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- Though COVID-19 patients must receive immediate care, this cannot be done by risking the lives of stroke patients, who are vulnerable to sudden-death scenarios.
- Every minute for which treatment is delayed, an ischemic stroke patient could lose up to 2 million brain cells.
- There is an urgent need for healthcare bodies to improve stroke awareness and implement strategies for acute treatment, triage, virtual check-ins and telestroke services.
The ongoing COVID-19 pandemic has burdened India’s healthcare system like never before. Apart from innumerable health challenges, it has compromised health workers’ safety while bringing the sector’s economic and infrastructural issues to the surface.
As neurological indications of the virus are being identified, it is now a well-established fact that COVID-19 has begun impacting the brain through complications being observed with “long COVID”. Earlier, only the lungs were being infected at the initial stage. Now, neural effects of the virus are becoming apparent as well.
While some causes remain unclear, it is partly because of the lack of oxygen to the brain. Other potential causes include blood clots, increased immune response and the virus invading the brain, all of which can be likely causes of stroke.
As a result, the condition needs accurate treatment and prompt decision-making.
In the present scenario, there are multiple hurdles within the healthcare system. Emergency personnel had no time to attend to stroke patients. Stroke care teams did not know how to go about its treatment while also abiding by the protocols regarding PPE, cross-infections, exposure risks and saving patients and themselves from exposure to COVID-19.
The treatment of stroke patients took a backseat in the time of COVID-19. Approximately 190 medical locations in the country could suitably treat stroke patients. Considering the population of the country and the fact that stroke is the second largest cause of death worldwide, and the third largest in India, this is definitely not a sufficient number.
Also, the chances of having successful outcomes while dealing with stroke cases were, and are, heavily impacted by the pandemic. This crisis is an alarm for our country, as we have an underdeveloped stroke-care system with inconsistent regulatory and delivery mechanisms.
Critical stakeholders, including the Central and state governments, must invest in upgrading infrastructure and constructing more operation theatres for endovascular treatment (EVT). There need to be provisions for subsidies for stroke therapy, so that it becomes affordable for the general public. Concomitantly, policymakers must formalise a ‘standard treatment protocol’ for stroke cases as well.
Today, treating COVID-19 patients has become the highest priority for our nation, but stroke has always been an area of concern in India for the last five decades. The way our medical system was crippled by COVID-19, and more specifically the second wave, should compel healthcare institutions to ponder the lack of healthcare resources and rectify.
Meanwhile, for two reasons, there is strong disagreement about sending COVID-19 stroke patients to specialised COVID-19 care centres. One is that the care team needs to have expertise in treating acute ischemic stroke; second, there is a loss of time incurred when shifting the patient. Every minute for which treatment is delayed, an ischemic stroke patient could lose up to 2 million brain cells (neurons). Both of them are vital fundamentals of stroke management, and attention to them is lacking in the newly set up COVID care centres.
In addition, the upcoming disruption of hyper-acute stroke treatment needs technologically advanced therapies, such as mechanical thrombectomy, which is effective on stroke patients for up to 24 hours after symptoms appear. Most EVT in India is administered by private hospitals, and they are presently overburdened and also excluded from treating stroke patients suspected to have COVID-19 symptoms.
Endovascular stroke treatment with mechanical thrombectomy is a standard treatment for ischemic stroke patients – a condition that occurs due to large vessel blockage. It is mandatory to screen all stroke patients for COVID-19 before admitting them for mechanical thrombectomy. However, being infected with the virus need not impact the decision of treating eligible ischaemic patients with EVT.
Also read: One in 10 Suffer Long-Term Effects Of COVID Months After Mild Infection: Study
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There is a dire need to ramp up awareness around receiving immediate medical aid for acute ischaemic stroke symptoms without being intimidated by the novel coronavirus. Confidence-building hygiene measures – such as timely triage, physical distancing and PPE kits – must be undertaken for patients coming for routine presentations. The physicians must be updated with pandemic and medical information of nearby locals, whereby stroke patients are directed to suitable stroke care centres at the earliest.
Stroke consultations using tele-stroke portals can be deployed in India to deliver high-quality treatment to triage cases, as well as in the entire stroke care pathway – even in settings with fewer resources. When COVID-19 cases surge, there could be a larger resource crunch in the outpatient department. This may be resolved to a great extent if telemedicine and tele-stroke portals could be incorporated early on into healthcare systems.
This pandemic has made stroke care more challenging. Different aspects of stroke care need to be identified and reorganised to ensure improved services during such a crisis. There is an urgent need for healthcare bodies to improve stroke awareness and implement proper strategies of acute treatment, triage, virtual check-ins and telestroke services. This will help maintain the continuum of care for stroke patients and reduce comorbidities.
In sum, though COVID-19 patients must receive immediate care, this cannot be done by risking the lives of stroke patients, who are vulnerable to sudden-death scenarios. If managed well, healthcare can offer better outcomes and a winning proposition for all patients and stakeholders.
Dr M.V. Padma Srivastava is the head of of the neurology department, AIIMS, New Delhi.