Stroke prevention during the pandemic

 

Sir, – Amidst the appropriate, radical and urgent restructuring of our healthcare services in Ireland and internationally to deal with the global Covid-19 pandemic, it is also essential that patients with other urgent high-risk conditions are diagnosed, investigated and treated urgently.

Stroke is the most common cause of acquired physical disability and the second or third most common cause of death in adults in middle-high income countries. Most strokes are due to reduced blood supply to the brain and are called “ischaemic strokes”.

Some are preceded by a transient ischaemic attack (TIA), which is sometimes referred to as a “warning stroke” by patients, and this provides patients and doctors with an extremely important window of opportunity for urgent stroke prevention.

Symptoms last for less than 24 hours with a TIA (usually minutes) and for 24 hours with a stroke, but the symptoms are the same. TIAs cause the “S” symptoms: sight (blurring or loss of vision or double vision); speech (impaired expression, understanding or slurring); swallowing (less common than with stroke); strength (weakness of the face, arm and/or leg), sensation (usually numbness or reduced sensation and less commonly pins and needles on the face, arm and/or leg), or stability (sudden unsteadiness or a sensation of movement called vertigo).

In addition to our other work at Tallaght University Hospital, we continue to run a daily one-stop rapid access stroke prevention (Rasp) service which is co-ordinated by the vascular neurology and age-related healthcare and stroke medicine consultants on alternate weeks, in close collaboration with our colleagues in vascular surgery, cardiology, phlebotomy, medical administration and radiology.

We accept email referrals from our local GPs, emergency department physicians and hospital consultant colleagues via our local e-referral pathway, with a view to assessing all patients with “suspected TIAs” within 24 hours or on the same day if they have “higher-risk” clinical symptoms.

Since the start of the Covid-19 pandemic, we are concerned that local referrals to our vascular neurology Rasp outpatient service have decreased by at least 50 to 80 per cent over a three-week period compared with a similar time period in 2019.

Anecdotally, a trend towards reduced referrals and attendances with suspected TIAs is also happening in other parts of the country and is also occurring internationally. The same has happened with stroke.

Some patients might be having difficulty getting through to their own GPs due to their GPs’ extremely busy workloads, but we suspect some patients may simply be afraid to present to their GPs or emergency department with symptoms of suspected TIAs, or are dismissing such symptoms because of fear of contracting Covid-19 if they attend hospital.

Busy doctors are never looking for more work, but if patients have had symptoms suggestive of a TIA, we advise that they must make urgent contact with their GP, or attend their local emergency department if they cannot access their GP, or if symptoms occur outside of normal working hours, for immediate assessment. GPs or emergency department staff can then refer patients for urgent vascular neurology and stroke specialist assessment at their local service Rasp service if a TIA is suspected.

Practices vary through the country, but in our own hospital we have maintained access to expedited outpatient specialised blood tests and neurovascular investigations, with face-to-face assessments in appropriate personal protective equipment by a consultant with expertise in TIA and stroke care to establish an accurate diagnosis and begin urgent treatment to optimally prevent a potentially disabling stroke on the same day.

We also advise selected patients if a brief inpatient stay for other urgent investigations or treatment is necessary.

With this expedited approach, international studies indicate that one can prevent more than 80 per cent of strokes following a TIA if we are given the opportunity to do so.

Therefore, the message is to stay safe and follow all HSE guidelines on Covid-19 regarding social distancing, self-isolation and cocooning, etc, but please do not ignore your symptoms and do not stay at home if you have had a suspected TIA which needs urgent medical assessment and treatment. – Yours, etc,

Prof DOMINICK

McCABE,

Dr ALLAN

McCARTHY,

Consultant Neurologists,

Tallaght University

Hospital.