Effects of COVID‐19 outbreak on stroke admissions in Brescia, Lombardy, Italy

Abstract

Italy was the first European country to be affected by the COVID-19 epidemic, with the outbreak estimated to have started in late February 2020. Currently, Italy has reported more than 228 000 COVID-19-positive cases, 14 326 of which were in the province of Brescia, Lombardy. Although emerging studies have shown a profound hypercoagulable state in COVID-19, it is still highly debated if COVID-19 increases the risk of cerebrovascular disorders. Some reports have shown a high frequency of stroke in patients with COVID-19 [1-3] whilst collaterally there was a decrease of approximately 39% of patients evaluated for stroke in US hospitals [4], possibly due to the fear of seeking care in the midst of the pandemic. On 8 March 2020, the ASST Spedali Civili Hospital was declared the hub for acute neurological disorders for the entire province, including ischaemic and haemorrhagic stroke (ICH), transient ischaemic attack (TIA) and seizures. The numbers of patients who had been discharged or died from the entire hospital in the first four months of 2020 were retrospectively analysed and compared to the average monthly discharges of the past 10 years (2010–2019). Patients were diagnosed on admission and, to our knowledge, none of the patients who were admitted COVID-free acquired COVID-19 during hospitalization. This study received approval from the local ethics committee of the ASST Spedali Civili Hospital (NP 4204, approved 5 June 2020). Out of 221 548 patients included in the study from 1 January 2010 to 30 April 2020, 3561 were admitted for TIA, 6324 for ischaemic stroke, 3100 for ICH and 2678 with seizures (Table 1). In January and February 2020 similar discharges for all diagnoses were observed compared to previous years. In March and April 2020, at the height of the Italian pandemic, a relevant increase in ischaemic stroke admissions was noticed, but not for TIA, ICH or seizures. For ischaemic stroke, in March 2020, 82 cases were observed, of which 35 (39%) with COVID-19, compared to an average of 49.7 (95% confidence interval 45.5–53.9) in March 2010–2019, whilst in April 2020 78 cases were observed, of which 17 (21.8%) with COVID-19, compared to an average of 48.2 (95% confidence interval 43.6–52.8) in April 2010–2019 (Fig. 1). The cumulative number of hospital admissions for ischaemic stroke was strongly associated with the number of patients with COVID-19. Mortality rates increased for all diagnoses, possibly because patients with mild symptoms did not seek medical help and were not admitted to hospital units during the outbreak. From the present analysis, it was observed that during the COVID-19 outbreak in Brescia, a metropolitan city of more than 1 200 000 inhabitants harshly hit by the COVID-19 outbreak, neurological admissions remained similar to previous years except for ischaemic stroke, which saw a relevant increase of cases (67.3% increase in March, 58.0% in April), potentially associated with COVID-19. These numbers seem to support the view that COVID-19 may be a relevant trigger for ischaemic stroke, probably related to the prothrombotic effect of the inflammatory response [5]. The evidence that neurological admissions for TIA, ICH and seizures were similar to previous years argues against a possible bias due to other factors such as the decrease of patients seeking medical assistance or the shutdown of other neurological units during the outbreak. Moreover, air pollution was greatly reduced in March–April 2020 in Brescia compared to previous months due to the lockdown, which could have positively affected stroke incidence. Future multicentre studies are warranted to confirm these findings. Funding: None. A. Benussi, E. Premi, I. Libri, A. Pezzini, C. Paolillo, B. Borroni, M. Magoni report no disclosures relevant to the paper. A. Pilotto is consultant and served on the scientific advisory board of Z-cube (Technology Division of Zambon Pharma), received speaker honoraria from Biomarin and Zambon Pharmaceuticals. A. Padovani is consultant and served on the scientific advisory board of GE Healthcare, Eli-Lilly and Actelion Ltd Pharmaceuticals, received speaker honoraria from Nutricia, PIAM, Lansgstone Technology, GE Healthcare, Lilly, UCB Pharma and Chiesi Pharmaceuticals.

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