Plenary Session: “Stroke in Low to Middle Income Countries”
While the landscape of stroke changes in terms of innovations, pathways and technology, there is a continuing increase of stroke burden in the low to middle income countries (LMICs). This session was moderated by Dr. Norlinah Ibrahim and Dr. Mayowa Owolabi.
Dr. Owolabi opened the discussion by giving an overview of the Lancet Commission in giving evidence-based recommendations that are pragmatic in nature extending to primary, secondary, and tertiary prevention, keeping in mind that these regions bear a burden due to limited resources. He emphasized the Stroke Quadrangle that includes epidemiological surveillance, acute care, rehabilitation, palliative care, health promotion, and disease prevention. He set the stage by reiterating that there is scarcity of funding for primary stroke prevention, particularly in LMICs. There is indeed an absence of an integrative approach. Regional and national differences in policymaking are also a variable.
COVID-19 complicates many aspects of clinical care, including care of stroke patients. Katsanos et al. conducted a meta-analysis on the impact of COVID-19 on the provision of stroke care, independent of SARS-CoV-2 infection status. They collected 46 studies capturing data from 129,491 patients across Africa, Asia, Europe, and the Americas comparing common stroke care variables pre- and post-pandemic onset. These included demographic information, vascular risk factors, intravenous thrombolysis (IVT) administration, endovascular thrombectomy (EVT) performance, relevant time metrics, and hospitalization outcomes.
In the age of checklists, quality metrics, and frequent audits, sometimes the importance of these indicators is taken for granted. Instead of serving as a guiding light for quality care, they may be seen as an annoyance, slowing down an already inefficient system. This study reviewing the association between quality indicators (QI) and outcomes is a good reminder of the importance of tending to these quality indicators.
This study utilized the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutschprachiger Schlaganfall Register), which is a network of nine stroke registers, comprising multiple regions throughout the country. 388,012 patients with acute ischemic stroke admitted to 736 hospitals were reviewed from 2015-2016. Of the hospitals participating, 55.6% of them had stroke unit services. Overall, 7-day in-hospital mortality was 3.4%, and median length of stay was 8 days.
Patients with acute large vessel occlusions (LVOs) have better outcomes if they are sent to the endovascular suite expeditiously. Yet, many times these patients are taken to the nearest primary stroke center under the “drip and ship” model.
In this study, the authors used geographic information, census data, and stroke center accreditor information to build an origin to destination matrix analyses of patient location to nearest primary stroke center and to nearest intervention center. To do so, four different triage strategies were compared: (1) always going directly to the nearest primary stroke center, (2) always going directly to an endovascular center; (3) using the current AHA algorithm suggesting direct transfer to endovascular center if driving time is less than 30 minutes when LVO is suspected and won’t preclude tPA administration; (4) using a modified algorithm that would allow for additional driving time if an LVO is suspected if thrombolysis isn’t precluded (adding <30 minutes of driving time, <60 minutes of driving time, or not restricting by driving time at all).
With the increasing importance of endovascular therapy in acute ischemic stroke care, triage and emergency transport strategies have taken on renewed importance. Current recommendations advise preferential transport to a comprehensive stroke center (CSC) if a large vessel occlusion (LVO) is suspected based on prehospital screening and when the total transport time is less than 30 minutes. The study summarized here evaluated alternative triage strategies in comparison with the current American Heart Association (AHA) recommendations.1
A previously utilized decision-tree model referred to in a prior study2 was used to map outcomes of a suspected LVO to either a primary stroke center (PSC) and then transferred for thrombectomy or directly to an intervention center. A base scenario was applied to the model in which emergency medical services (EMS) was activated for a hypothetical patient with a suspected stroke within 4.5 hours of symptom onset with several time assumptions corresponding to “Get With the Guidelines” recommendations. LVO prevalence was estimated at 20% among suspected stroke patients based on prior studies,2-3 and prehospital assessment applied the rapid arterial occlusion evaluation (RACE) with an assumed sensitivity of 84% and specificity of 60% at a cutoff of 5 points.
How has the COVID-19 pandemic affected our modern systems of acute stroke care? Montaner et al. performed a descriptive analysis before and during the current COVID-19 era, giving a glimpse into how the pandemic can negatively affect acute stroke care. The study was done in a southern region of Spain. Key metrics in the study were taken from pre-hospital and hospital acute care.
Data was collected from a region comprised of 2 stroke units and 2 large hospitals. One of the hospitals served as a thrombectomy referral center and the other as a tele-stroke referral center for several community hospitals. Data for the study was collected from an ongoing stroke registry. The study samples included 41 thrombectomies, 32 tele-stroke consults, and 51 patients treated with thrombolysis therapy. The bulk of the analyses focused on data 15 days prior to the outbreak to 15 days after (March 31, 2020).
On March 11, 2020, the World Health Organization declared Coronavirus
Disease 2019 (COVID-19) a pandemic. As of this writing, the global number of
cases exceeds 8.1 million. However, despite the rapidly increasing prevalence
of COVID-19, many questions remain regarding this unusual and highly lethal
disease. The pathogenesis of COVID-19–associated neurologic injury remains to
be established. SARS-CoV-2 has been shown to induce a hypercoagulable state,
thus increasing the risk of arterial thrombosis with acute ischemic stroke.(1)
From late 2019 to early 2020, COVID-19 started to disrupt the
healthcare systems of many nations. From the beginning of the pandemic, it has
been a major concern for doctors and public authorities that resources needed
to treat other conditions such as stroke are diverted for COVID-19.(2) The
authors are keen to note that “patients may be unwilling to go to a hospital
for stroke treatment due to fear of becoming contaminated with the disease.”
Using a population-based stroke registry, the authors of this original
contribution investigated the impact of the onset of the COVID-19 pandemic on
stroke admissions in Joinville, Brazil. The authors’ hypotheses were as follows:
First, hospital admissions for stroke were reduced after the onset of the
COVID-19 pandemic. Next, the reduction occurred only in transient ischemic
attacks (TIA) and mild cases. Also, there was a change in the time between
stroke onset and hospital admissions. Finally, the number of patients receiving
reperfusion therapies (IVT and MT) has decreased.
The number of deaths due to stroke is 10 million per year globally, with
a prevalence of 42 million. Large vessel occlusions (LVO) account for a third
of all occlusive ischemic strokes and are the largest contributor to the
morbidity and mortality associated with ischemic stroke. The evolution and use
of endovascular thrombectomy (EVT) for these patients have transformed stroke treatment
and care; clinical trials utilizing EVT demonstrated the benefits of this
technique during post-stroke recovery, including reduced disability and
improved outcome. In multiple countries, EVT has been adopted as the standard
of care for LVO and is recommended for use where possible in other countries —
limits come from availability of suitably trained staff and equipment.
Despite the progress in stroke treatment protocols in the
United States, the rate of tPA use remains low due to the inability of ischemic
stroke patients to reach the hospital within the narrow therapeutic window. EMS
plays a very crucial role in acute stroke care by decreasing prehospital delay
and by providing prenotification for the stroke team activation, which leads to
decrease in door-to-needle time.
Gu et al. analyzed data from the Chinese Stroke Centre
Alliance for patients with ischemic stroke from 2015 to 2018 to study the
pattern of EMS use, factors associated and its impact on prehospital delay and the
treatment. Absolute standardized difference and multivariate logistic models
were used. Of 560447 patients with ischemic stroke, only 12.5% used EMS for
transportation to the hospital. EMS use was significantly less in the younger
population, low income group, milder stroke symptoms, HTN, DM and PVD, while
its use was significantly more in patients with history of CVD. Perhaps EMS
education regarding stroke in the young might still be something to continually
work on. EMS transport was significantly associated with less prehospital
delay, shorter onset-to-door time, shorter door-to-needle time (if
prenotification is sent) and more rapid treatment. The authors concluded that a
low proportion of AIS patients using EMS could be due to lack of accessibility
to EMS or lack of awareness for urgent stroke treatment.
Dr. Del Brutto: First of all, I would like to thank you and
your team for putting together these thoughtful recommendations on how to
evaluate patients with suspected stroke during the Coronavirus Disease 2019
(COVID-19) pandemic. As a stroke neurologist, I share the global feeling of
uncertainty that this pandemic has caused and look forward to modifying my
institution practices in order to maximize patients’ outcomes, their safety,
and the safety of the professionals involved in their care. In your article,
you mention that stroke patients are at an increased risk of suboptimal
outcomes during the COVID-19 pandemic. Could you please comment on the factors
that may influence patient outcomes?
Dr. Khosravani: During the COVID-19 pandemic,
patients are affected at several junctions in stroke care, including during the
hyperacute phase. For example, paramedics responding to a stroke call, in some
jurisdictions, will begin the screening process prior to arrival and then again
on scene. When screening is positive, pre-notification to the hospital should
occur, and this triggers a protected code stroke (PCS). Patients being brought
directly to the ED will require additional screening. The necessary use of PPE,
with a Safety Lead observing, will add some delays to the front-end processes,
but these are essential to keeping providers safe. It is very plausible that,
for example, door-to-needle/door-to-groin puncture times will be impacted.
Similarly, at the point-of-care, a COVID-19–suspected patient going to imaging
will result in having special precautions used in the scanner or
neuroangiography suite, which will add additional time (for cleaning as well);
this impacts scenarios with back-to-back code strokes as well.