Timely diagnosis, transportation, and emergent in-hospital care, including recanalization treatment and admission to a dedicated stroke unit, are essential components of acute stroke care. Amid the coronavirus disease 2019 (COVID-19) pandemic, because of the shortage of medical resources and staff, suboptimal stroke care may occur resulting in worse clinical outcomes [1]. Additionally, hospital personnel, including doctors, nurses, and technicians, are at higher risk for exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, during emergent stroke care. Therefore, there is an urgent need to provide stroke centers with a tentative guidance to ensure the quality of acute stroke care and the safety of hospital personnel involved in stroke care.
The transmission of SARS-CoV-2 is known to occur through droplets emitted during sneezing, coughing, or a casual conversation [2]. Patients with COVID-19 usually present with fever, sore throat, cough, chest pain, dyspnea, headache, generalized body aches, vomiting, and diarrhea. Olfactory and gustatory dysfunctions may occur [3]. The clinical course is mild in most cases, but lower respiratory infections including pneumonia can develop from the early days of illness [2,4]. Viral shedding may be high during the prodromal phase.
Dizziness and headache may occur in 36% of COVID-19 cases. Stroke has been reported to occur in 6% of confirmed COVID-19 patients at a median of 10 days after the initial symptoms [5,6]. Presumed stroke mechanisms include hypercoagulability because of critical illness and cardioembolism due to viral myocarditis or cardiac failure.
International stroke societies and organizations are currently working to devise an action plan to provide optimal stroke care amid the COVID-19 pandemic. Their plans can be summarized as follows: (1) centralization of regional stroke systems of care and (2) development and implementation of protected intramural code stroke protocols to ensure the quality of stroke care and protect hospital personnel from the SARS-CoV-2 infection [1,7,8]. A recent Chinese guideline for neurologists recommended performing brain and chest computed tomography simultaneously in cases of neurological symptoms or stroke with a high suspicion of COVID-19 [9].
As of mid-April 2020, the COVID-19 epidemic in Korea seems to have stabilized, and the number of newly diagnosed cases per day remains below 50 [10]. The Korean government is still warning about a possible second wave of new infections, emphasizing the importance of social distancing and personal hygiene.
During this COVID-19 pandemic, patients with acute stroke may be categorized into the following four groups: (1) Acute stroke patients with a laboratory-confirmed COVID-19; (2) Acute stroke patients not yet diagnosed with COVID-19, but in quarantine because of an epidemiological suspicion of exposure to COVID-19—close contact with confirmed cases or a recent trip, within the last 2 weeks, to COVID-19 affected regions or abroad; (3) Acute stroke patients not yet diagnosed with COVID-19, but are febrile or have respiratory symptoms; (4) Acute stroke patients not diagnosed with COVID-19 and who neither are febrile nor have respiratory symptoms.
If hospitals and emergency rooms establish pre-arrival screening measures for COVID-19, including assessment of travel history and respiratory symptoms, it would save time for acute stroke care. Otherwise, screening for COVID-19 should be performed for every patient before the protected code stroke is activated [8].
Additional protective measures to mitigate the spread of SARS-CoV-2 transmission should be implemented in the following cases: (1) Acute stroke patients with a laboratory-confirmed COVID-19; (2) Acute stroke patients not yet diagnosed with COVID-19 but in quarantine because of an epidemiological suspicion of exposure to COVID-19.
Measures to contain SARS-CoV-2 transmission during acute stroke care in the emergency room in case of out-of-hospital occurrence or at the place of onset in case of in-hospital stroke
(1) All medical staff should use personal protective equipment (PPE), including full-sleeved gown, N95 respirator, eye protection (goggles or face shields), and gloves.
(2) All non-intubated patients should wear a surgical mask.
(3) Minimize close contact with patients—a brief neurological examination suffices to assess the National Institute of Health Stroke Scale score.
(4) Limit neuroimaging studies to those that can detect large vessel occlusions and proceed to decide recanalization treatment; avoid advanced neuroimaging until COVID-19 is excluded.
(5) Secure a negatively pressurized or properly isolated room to monitor the stroke patient after intravenous thrombolysis or endovascular treatment.
(6) Minimize in-hospital patient transportation—use an isolation stretcher or wheelchair with negative pressure and clear out the hallway during in-hospital patient transportation.
Measures to contain SARS-CoV-2 transmission during endovascular treatment in an angiography suite
(1) Use a negatively pressurized angiography suite, if available. Otherwise, designate an angiography suite for treating a stroke patient with COVID-19 and prepare isolation measures beforehand. After treatment, complete disinfection and decontamination must be performed.
(2) Designate interventionists, technicians, and nurses for treating possible COVID-19 cases and make sure they are accustomed to proper donning and doffing of PPE.
(3) Turn off automatic doors to the suite. Shut down doors and restrict access to the suite during any procedure.
(4) Minimize the number of medical staff in the angiography suite during the procedure. One medical doctor may assume the role of crisis resource management [8].
(5) The patient should wear a surgical mask during the procedure unless an oxygen mask or intubation is needed.
(6) Properly discard disposable items according to the institutional or national/regional guidelines.
(7) After the procedure, the patient should be admitted to a negatively pressurized or properly isolated intensive care unit or stroke unit.
The COVID-19 outbreak is ongoing, and the current situation is highly volatile. The statement and guidelines in this paper are based on scientific evidence and expert opinion available as of April 2020. It is recommended that each stroke center develops and updates an institutional protocol for providing safe and efficient stroke care amid the COVID-19 pandemic, based on its medical resources, local epidemics, and emerging prevention and treatment options against COVID-19.
The management of a patient with acute stroke who is neither diagnosed as COVID-19 nor in quarantine but has a fever or respiratory symptoms may depend on the local epidemiologic status of COVID-19. In an area with suspicion of widespread community transmission, applying the protected code stroke protocol to such a patient may be justified. It has been reported that asymptomatic COVID-19 patients may be contagious [11]. Patients with acute stroke often require endotracheal suction or intubation, both of which can produce a large amount of virus-rich aerosols. In the long run, it should be discussed when and how to implement PPE and other containment measures against potentially contagious sources during acute stroke care in the emergency room.
Establishing regional or national stroke care networks is warranted. Shortage of medical resources can occur when hospitals are designated as COVID-19 dedicated centers or when hospitals shut down because of an in-hospital outbreak. These shortages may derange pre-existing regional stroke care systems. Therefore, centralized triage systems, including flexible rerouting and sharing of resource information, maybe the best option in these cases. Conventional stroke pre-notification by emergent medical services should include information on the diagnosis of COVID-19, exposure to COVID-19, fever, and respiratory symptoms.
The COVID-19 pandemic is rapidly spreading, and containing the virus and mitigating disease burden is currently the most important goal. However, physicians should endeavor to provide the best care to stroke patients even in these trying times.
The Korean version of this statement is provided as a Supplementary material.
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