LAUSR

Severe acute respiratory syndrome coronavirus 2 (SARSCoV2) causes an infectious disease with the involvement of multiple organ systems widely known as coronavirus disease 2019 (COVID19) and was first reported in China in December 2019. Since then, SARSCoV2 has nearly spread universally with over 200 million confirmed cases of COVID19 disease and over 4.5 million deaths worldwide.1 The implications on healthcare systems are worldwide devastating by the increased volume of admissions during the COVID19 pandemic. As far as the stroke care concerns, a direct impact has been noticed due to a presumed association between endothelial inflammation and thrombotic diathesis resulting in increase in cryptogenic strokes involving patients with SARSCoV2 infection. In addition, there is also an indirect impact resulting from the global reported decline in the rates of stroke hospitalizations and the proportion of patients receiving reperfusion therapies (intravenous thrombolysis— IVT and/or mechanical thrombectomy— MT) for acute ischemic stroke (AIS) especially in the first wave of the pandemic.2 However, even in the setting of COVID19 pandemic and despite all COVID19imposed restrictions, stroke remains a medical emergency. Therefore, acute treatment should be applied as indicated through a safe pathway for both the patients and the medical personnel.3 In this context, soon after the pandemic outbreak, practice recommendations for neurovascular ultrasound investigations of acute stroke COVID19 patients or suspected COVID19 patients were released from the European Society of Neurosonology and Cerebral Hemodynamics, highlighting once again the importance of staying committed to the goal of the timely offer of reperfusion treatment in AIS.4 One of the first studies reporting on IVT treatment in AIS patients during the first months of COVID19 pandemic came from Wuhan, the site where the virus first emerged in late 2019. At that time, a significant delay in the administration of intravenous tPA was noticed. Remarkable was the almost doubling of time of doortoneedle time. Possible explanations were the shortage of stroke personnel and a slowdown of inhospital workflow mainly due to practicing novel precautionary procedures.5 In line with this study, several studies showed so far declines in the volumes for stroke hospitalizations, performed IVT and also MT in AIS over the pandemic also resulting from delays in hospital arrivals and treatment pathways.6– 8 The optimization of the abovementioned workflows should be a priority for all stroke care systems in order to treat effectively the nonCOVID19 and the COVID19 AIS patients as both groups clearly profit from reperfusion treatments. The latter is shown in the observational retrospective study of Sobolewski et al.— featured in the current issue of Acta Neurologica Scandinavica— including 70 AIS patients, 22 of them infected with SARSCoV2.9 IVT has similar shortterm efficacy and safety profile in both groups. A further interesting point arising from that study is the fact that no impact of COVID19 infection on patients' inhospital mortality or functional status on discharge has been observed. The factors that determined patients' outcome when dismissed were the baseline NIHSS, the higher age, and the presence of carotid stenosis. The fact that COVID19 infection does not have any statistically significant impact on thrombolysed AIS patients' outcome emerged already from previous studies in nonCaucasian population.5,10 Consequently, the implementation of IVT in AIS patients during COVID19 pandemic should not differ in COVID19 or in nonCOVID19 patients as COVID19 infection is not the determining factor for an AIS patients' outcome. Therefore, all AIS patients should be timely offered reperfusion treatments. Thus, stroke care systems should continue optimizing their treatments' workflows in AIS patients in order to minimize the collateral damage of COVID19 by sustaining optimal patient care.