Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of
stroke experts, assesses the rapidly growing research and personal experience with
COVID-19 stroke and offers recommendations for
stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or
stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions.
SUMMARY: The severe acute respiratory syndrome coronavirus 2 uses spike
proteins binding to tissue
angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to
COVID-19. Clinicians facing the many etiologies for
stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are
vasculitis,
cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of
acute stroke management remain in force, but
COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending
COVID-19 determination and also for those shown to be
COVID-19 affected, strict infection control is needed at all times to reduce spread of
infection and to protect healthcare staff, using the wealth of well-described methods. For
COVID-19 patients with
stroke, thrombolysis and
thrombectomy should be continued, and the usual early management of
hypertension applies, save that recent work suggests continuing
ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic
LMWH unless
bleeding risk is high. COVID-19-related
cardiomyopathy adds risk of
cardioembolic stroke, where
heparin or
warfarin may be preferable, with experience accumulating with DOACs. As ever,
arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related
stroke also forces rehabilitation services to use protective precautions. As with all
stroke patients, health workers should be aware of symptoms of depression, anxiety,
insomnia, and/or distress developing in their patients and caregivers. Postdischarge
outpatient care currently includes continued
secondary prevention measures. Although hoping a
COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges,
stroke care teams will also overcome this one. Key Messages: Evidence-based
stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.