New Guidance to Protect Providers, Manage Stroke in COVID-19

Batya Swift Yasgur, MA, LSW

May 21, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

An international panel of stroke experts from 18 countries has issued a set of recommendations for managing patients with acute ischemic stroke who have either suspected or confirmed COVID-19 infection, and for protecting the healthcare providers who are evaluating and treating these patients.

"People may come to the emergency department (ED) with stroke, and that may be the initial presentation of COVID-19 infection, which puts a clear burden on providers because now you may not know if the patient you are evaluating for stroke may actually have underlying COVID-19 infection," lead author Adnan I. Qureshi, MD, Stroke Institute and Department of Neurology, University of Missouri, Columbia, said in a press release.

"The purpose of these recommendations is to provide a step-by-step guide of how to manage these patients," he said.

The statement was published online May 3 in the International Journal of Stroke.

"Global Evaluation"

"In the initial part of the COVID-19 pandemic, people suspected that there might be increased risk of stroke and MI [myocardial infarction], based on the fact that previous respiratory infections, such as influenza, also showed greater risk, but then we started to see reports coming from China that showed patients with COVID-19 were clearly having strokes — typically ischemic stroke," Qureshi told theheart.org | Medscape Cardiology.

An international panel was therefore convened to conduct an extensive literature review and develop recommendations for evaluating and managing stroke in patients with COVID-19.

Patients with COVID-19, "carry a high risk of developing stroke, especially in those with multiple organ dysfunctions," Qureshi noted.

Hypercoagulopathy may be associated with this increased risk, even in young people without previous risk factors for stroke, the authors suggest.

This risk lingers beyond the early stages of illness and may affect patients in more advanced stages, with a median duration of 10 days from the first symptoms of COVID-19 to the development of stroke.

"One of the interesting things we learned from our review of the studies is that stroke patients with COVID-19 frequently have other diseases of the lungs, kidney, or liver for example, and the outcome is more likely to be determined by these other comorbidities than by the stroke itself," Qureshi noted.

"So the panel agrees that the evaluation should not only be neurological but global, so we know how sick the patient is and treat accordingly," he said.

Obtaining a Sequential Organ Failure Assessment (SOFA) score is a component of this global evaluation and can help inform prognosis and treatment plan.

Two CT Scans

"Unlike a patient with COVID-19 who already has a diagnosis and then has a stroke, we have to have an even higher level of due diligence when evaluating patients [who are asymptomatic or have suspected infection] and take precautions as if the patient were confirmed as having the infection," Qureshi said.

Given the challenges in obtaining a timely diagnosis of COVID-19, it is critical to be "more aggressive than usual in testing for the infection," Qureshi emphasized.

To assist in the diagnostic process, the authors recommend performing chest CT and/or radiography to identify radiologic abnormalities "suggestive of COVID-19 infection," although the CT scan may be normal in the early phase of the infection.

"We obtain a CT scan of the brain in every stroke patient, so why not add a CT of the chest at the same time, even if the patient is not displaying symptoms, since abnormalities found on chest CT may be early signs of infection," Qureshi suggested.

The authors recommend taking into account risk factors for contrast-induced nephropathy, given the high rate of renal insufficiency in patients with COVID-19.

Double-Edged Sword

"Mechanical thrombectomy has become the standard of care for anyone with a blockage in the intracranial arteries, but this poses unique challenges in patients with COVID-19 because of the excessive set of precautionary measures that have to be taken, which may unfortunately delay the procedure," Qureshi noted.

Moreover, "almost a third of patients who require the procedure require intubation and mechanical ventilation, which is a double-edged sword: On the one hand, some data suggest that that if you intubate and use a mechanical ventilator, the risk of disease for people performing the procedure might be lower," he continued.

"On the other hand, intubation is not a benign procedure, and the person intubating has a much higher risk [of infection] because it's an aerosol-generating procedure."

He noted that there is "some ambiguity here and we don't know the best way to go forward," although in patients with underlying respiratory failure, "the answer is clear — it is better to intubate and mechanically ventilate during the procedure."

If intubation is needed, the authors recommend performing the procedure in a negative-pressure room with teams of two to four "experienced" team members wearing "enclosed, ventilated protective suits" and using video-guided laryngoscopy.

At the time of intubation, a tracheobronchial specimen may be taken to confirm suspected COVID-19 infection.

Qureshi noted that if intubation and mechanical ventilation are performed, it is important to ascertain that there is no decrease in blood pressure or abnormal blood gases during the procedure. To this end, the authors recommend using the parameters put forth in the SIESTA trial.

Protecting Healthcare Providers

It is critical to minimize the number of healthcare professionals who are in contact with a stroke patient with confirmed or suspected COVID-19, both during evaluation and during treatment.

"Telemedicine has been used extensively in stroke during the past two decades, and this might be a scenario in which it is especially important to reduce the total number of people in contact with the patient," Qureshi commented.

Telestroke "has demonstrated equivalence to that of a bedside assessment for immediate assessment of stroke severity," the authors write, adding that low-cost smartphone application systems may be a plausible substitute if telestroke networks are not available.

"One of the unique things about this virus is that it isn't only transmitted by aerosol and droplets but also can survive on surfaces for long periods of time," Qureshi remarked.

The authors emphasize the importance of frequent handwashing and sanitizing all surfaces in areas where the patient has been evaluated or treated (eg, the angiography suite).

"Comprehensive" Statement

Commenting on the recommendations for theheart.org | Medscape Cardiology, Ameer E. Hassan, DO, head of the neuroscience department and associate professor of neurology and radiology, University of Texas Rio Grande Valley, said that this type of guidance "helps centers around the world handle the current COVID-19 crisis with an excellent workflow and prepares them for anything else that comes down the road."

The "most impactful" points for healthcare workers are the practice implications mentioned in the transmission risk section — ie, using basic disease prevention principles and implementation of telestroke services, stated Hassan, who was not involved in authoring the statement.

Although the American Heart Association/American Stroke Association (AHA/ASA) also issued interim guidance for stroke management during COVID-19 and prehospital triage of acute stroke patients during COVID-19, Hassan called the current statement "much more comprehensive."

Qureshi added that the AHA/ASA statements "are similar in principles, and the big concern of all these guidelines is to highlight that there are going to be several emergency departments, stroke teams, and interventional teams involved in care to these patients, so we want to make sure that they deliver the best possible care without exposing healthcare providers to risk as they provide that care."

Qureshi and coauthors received no financial support for the research, authorship, or publication of the paper. The authors and Hassan have disclosed no relevant financial relationships.

Int J Stroke. Published online May 3, 2020. Statement

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