Andrew Russman, DO

When we look back on changes in our lives during the novel coronavirus disease 2019 (COVID-19) pandemic, I hope we’ll remember how we confronted these challenges, adapted, innovated, and persevered. Resilience, whether individual or societal, can be an essential by-product of crisis.

During an initial surge in COVID-19 cases, neurologists reported 20% to 50% reductions in acute stroke imaging and clinical presentations to emergency departments (EDs).

 Among patients with COVID-19, multiple anecdotal cases of a variety of etiologies for stroke have emerged. Complications in patients with COVID-19 are being attributed to reported viral-induced thrombophilia,

Patients have expressed their uncertainty regarding the safety of presenting to the ED with stroke symptoms by staying home rather than seeking necessary emergency care. Patients’ self-selection from ED and hospitalized care has shifted an increasing burden of illness to outpatient management, with consequent delays in diagnosis and treatment. I have witnessed patients of mine who have suffered new acute stroke presentations and delayed their presentation to the ED until they were ineligible for thrombolytic therapy and could not manage their disability, out of fear of exposure to COVID-19.

Our dedicated cerebrovascular team of outpatient nurses, advanced practice providers, and physicians has spent considerable time reassuring patients and encouraging them to present to the ED so we can best care for their acute stroke.

An experience during the early stages of the COVID-19 surge in northeast Ohio illustrated the anxiety that prehospital providers experience when caring for patients with acute stroke. A patient with acute ischemic stroke and a negative COVID-19 symptom screen was transported on our mobile stroke unit. Immediately on arrival in the ED, he underwent a CT angiogram of the head and neck, which demonstrated ground-glass opacities concerning for viral pneumonia. Close exposure to a patient with suspected COVID-19 generates a variety of concerns among members of the health care team. Uncertainty regarding proper donning and doffing of personal protective equipment (PPE) and potential risk to self, patients, and family reach a crescendo during the uncertain interval while COVID-19 testing is pending.

In planning for the COVID-19 surge, I’ve spent countless hours developing new clinical workflows for the assessment of acute stroke symptoms in temporary hospitals we hope we will never need, restructured outpatient and inpatient clinician schedules to protect patients and providers, and designed staged redeployment plans for our stroke physician faculty. I have observed a significant increase in the efficiency of holding virtual faculty meetings but lamented the reduced banter among myself and my colleagues, as the usual exchange has always been for the betterment of our clinical and academic practice.

As a provider of telestroke services, I have learned a new appreciation for this capability and its timeliness in caring for patients during the COVID-19 pandemic. As a teaching physician and a section head for stroke services, I have had to develop new rounding practices and witnessed the impact on clinical care and trainee experience.

To reduce provider exposure risk, steward our PPE resources, and optimize clinical decision-making in the ED, we have employed a hybrid telemedicine model in our academic practice that uses a single neurological trainee at bedside with supervision from a vascular neurology fellow or staff member.

On stroke teaching rounds, we use a virtual meeting platform to present the patient history and physical, facilitate review of imaging, discuss clinical management, and review relevant literature. We have limited the number of team members who interact at the bedside and reduced redundant clinical examination for patients with suspected or confirmed COVID-19.

On an outpatient basis, we were already performing a small portion of our clinical visits using a virtual platform. With the emergence of the COVID-19 pandemic, we were challenged to rapidly shift the vast majority of outpatient services to virtual platforms to facilitate social distancing, reduce PPE use, and provide effective care for our patients. We have found new and innovative ways to conduct physical examinations through our virtual platforms. Patients have had to adapt their expectations of the virtual visit experience and manage previously unfamiliar application technology tasks using their smartphones. Hands-on outpatient rehabilitative care has suffered.

Stroke-related research involving COVID-19 has flourished with numerous anecdotal experiences, case reports, and case series popping up in the literature, reflecting the stroke community’s commitment to tackle the beast of uncertainty surrounding clinical management of acute stroke in patients with COVID-19. However, research involving patients without COVID-19 has suffered, with many important clinical trials being put on hold

 and institutional review boards delaying expedited review of minimal-risk, non—COVID-19–related research.

Stroke systems of care are rapidly evolving to meet the challenges of the COVID-19 pandemic. As we slowly emerge from stay-at-home orders, restart office clinical practices, and perform elective procedures, we must advocate for our patients by telling them what they don’t know—EDs and hospitals are safe for patients, and acute stroke needs to be managed emergently to reduce disability and prevent complications. I appeal to my neurology colleagues throughout the world: Engage with your local print and television media, tweet your support and post on other social media, make an impassioned video appeal, start a blog, and otherwise get the word out to patients with stroke that there is no time like the present to seek our care and expertise and confront their fears with our help, rather than doing harm to themselves by ignoring it.

1. Leira EC, Russman AN, Biller J, et al. Preserving stroke care during the COVID-19 pandemic: potential issues and solutions. Neurology. Published online May 8, 2020. doi:10.1212/WNL.0000000000009713 

2. Kansagra AP, Goyal MS, Hamilton S, Albers GW. Collateral effect of Covid-19 on stroke evaluation in the United States. N Engl J Med. Published online May 8, 2020. doi:10.1056/NEJMc2014816 

3. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-847. doi:10.1111/jth.14768 

4. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol. Published online March 27, 2020. doi:10.1001/jamacardio.2020.1286 

5. Zhang Y, Gao Y, Qiao L, Wang W, Chen D. Inflammatory response cells during acute respiratory distress syndrome in patients with coronavirus disease 2019 (COVID-19). Ann Intern Med. Published online April 13, 2020. doi:10.7326/L20-0227 

6. Meschia JF,&#8239;Barrett KM,&#8239;Brown RD, et al. The CREST-2 experience with the evolving challenges of COVID-19: a clinical trial in a pandemic. Neurology.&#8239;Published online May 1, 2020. doi:10.1212/WNL.0000000000009698 

Articles

Andrew Russman, DO, guest editor for NeurologyLive, provides insight on how stroke care has changed during the COVID-19 pandemic. 

Stroke Care Evolves During These Uncertain Times

“The telehealth revolution is here; the systems to support it are not.”

Although telemedicine and telestroke have improved the treatment options available to stroke neurologists and patients, many restrictions to its use still exist. While a stroke specialist may have plenty of experience with conducting evaluations and follow-up care via telemedicine, if they are not licensed in the specific state where a patient is located, their impact is significantly minimized.

Andrew Russman, DO, medical director of the Comprehensive Stroke Center at Cleveland Clinic, shared some of his frustrations with the legal restrictions that specialists face when treating patients through telemedicine. The current certification process is complicated, and may unnecessarily restrict qualified physicians from being able to provide clinical care for patients from a remote location.

, Russman detailed some of the licensing issues and the changes he hopes to see in the future so that access to care does not continue to fall far behind the pace of telemedicine technology.  

Videos

The medical director of the Comprehensive Stroke Center at Cleveland Clinic provided an in-depth look at the problems surrounding access to care, including those that limit the application of telemedicine.

Andrew Russman, DO: Addressing Telehealth Restrictions in Stroke Care 

“There has been so much investment over time in these [neuroprotection] trials and none of them have really shown success. Neurorestoration may show more promise.”

Thrombolytic therapies are the primary method of neuroprotection for patients following acute ischemic stroke (AIS), with the goal of preventing the infarction from increasing in size. Other therapies, including cooling, have been tried; however, many of those therapies are likely not as effective as thrombolysis and thrombectomy.

Andrew Russman, DO, medical director of the Comprehensive Stroke Center at Cleveland Clinic, believes that neurorestoration may have more potential than neuroprotection, as it is aimed at regenerating tissue and reducing disability. This includes deep brain stimulation and cell therapies.

, Russman discussed why the pursuit of neurorestoration therapies may be a more viable option for improving long-term outcomes in patients with AIS.

The medical director of the Comprehensive Stroke Center at Cleveland Clinic detailed the differences between neuroprotection and neurorestoration, and the available options for each.

Andrew Russman, DO: Neuroprotection Versus Neurorestoration  

“Early administrations can be critically important. When we think about novel approaches to thrombolytics, the first thing we should look at is novel approaches that get the drug to patients faster and more effective.”

Administration of alteplase, an intravenous tissue plasminogen activator (IV tPA), remains the gold-standard treatment for stroke however, the next generation of thrombolytic agents, including tenecteplase, present several advantages and benefits.  

Andrew Russman, DO, medical director of the Comprehensive Stroke Center at Cleveland Clinic, stressed the importance administering these agents as early as possible, in turn maximizing the clinical benefits they provide. Through the use of mobile stroke units, patients can receive thrombolytic therapies and begin this process earlier compared to traditional treatment in an emergency department.  

While data is still accumulating, trials have shown that there are still benefits to late window thrombolysis. In an interview with 

, Russman detaild the benefits that thrombolytic therapy can have in both early and late treatment windows.

The medical director of the Comprehensive Stroke Center at Cleveland Clinic reviewed the timeline of administering various thrombolytic agents and the benefits they bring.

Andrew Russman, DO: Advances in Thrombolytic Therapies to Treat Stroke 

“Intensive blood pressure management is a much better approach for long term reduction for stroke and other cardiovascular events.”

An increased rate of blood pressure can not only raise the risk of cardiovascular events but put patients in danger for other diseases caused by uncontrolled hypertension. Clinicians treating stroke, such as Andrew Russman, DO, medical director, Comprehensive Stroke Center, Cleveland Clinic, believe that 120 over 80 is the ideal blood pressure to avoid cardiovascular events such as stroke.

Patients have a tendency to shy away from being as aggressive to lower their blood pressure because of the adverse effects that may come with this practice—this overly aggressive effort can lead to complications such as ischemia buildup in the brain over time. Although, Russman believes the benefits of having lowered blood pressure outweigh the complications that come with it.

Additionally, high blood pressure comes with a slew of adverse effects on its own, leading to uncontrolled hypertension, which can cause additional strain on the heart, leaving organ damage and increasing the risk of other events such as renal disease, eye diseases, and brain diseases. In an interview with 

, Russman discusses why keeping blood pressure at a lower, more normal level is beneficial, especially for the long-term future of patients. 

The medical director of the Comprehensive Stroke Center at Cleveland Clinic detailed the advantages of controlling blood pressure.

Andrew Russman, DO: Importance of Controlled Blood Pressure 

“I think when you have more access, you feel more empowered to take care of your health. When you don’t, you feel less empowered and wonder, ‘What am I putting the time into when I can’t get in to see the doctor or get the medications I need?”

At-risk populations, including people who have multiple risk factors and those who live in areas with limited access to medical care and resources, face a challenging complex. While reducing high blood pressure, quitting smoking, and controlling diabetes are among the modifiable risk factors that can reduce stroke risk, taking action without access to a primary care provider or other healthcare professional can make managing personal health concerns especially difficult.  

Andrew Russman, DO, medical director of the Comprehensive Stroke Center at Cleveland Clinic, believes that, to a degree, patients should be held responsible for their own health, but understands that appropriate care is not often accessible in underserved communities.

For a patient in these communities, waiting extended periods of time to see a physician may keep them from staying on top of their health. In addition, the use of the emergency department for primary care needs is not sustainable, and often leaves patients with no direction for future care.

, Russman detailed why greater continuity of care by building a strong relationship between a patient and a medical provider can ultimately lead to improved management of risk factors and in turn, a lower risk of stroke.

The medical director of the Comprehensive Stroke Center at Cleveland Clinic described the effects of limited medical resources on patients who have risk factors for stroke.