Vascular disease

Stroke units get management advice for COVID-19


Patients infected with the COVID-19 virus may have neurological symptoms that may be mistaken for stroke or may be co-occurring stroke, according to new guidance published by the American Stroke Association.

In its “Temporary Emergency Guidance to US Stroke Centres During the COVID-19 Pandemic” the ASA notes that two retrospective case series from three hospitals in Wuhan, China, up to 36% of COVID-19 patients manifest neurological symptoms

The most common neurological manifestations were dizziness (16.8%), headache (13.1%), and encephalopathy (2.8%). The most common peripheral signs and symptoms were anosmia (5.1%), dysgeusia (5.6%), and muscle injury (10.1%, detected by elevated creatine kinase).

The ASA also highlights the fact that stroke complicated COVID-19 infection in 6% of patients at 10 days after symptom onset.

A potential mechanism linking COVID-19 and stroke could include hypercoagulability from critical illness and cardioembolism from virus-related cardiac injury.

“Some of these observations reflect the known biology of the virus, as the obligate receptor for the virus spike protein, human angiotensin converting enzyme, ACE2, is expressed in epithelial cells throughout the body, including in the central nervous system, raising the possibility of a direct role in viral infection,” said the guidance, written by a ASA working group led by Dr Patrick Lyden of the Department of Neurology Cedars-Sinai Medical Center, Los Angeles.

The guidance states that stroke units may face three major issues of PPE shortages, staff unavailability due to reassignment or quarantine, and difficulty in accessing ICU beds for acute stroke patients.

The guideline authors recommend that in units that are under pressure the focus should be on patient selection and treatment over “logistic or process compliance.”

“We believe that all stroke teams should endeavour to adhere to all published guidelines regarding patient selection for therapy; treatment times (e.g., door-to-needle and door-to-groin puncture); and post-recanalisation monitoring.

“However, we wish to inform regulatory authorities—and we wish to reassure stroke teams— that in the setting of the pandemic full compliance has become a goal, not an expectation. Across the wide variety of health care delivery systems in our country, full compliance with all guidelines cannot happen at all times in every locality.”

And while stroke neurologists should aim to retain access to NeuroICU beds for critically ill stroke patients, they say there may be a need to relax the current rigid protocols that keep stroke patients under observation in an ICU setting for 24 hours after thrombolysis or thrombectomy, regardless of their status,

“There is no evidence base underlying this practice. In the absence of data supporting current practice, we suggest that it is feasible to move stable stroke patients to step-down or other units if an intensive care unit bed is needed,” they write.

The ASA says it is still working to provide more specific advice on ‘creative’ approaches to addressing PPE shortages and also guidance on whether delaying to seek medical assistance for stroke and TIA.

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