International Panel Makes Recommendations for Management of Acute Ischemic Stroke in the Context of COVID-19 

An panel of international experts has published recommendations for managing stroke in the context of COVID-19 in the International Journal of Stroke. The panel reviewed research reports from 18 countries that had COVID-19 outbreaks and provides more than 40 recommendations for evaluating and treating people with acute ischemic stroke and suspected or confirmed COVID-19 infection. The panel also examined the link between stroke and COVID-19.

Increased clotting is noted in people with COVID-19, which may increase stroke risk. People without previous risk factors for stroke experienced ischemic stroke with clots in the neurovasculature presumably related to COVID-19. The average onset of stroke in those with COVID-19 occurred 10 days after infection, but in some cases, stroke was the initial symptom.

Key recommendations include: 

• Recognize that people with COVID-19 may develop stroke after the diagnosis of infection, consistent with acute stroke seen with other respiratory tract infections.
• A COVID-19 infection is unlikely to be confirmed or excluded using laboratory assessment during the initial evaluation in acute stroke patients. 
• A clinically suspected COVID-19-infected patient with stroke must be evaluated under the assumption that the patient has COVID-19. 
• People with acute stroke may have undiagnosed COVID-19 because appropriate screening was not possible, adequate history was not available, COVID-19 is in the prodromal stage, the person was an asymptomatic carrier, or neurologic deficits were seen before COVID-19 symptoms were evident 
• If a person with stroke patient is suspected to have COVID-19, pulmonary imaging may be helpful in identifying radiological abnormalities that suggest COVID-19. 

Healthcare workers are at risk of acquiring COVID-19 from people presenting with stroke and should take safety precautions, including setting limits on the number of care providers who have direct interactions with each patient. 

The recommendations call for providers to treat any person with suspected COVID-19 and stroke as if the person has COVID-19, ensuring sanitation of all equipment used during the stroke assessment. People with symptoms of stroke should be encouraged to report 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, the recommendations suggest a sequential organ failure assessment (SOFA) to provide an overall prognosis before determining the appropriate stroke treatment in COVID-19 patients.
“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,” said Adnan I. Qureshi, MD, professor of clinical neurology, University of Missouri School of Medicine. “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.”