysis in Stroke-Monitoring Study) criteria. Results: Median serum NT-proBNP level was 349 pg/mL (interquartile range, 89–1250 pg/mL). One hundred twenty-one (11.6%) patients died. Malignant edema was observed in 78 (7.5%) patients. Ln(NT-proBNP) was independently associated with 3-month mortality in patients with intravenous thrombolysis only (odds ratio, 1.465 [95% CI, 1.169–1.836]; P =0.001) and in those receiving EVT (odds ratio, 1.563 [95% CI, 1.139–2.145]; P =0.006). The elevation of Ln(NT-proBNP) was also independently associated with malignant edema in patients with intravenous thrombolysis only (odds ratio, 1.334 [95% CI, 1.020–1.745]; P =0.036), and in those with EVT (odds ratio, 1.455 [95% CI, 1.057–2.003]; P =0.022). Conclusions: An early increase in NT-proBNP levels was related to malignant edema and stroke mortality after reperfusion therapy.

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Changes in Stroke Patients’ Health-Seeking Behavior by COVID-19 Epidemic Regions: Data from the Korean Stroke Registry

Cerebrovascular Diseases ◽

10.1159/000519093 ◽

2021 ◽

pp. 1-9

Author(s):

Han-Yeong Jeong ◽

Eung-Joon Lee ◽

Min Kyoung Kang ◽

Ki-Woong Nam ◽

Jeonghoon Bae ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Patient Characteristics ◽

Stroke Care ◽

Health Seeking ◽

Stroke Patients ◽

Stroke Registry ◽

Care Services ◽

Health Seeking Behaviors ◽

Number Of Patients ◽

Using Data

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has led to changes in stroke patients’ healthcare use. This study evaluated changes in Korean stroke patients’ health-seeking behaviors and stroke care services using data from the Korean Stroke Registry (KSR). Methods: We reviewed data from patients with acute stroke and transient ischemic attack (TIA) during 2019 (before COVID-19 period) and 2020 (COVID-19 period). Outcomes included patient characteristics, time from stroke onset to hospital arrival, and in-hospital stroke pathways. Subgroup analyses were performed for an epidemic region (Daegu city and Gyeongsangbuk-do region, the D-G region). Results: The study included 1,792 patients from the pre-COVID-19 period and 1,555 patients from the COVID-19 period who visited hospitals that contribute to the KSR. During the COVID-19 period, the D-G region had two-thirds the number of cases (vs. the pre-COVID-19 period) and a significant decrease in the proportion of patients with TIA (9.97%–2.91%). Unlike other regions, the median onset-to-door time increased significantly in the D-G region (361 min vs. 526.5 min, p = 0.016), and longer onset-to-door times were common for patients with mild symptoms and who were in their 60s or 70s. The number of patients who underwent intravenous thrombolysis also decreased during the COVID-19 period, although the treatment times were not significantly different between the 2 periods. Discussion/Conclusion: Korean stroke patients in a COVID-19 epidemic region exhibited distinct changes in health-seeking behaviors. Appropriate triage system and public education regarding the importance of early treatment are needed during the COVID-19 pandemic.

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Diagnosis and management of acute ischaemic stroke

Practical Neurology ◽

10.1136/practneurol-2020-002557 ◽

2020 ◽

Vol 20 (4) ◽

pp. 304-316 ◽

Cited By ~ 1

Author(s):

Robert Hurford ◽

Alakendu Sekhar ◽

Tom A T Hughes ◽

Keith W Muir

Keyword(s):

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Neuronal Damage ◽

Early Recognition ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Close Monitoring ◽

Endovascular Thrombectomy ◽

Early Neurological Deterioration ◽

Ischaemic Penumbra

Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.

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Abstract 122: Quality of Care for Patients With Acute Ischemic Stroke as a Function of Hospital Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator Capability: Insights From China National Stroke Registry II

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.122 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Zhenzhen Rao ◽

Zixiao Li ◽

Hongqiu Gu ◽

Yilong Wang ◽

Yongjun Wang

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Stroke Care ◽

Care Quality ◽

Composite Score ◽

Stroke Patients ◽

Stroke Registry

Background: Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator (rt-PA) availability at Chinese hospitals varies and may affect care quality for acute ischemic stroke patients. Limited research has shown whether there were differences in quality of care at China National Stroke Registry (CNSR II) hospitals based on rt-PA capability. Methods: For acute ischemic stroke patients admitted to CNSR II hospitals between 2012 and 2013, care quality at hospitals with or without Intravenous rt-PA capability was examined by evaluating conformity with performance and quality measures. The primary outcome was guideline-concordant care, defined as compliance with 10 predefined individual guideline-recommended performance metrics and composite score. A composite score was defined as the total number of interventions actually performed among eligible patients divided by the total number of recommended interventions among eligible patients. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to compare the relationship between hospitals with rt-PA capability and hospitals without rt-PA on quality measures. Results: This study included 19604 acute ischemic stroke patients admitted to 219 CNSR II hospitals. Before matching, there were 7928 patients admitted to 86 (40.4%) hospitals with rt-PA capability and 11676 patients admitted to 133 (59.6%) hospitals without rt-PA capability. After matching, 7606 pairs of patients in rt-PA-capable hospitals and rt-PA-incapable hospitals were analyzed. Before matching, the composite score of guideline-concordant process of care was higher at hospitals with rt-PA capability than hospitals without rt-PA capability (74% versus 73%, P=0.0126). Hospitals with rt-PA capability were more likely to perform deep vein thrombosis prophylaxis within 48 hours of admission, dysphagia screening, assessment or receiving of rehabilitation, discharge antithrombotic, anticoagulation for atrial fibrillation and medications for lowering low-density lipoprotein (LDL) ≥100mg/dL. But hospitals with rt-PA capability were less likely to perform antithrombotic medication within 48 hours of admission and hypoglycemic therapy at discharge for patients with diabetes. After matching, differences of stroke care quality between hospitals with rt-PA capability and without rt-PA capability still exist after adjusting covariates. Conclusions: The CNSR II hospitals were associated with better performance in some of the hospitals but not all of them. The difference in conformity between rt-PA-capable hospitals and rt-PA-incapable hospitals was modest for performance measures of stroke care. However, more room for improvement still exists in key quality performance measures and further studies should be explored.

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Abstract TP62: Frequency, Characteristics, and Outcomes of Acute Ischemic Stroke Patients With “Total Mismatch” on Penumbral Imaging Before Reperfusion Therapy

Stroke ◽

10.1161/str.51.suppl_1.tp62 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Hai Jui CHU ◽

David Liebeskind ◽

Yannan Yu ◽

Bryan Yoo ◽

Latisha Sharma ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Reperfusion Therapy ◽

Frequency Characteristics ◽

Lesion Volume ◽

Therapy Outcomes ◽

Stroke Patients ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Penumbral Imaging ◽

Acute Cerebral Ischemia

Background: When penumbral imaging shows “total mismatch” (large perfusion lesion and no irreversibly infarcted core), the entirety of jeopardized brain is still salvageable and the benefits of reperfusion therapy may be enhanced. The frequency, characteristics, and reperfusion therapy outcomes of total mismatch patients has not been well-characterized. Methods: Analysis of consecutive acute cerebral ischemia patients in anterior circulation undergoing CT or MR penumbral imaging prior to intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT). Patients were classified in four groups: 1) total mismatch (core 0% of perfusion lesion), 2) non-total but substantial mismatch (core 1-20% of perfusion lesion), 3) moderate or no mismatch (core 20-100% of perfusion lesion), and 4) small perfusion lesion (perfusion lesion volume <10 ml). Results: Among 180 patients, pretreatment imaging patterns were: total mismatch 28.9%, substantial mismatch 22.8%, moderate or no mismatch 22.8%, and small perfusion lesion 25.6%. Among total mismatch patients, the Tmax>6 sec perfusion lesion volume was 56.5 ml (IQR 28.3-85.6) and time from last known well to imaging was 89 mins (IQR 65-296). Compared to moderate patients, clinical features of total mismatch patients were: older (76.0 vs 65.9, p=0.006), lower NIHSS (median 12 vs 18, p=0.019), and more cardioembolism (76.9% vs 48.8%, p=0.005). Total mismatch patients more often had CT than MR (65.4% vs 14.6%, p=0.000), less ICA occlusion (15.4% vs 34.1%, p=0.035), and smaller perfusion lesions (median 56.5 vs 82.1 ml, p=0.007). Total mismatch patients were treated with combined IVT+EVT in 32.7%, IVT alone in 26.9%, and EVT alone in 40.4%. Freedom from disability (mRS 0-1) at discharge was more frequent, 35.6% vs 16.2%, p=0.049 and disability levels at day 90 were lower in total mismatch patients, mean mRS 2.7 vs 3.9, p=0.029. Conclusion: Total mismatch is present in one-quarter of patients undergoing reperfusion therapy, more often in older patients with cardioembolism as etiology of stroke. Total mismatch patients have better disability outcomes from reperfusion therapy, but more than half show disability indicating need for more complete reperfusion.

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Cohort profile: Thrombolysis in Ischemic Stroke Patients (TRISP): a multicentre research collaboration

BMJ Open ◽

10.1136/bmjopen-2018-023265 ◽

2018 ◽

Vol 8 (9) ◽

pp. e023265 ◽

Cited By ~ 3

Author(s):

Jan F Scheitz ◽

Henrik Gensicke ◽

Sanne M Zinkstok ◽

Sami Curtze ◽

Marcel Arnold ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Functional Outcome ◽

Research Collaboration ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Laboratory Findings ◽

Endovascular Thrombectomy ◽

Multicentre Research

PurposeThe ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration aims to address clinically relevant questions about safety and outcomes of intravenous thrombolysis (IVT) and endovascular thrombectomy. The findings can provide observational information on treatment of patients derived from everyday clinical practice.ParticipantsTRISP is an open, investigator-driven collaborative research initiative of European stroke centres with expertise in treatment with revascularisation therapies and maintenance of hospital-based registries. All participating centres made a commitment to prospectively collect data on consecutive patients with stroke treated with IVT using standardised definitions of variables and outcomes, to assure accuracy and completeness of the data and to adapt their local databases to answer novel research questions.Findings to dateCurrently, TRISP comprises 18 centres and registers >10 000 IVT-treated patients. Prior TRISP projects provided evidence on the safety and functional outcome in relevant subgroups of patients who were excluded, under-represented or not specifically addressed in randomised controlled trials (ie, pre-existing disability, cervical artery dissections, stroke mimics, prior statin use), demonstrated deficits in organisation of acute stroke care (ie, IVT during non-working hours, effects of onset-to-door time on onset-to-needle time), evaluated the association between laboratory findings on outcome after IVT and served to develop risk estimation tools for prediction of haemorrhagic complications and functional outcome after IVT.Future plansFurther TRISP projects to increase knowledge of the effect and safety of revascularisation therapies in acute stroke are ongoing. TRISP welcomes participation and project proposals of further centres fulfilling the outlined requirements. In the future, TRISP will be extended to include patients undergoing endovascular thrombectomy.

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Stroke Patients’ Characteristics and Clinical Outcomes: A Pre-Post COVID-19 Comparison Study

Medicina ◽

10.3390/medicina57050507 ◽

2021 ◽

Vol 57 (5) ◽

pp. 507

Author(s):

Hong Chuan Loh ◽

Kar Keong Neoh ◽

Angelina Siing Ngi Tang ◽

Chen Joo Chin ◽

Purnima Devi Suppiah ◽

...

Keyword(s):

Ischaemic Stroke ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Stroke Severity ◽

Stroke Patients ◽

Acute Stroke Care ◽

Cross Sectional ◽

Scan Time ◽

Care Systems ◽

Stroke Centre

Background and Objectives: The Coronavirus disease 2019 (COVID-19) pandemic caused significant disruption to established medical care systems globally. Thus, this study was aimed to compare the admission and outcome variables such as number of patient and its severity, acute recanalisation therapy given pre-post COVID-19 at a primary stroke centre located in Malaysia. Methods: This cross-sectional hospital-based study included adult ischaemic stroke patients. Variables of the study included the number of ischaemic stroke patients, the proportions of recanalisation therapies, stroke severity during admission based on the National Institutes of Health Stroke Scale, functional outcome at discharge based on the modified Rankin Scale, and relevant workflow metrics. We compared the outcome between two six-month periods, namely the pre-COVID-19 period (March 2019 to September 2019) and the COVID-19 period (March 2020 to September 2020). Results: There were 131 and 156 patients, respectively, from the pre-COVID-19 period and the COVID-19 period. The median door-to-scan time and the median door-to-reperfusion time were both significantly shorter in the COVID-19 period (24.5 min versus 12.0 min, p = 0.047) and (93.5 min versus 60.0 min, p = 0.015), respectively. There were also significantly more patients who received intravenous thrombolysis (7.6% versus 17.3%, p = 0.015) and mechanical thrombectomy (0.8% versus 6.4%, p = 0.013) in the COVID-19 period, respectively. Conclusions: The COVID-19 pandemic may not have caused disruptions of acute stroke care in our primary stroke centre. Our data indicated that the number of ischaemic stroke events remained stable, with a significant increase of recanalisation therapies and better in-hospital workflow metrics during the COVID-19 pandemic period. However, we would like to highlight that the burden of COVID-19 cases in the study area was very low. Therefore, the study may not have captured the true burden (and relevant delays in stroke patient management) during the COVID-19 pandemic. The effect of the pandemic crisis is ongoing and both pre-hospital and in-hospital care systems must continue to provide optimal, highly time-dependent stroke care services.

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