Recommendations on stroke management in a COVID-19 setting — international panel

Organisation: Position: Deadline Date: Location:

Neurologist Dr Adnan I Qureshi, a professor of clinical neurology at the University of Missouri-Columbia School of Medicine, led a team of stroke experts from 18 countries with documented COVID-19 outbreaks to develop recommendations for doctors evaluating patients with acute ischemic stroke who have either suspected or confirmed COVID-19 infection.

The international panel noted increased clotting in COVID-19 patients, which raised their risk for stroke. The research team found evidence that young people without previous risk factors for stroke are experiencing ischemic stroke with clots in the arteries of the brain presumably related to a COVID-19 infection. The average onset of stroke in COVID-19 patients occurred 10 days after infection, but in some cases, stroke was the initial symptom.

“People may come to the emergency department with stroke, and that may be the initial manifestation 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,” Qureshi said. “The purpose of these recommendations is to provide a step-by-step guide of how to manage these patients. The modifications we suggest have implications for the health of patients, but also the health of those who are involved in their care.”

Qureshi’s research indicates health care workers are at risk of acquiring COVID-19 from stroke patients and they should take safety precautions while limiting the number of care providers who have direct interaction with each patient. The guidelines also call for providers to treat any suspected COVID-19 stroke patient as though the patient has the infection, ensuring the sanitation of all equipment used during the stroke assessment. If a stroke patient is suspected to have COVID-19, a chest CT scan can provide rapid evidence of a possible infection in the lungs.

“Since COVID-19 actually involves the lungs, a simultaneous scan of the chest and brain can check for stroke and identify changes in the lungs that may identify whether this patient truly has or does not have COVID-19 infection,” Qureshi said. “This step has been incorporated into acute stroke protocol at MU Health Care.”

Qureshi encourages stroke patients and their family members to recall any symptoms of dry cough, fever or body aches before the stroke, which may help the provider determine if the stroke is related to an underlying COVID-19 infection. If a COVID-19 infection is confirmed and other organs have been affected, guidelines suggest a Sequential Organ Failure Assessment (SOFA) can provide an overall prognosis before determining the appropriate stroke treatment in COVID-19 patients.

Qureshi’s study, “Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel,” also featured contributions from MU Health Care neurologist Dr Camilo R Gomez, professor of clinical neurology at the MU School of Medicine.

Abstract
Background and purpose: On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection.

Methods: The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document.
Results: This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection.
Conclusions: These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.

Authors
Adnan I Qureshi, Foad Abd-Allah, Fahmi Alsenani, Emrah Aytac, Afshin Borhani-Haghighi, Alfonso Ciccone, Camilo R Gomez, Erdem Gurkas, Chung Y Hsu, Vishal Jani, Liqun Jiao, Adam Kobayashi, Jun Lee, Jahanzeb Liaqat, Mikael Mazighi, Rajsrinivas Parthasarathy, Thorsten Steiner, M Fareed K Suri, Kazunori Toyoda, Marc Ribo, Fernando Gongora-Rivera, Jamary Oliveira-Filho, Guven Uzun, Yongjun Wang

University of Missouri-Columbia material

International Journal of Stroke abstract

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