Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes an infectious disease with the involvement of multiple organ systems widely known as coronavirus disease 2019 (COVID-19) and was first reported in China in December 2019. Since then, SARS-CoV-2 has nearly spread universally with over 200 million confirmed cases of COVID-19 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 COVID-19 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 SARS-CoV-2 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 COVID-19 pandemic and despite all COVID-19-imposed 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 COVID-19 patients or suspected COVID-19 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 COVID-19 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 door-to-needle time. Possible explanations were the shortage of stroke personnel and a slowdown of in-hospital 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 above-mentioned workflows should be a priority for all stroke care systems in order to treat effectively the non-COVID-19 and the COVID-19 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 SARS-CoV-2.9 IVT has similar short-term efficacy and safety profile in both groups. A further interesting point arising from that study is the fact that no impact of COVID-19 infection on patients' in-hospital 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 COVID-19 infection does not have any statistically significant impact on thrombolysed AIS patients' outcome emerged already from previous studies in non-Caucasian population.5, 10

Consequently, the implementation of IVT in AIS patients during COVID-19 pandemic should not differ in COVID-19 or in non-COVID-19 patients as COVID-19 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 COVID-19 by sustaining optimal patient care.

The authors report that they have no financial disclosures.