An interview with Dr. Anna Bersano, MD, PhD, at the Cerebrovascular Unit of Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy, about the impact of the COVID-19 pandemic on stroke care in Italy.
Interviewed by Francesca Tinelli, MCs, rare cerebrovascular disease fellow at Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
Dr. Tinelli: First of all, I present you Dr. Anna Bersano, the neurologist I work with, and I would like to thank Anna for agreeing to do this interview.
Anna is a stroke neurologist with long-term expertise in cerebrovascular diseases, particularly in genetics of monogenic and complex stroke diseases, combining research with an active practice as a vascular care neurologist. She coordinated several studies on genetics of stroke, such as the Lombardia GENS study on stroke monogenic disease and the SVE-LA study on genetics of small vessel disease and lacunar stroke. Recently, she implemented an Italian network for the study of Moyamoya disease named GE-NO-MA (Genetics of Moyamoya Disease) and an Italian network for the study of Cerebral Amyloid Angiopathy (SENECA project).
Dr. Bersano: Thank you for discussing this relevant and critical topic in the current situation.
Dr. Tinelli: What is the correlation between SARS-CoV2 and cerebrovascular diseases?
Dr. Bersano: It is well known that SARS-CoV2 invades human respiratory epithelial cells through its S-protein and ACE2 receptor on human cell surface. Then, the virus can spread from the respiratory tract to the central nervous system, causing possible neurological complications. A recent study on 214 Chinese COVID-19 patients reported acute cerebrovascular events in 5.7% of COVID-19 patients. However, the exact relationship between SARS-CoV2 and stroke is unclear. Patients affected by COVID-19 have been observed to have a higher risk of cerebrovascular events, probably due to the activation of coagulation and inflammatory pathways, which lead to cardiovascular and thrombotic complications, or to cardioembolic causes.
Dr. Tinelli: Did COVID-19 impact your work and research activity?
Dr. Bersano: Yes, the COVID-19 crisis had a negative impact on stroke care since we could not completely assist patients with cerebrovascular diseases, due to the driving of resources towards SARS-CoV2 patient needs. Also, scientific research was negatively impacted by the SARS-CoV2 pandemic, and many ongoing clinical trials and investigations about pathophysiology and treatment of cerebrovascular diseases were stopped or slowed down.
Dr. Tinelli: How has stroke management changed in the last months during the COVID-19 outbreak?
Dr. Bersano: The massive reorganization of the health system imposed to completely re-draw the stroke pathways. The new organization centralized several stroke units and neurointensive care units, creating COVID- and COVID+ areas. Stroke patients were concentrated in a limited number of hospitals, depending on regional location and availability of beds and thrombectomy equipment.
Dedicated acute stroke protocols were activated. Patients were isolated and screened for COVID-19 signs and symptoms, and they underwent biochemistry analysis, CT brain, CT angiography, and chest X ray or CT scan. Given the critical scenario, the complementary investigations, such as brain MRI and angiography, were hampered to better protect diagnostic services and manage COVID-19 patients. Also, the post-stroke rehabilitation workplaces were centralized in order to guarantee the adequate support and care to patients, and to ensure measures against the spread of the virus.
Dr. Tinelli: How has patient care changed, and what are the medium- to long-term consequences?
Dr. Bersano: COVID-19 is having a negative impact on pre- and in-hospital stroke care. A reduced number of emergency accesses, as well as mechanical thrombectomy cases, was observed during the period March-May 2020, mostly due to the fear of contagion. Patients with cerebrovascular diseases in this period suffered from lack of services, dedicated personnel, and assistance. Although telemedicine platforms, phone support, and virtual stroke clinics were implemented to guarantee patients periodic consultation and adequate rehabilitation support, providing social distancing, these efforts are not always applicable. Thus, we expect an important burden in terms of disabilities due to stroke assistance failure.
Dr. Tinelli: What do you think could be the future ‘panorama’ given the new spreading of infection in Italy?
Dr. Bersano: The infection is newly spreading worldwide, and new organization of stroke pathways is necessary to guarantee proper acute care and follow-up assistance to all stroke patients with the goal of applying correct prevention measures and minimizing treatment delay. I hope that our previous experience could help in overcoming errors in patient care and that people do not forget that stroke is one of the most important causes of disabilities and its severity should not be underestimated.
Dr. Tinelli: Thank you, Anna, for granting me this interview, which provides all readers of our blog with an important contribution to understand the impact of the pandemic on stroke care in Italy.