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.
Mao L, Wang M, Chen S, He Q, Chang J, Hong C, et al. Neurological manifestations of hspitalized ptients with COVID-19 in Wuhan, China: a retrospective case series study. medRxiv 2020.02.22.20026500, https://doi.org/10.1101/2020.02.22.20026500 (accessed 17 April 2020).
4.
ZhouFYuTDuR, et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet2020; 395(10229): 1054--1062. .
5.
SmeethLThomasSLHallAJHubbardRFarrington P and VallanceP. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med2004; 351: 2611–2618.
6.
Warren-GashCBlackburnRWhitakerHMcMenaminJHaywardAC. Laboratory-confirmed respiratory infections as triggers for acute myocardial infarction and stroke: a self-controlled case series analysis of national linked datasets from Scotland. Eur Respir J2018; 51(3): 1701794. .
7.
ZuntJ. Invited commentary: neurology during the COVID-19 pandemic: lessons learned at the initial U.S. epicenter. Neurology2020. Available at: blogs.neurology.org (accessed 10 April 2020).
WuZMcGooganJ. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA2020. Forthcoming.
10.
LivingstonEBucherK. Coronavirus disease 2019 (COVID-19) in Italy. JAMA2020. Forthcoming.
11.
QureshiAIGilaniSAdilMM, et al.Pattern of informed consent acquisition in patients undergoing emergent endovascular treatment for acute ischemic stroke. J Vasc Interv Neurol2014; 7: 21–25.
12.
KimD-HSaverJLStarkmanS, et al.Enrollment yield and reasons for screen failure in a large prehospital stroke trial. Stroke2016; 47: 232–235.
13.
China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med2020. Forthcoming.
14.
ZhaoWZhongZXieXYuQLiuJ. Relation between chest CT findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: a multicenter study. AJR Am J Roentgenol2020; 3: 1–6.
15.
LauerSAGrantzKHBiQ, et al.The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med2020. Forthcoming.
16.
ZouLRuanFHuangM, et al.SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med2020; 382: 1177–1179.
17.
MizumotoKKagayaKZarebskiAChowellG. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill2020; 25: 1--5.
18.
NishiuraHKobayashiTSuzukiA, et al.Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis2020. Forthcoming.
19.
van DoremalenNBushmakerTMorrisDH, et al.Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med2020; 382: 1564--1567.
20.
SetoWHTsangDYungRWH, et al.Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet2003; 361: 1519–1520.
21.
LoebMDafoeNMahonyJ, et al.Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA2009; 302: 1865–1871.
SilvaGSSchwammLH. Use of telemedicine and other strategies to increase the number of patients that may be treated with intravenous thrombolysis. Curr Neurol Neurosci Rep2012; 12: 10–16.
24.
AgarwalSDayDJSibsonL, et al.Thrombolysis delivery by a regional telestroke network – experience from the U.K. National Health Service. J Am Heart Assoc2014; 3: e000408.
25.
MartinsSCOWeissGAlmeidaAG, et al.Validation of a smartphone application in the evaluation and treatment of acute stroke in a comprehensive stroke center. Stroke2020; 51: 240–246.
26.
LuJGuJLiK, et al.COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. Emerg Infect Dis2020; 51(1): 240--246.
27.
WuYGuoCTangL, et al.Prolonged presence of SARS-CoV-2 viral RNA in faecal samples. Lancet Gastroenterol Hepatol2020. Forthcoming.
28.
Santarpia J, Rivera D, Herrera V, Morwitzer M, Creager H, Santarpia G, et al. Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center, https://doi.org/10.1101/2020.03.23.20039446 (accessed 17 April 2020).
29.
HeQWuCLuoH, et al.Trends in in-hospital mortality among patients with stroke in China. PLoS One2014; 9: e92763.
30.
RuanQYangKWangWJiangLSongJ. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med2020; 9: e92763.
31.
WuCChenXCaiY, et al.Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med2020. Forthcoming.
32.
ShiSQinMShenB, et al.Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol2020. Forthcoming.
33.
MorenoRVincentJLMatosR, et al.The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working Group on sepsis related problems of the ESICM. Intensive Care Med1999; 25: 686–696.
34.
PowersWJRabinsteinAAAckersonT, et al.Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2019; 50: e344–e418.
35.
Yichun C, Ran L and Kun W. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney international, https://doi.org/10.1016/j.kint.2020.03.005 (accessed 17 April 2020).
36.
MüllerMCMeijersJCMVroomMBJuffermansNP. Utility of thromboelastography and/or thromboelastometry in adults with sepsis: a systematic review. Crit Care2014; 18: R30.
37.
Helsinki Stroke Thrombolysis Registry Group. Body temperature, blood infection parameters, and outcome of thrombolysis-treated ischemic stroke patients. Int J Stroke2013; 8: 632–638.
38.
HsuP-JChenC-HYehS-JTsaiL-KTangS-CJengJ-S. High plasma d-dimer indicates unfavorable outcome of acute ischemic stroke patients receiving intravenous thrombolysis. Cerebrovasc Dis2016; 42: 117–121.
39.
StravitzRTLismanTLuketicVA, et al.Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography. J Hepatol2012; 56: 129–136.
40.
HarrisonMF. The misunderstood coagulopathy of liver disease: a review for the acute setting. West J Emerg Med2018; 19: 863–871.
41.
FroehlerMTSaverJLZaidatOO, et al.Interhospital transfer before thrombectomy is associated with delayed treatment and worse outcome in the STRATIS Registry (systematic evaluation of patients treated with neurothrombectomy devices for acute ischemic stroke). Circulation2017; 136: 2311–2321.
42.
van VeenendaalPYanBChurilovLDowlingRBush S and MitchellP. Endovascular clot retrieval by hub-and-spoke service delivery is feasible compared with direct-to-mothership. Cerebrovasc Dis2018; 46: 172–177.
43.
WeltFGPShahPBAronowHD, et al.Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: From ACC's Interventional Council and SCAI. J Am Coll Cardiol2020; 136(24): 2311--2321.
44.
ZengJHuangJPanL. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People's Hospital. Intensive Care Med2020; 6(3-4): 172--177.
45.
EmiruTChaudhrySAQureshiAI. A survey of preprocedural intubation practices for endovascular treatment of acute ischemic stroke. J Vasc Interv Neurol2014; 7: 30–33.
46.
SchönenbergerSMöhlenbruchMPfaffJ, et al.Sedation vs. intubation for endovascular stroke treatment (SIESTA) – a randomized monocentric trial. Int J Stroke2015; 10: 969–978.
47.
TranKCimonKSevernMPessoa-SilvaCLConlyJ. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One2012; 7: e35797.
48.
VerbeekPRSchwartzBBurgessRJ. Should paramedics intubate patients with SARS-like symptoms?. CMAJ2003; 169: 299–300.
49.
RasmussenMSchönenbergerSHendènPL, et al.Blood pressure thresholds and neurologic outcomes after endovascular therapy for acute ischemic stroke: an analysis of individual patient data from 3 randomized clinical trials. JAMA Neurol2020; 7: Forthcoming.
50.
CurleyGKavanaghBPLaffeyJG. Hypocapnia and the injured brain: more harm than benefit. Crit Care Med2010; 38: 1348–1359.
51.
SchönenbergerSUhlmannLHackeW, et al.Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. JAMA2016; 316: 1986–1996.
52.
SimonsenCZYooAJSørensenLH, et al.Effect of general anesthesia and conscious sedation during endovascular therapy on infarct growth and clinical outcomes in acute ischemic stroke: a randomized clinical trial. JAMA Neurol2018; 75: 470–477.
53.
Löwhagen HendénPRentzosAKarlssonJ-E, et al.General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke: the anstroke trial (anesthesia during stroke). Stroke2017; 48: 1601–1607.
54.
ChambersCEEisenhauerMDMcNicolLB, et al.Infection control guidelines for the cardiac catheterization laboratory: society guidelines revisited. Catheter Cardiovasc Interv2006; 67: 78–86.
55.
PernerstorferTHollensteinUHansenJB, et al.Lepirudin blunts endotoxin-induced coagulation activation. Blood2000; 95: 1729–1734.
56.
KullayaVde JongeMILangereisJD, et al.Desialylation of platelets by pneumococcal neuraminidase a induces adp-dependent platelet hyperreactivity. Infect Immun2018; 48(6): 1601--1607.
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