Dr Andrew RussmanAndrew N. Russman, DO
This month, a group of authors published recommendations in Neurology to point to the possible issues and their solutions regarding stroke care amid the COVID-19 pandemic. They offered advice and specifically addressed the potential impact of the pandemic on the quality of care, ethical considerations, safety and logistic issues, and research in stroke.1

The paper ultimately concluded that stroke providers need to balance the overall needs of the community while remaining advocates for those with stroke and the safety of providers, including making adjustments in the delivery care that should be adapted to each unique environment. Additionally, they noted it is important to keep in mind that as care continues during the pandemic, stroke providers will need to rely on prediction modeling and surge planning to continue to adapt to best serve all patients with stroke.

Andrew N. Russman, DO, head, Stroke Program, and medical director, Comprehensive Stroke Center, Cleveland Clinic, and coauthors wrote that they anticipate that ongoing and emergent research will continue to offer additional insights that will provide evidence which could prompt the modification or removal of some of their recommendations.

“These [case-based] articles raise questions more than they have provided us answers about how to address this,” Russman told NeurologyLive. “With patients who present with stroke and COVID-19, we should be aware that there is more than 1 potential mechanism by which the virus may contribute to the risk of stroke. We should be vigilant about looking for these potential possibilities—not all of it is related to hypercoagulability. Some of it is related to cardiomyopathy. Some of it may be related to underlying mechanisms that the patients had regardless of COVID-19 and the state of any systemic inflammation from the virus is what might have precipitated stroke in that individual patient, just as it’s been reported in other individual circumstances.”

Russman added that providing recommendations for the treatment of these patients is even more complex and based on the information that the community has to work with—which often lacks evidenced-based analysis and in-depth consistency in their investigation—the ability to create a standard approach or treatment for these patients is complicated even further.

“That’s what we should take away from this—we need more data and more information, a registry of these patients, and then, potentially, randomized studies of how we’re going to approach treatment in this population,” he said.
 
READ MORE: The State of Stroke Care: Adjusting to COVID-19 and Recent Research

For the delivery of stroke care, Russman et al. noted that the community should prepare for the possibility of physician shortages and that restructuring stroke call and inpatient services might be required to maintain a viable workforce of providers. Additionally, they advised that contingency plans include that neurologists with stroke expertise be prepared to assume consultative roles in different facilities as well as make treatment triage decisions in a multidisciplinary sense, similar that utilized in critical care.

They recommended that in acute stroke, all of those patients in highly contaminated areas should be approached as potentially infected. Russman and colleagues wrote that “acute stroke is an area with high-risk for provider exposure to infection; it is a fast-paced setting, involving multiple patient interactions and limited opportunities for COVID-19 screening with patients who often have impaired cognition and language.”

Video conferencing was also recommended as a supplement to trainee education while maintaining physical distancing, which they noted has seen “across the country at all levels of educational programming.” Protocols to protect personnel who are caring for those with acute stroke should depend on the availability and reliability of COVID-19 screening and testing, and in light of a crisis capacity mode, the role of trainees might need to be redefined, according to the recommendations.

As for research, the group acknowledged that the pandemic has created a challenge in conducting trials and studies with the risk of exposure, and wrote that “as a research community, a reasonable conclusion is that research that does not involve in-person contact is logistically feasible,” they wrote.

These recommendations come on the heels of growing reports of large-vessel occlusion (LVO) stroke in patients with COVID-19, particularly in those younger than 50. A case-based report, recently published in the New England Journal of Medicine, included 5 cases of LVO stroke in the Mount Sinai Health System. All 5 patients presented over a 2-week period from March 23 to April 7, 2020, with new-onset symptoms of large-vessel ischemic stroke and a positive test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The mean National Institutes of Health Stroke Scale (NIHSS) score was 17, and 1 patient had a history of stroke.2

The authors noted that by comparison, every 2 weeks over the previous 12 months, the service had treated 0.73 patients younger than 50 years of age with large-vessel stroke on average. Two of the patients in the series delayed calling an ambulance due to fears about going to a hospital during the pandemic.2

When asked about this continually changing environment, Jeremy Payne, MD, PhD, director, Stroke Center, Banner-University Medicine Neuroscience Institute, told NeurologyLive, “It's difficult work, and it's difficult to wrap our heads around that in this short period of time—and that, in a large part, gets back to the conversation we'll often have with our patients with stroke and their families that there's almost never a smoking gun with stroke.”

“It's a multifactorial disease—in most cases, it’s the result of just wear and tear on the vasculature and the blood clotting system and the structures that support blood supply to the brain, which we talk about in terms of risk factors. We'll often find a spectrum of potential contributors to somebody stroke but finding an actual smoking gun isn't usually how that works,” Payne explained. “We do certainly find smoking guns, but mostly its risks that we manage, so it's a little early in our experience with stroke and COVID to clearly say, ‘Yes, it’s a risk for stroke,’ but it's certainly bubbling up and the little hints we've had here and there are quite compelling.”

In recent weeks, those hints have continued to come. One recent assessment suggested that the pandemic may have a negative impact on care for those with acute conditions, finding that the number of patients who underwent imaging decreased by 39%, from 1.18 patients per day per hospital in the pre-pandemic 29-day epoch from February 1 to February 29, 2020, to 0.72 patients per day per hospital in the 14-day epoch during the early pandemic from March 26 to April 8, 2020. The authors wrote that this apparent increase in patients undergoing imaging after the early-pandemic epoch warrants further investigation.3

Another assessment published in the New England Journal of Medicine that included data on 231,753 patients who underwent imaging in 856 hospitals in the United States from July 1, 2019, to April 27, 2020, noted that there was a 31% incidence of thrombotic complications in ICU patients with COVID-19 infections, which the authors noted is “remarkably high.” They added that the findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all patients with COVID-19 admitted to the ICU. As well, they wrote that the data are strongly suggestive that prophylaxis should increase towards high-prophylactic doses—even without randomized evidence.4

“We see that some people tend to have abnormal markers of blood clotting when they have COVID—stroke or not,” Payne said. “We'll see, for example, that that the things that we see in their lungs may not be typical or traditional pulmonary disease but may actually have to do with clots forming in the small arteries, and maybe that's what's happening in their kidneys. Now, we've taken to looking at sort of the clotting profile of patients we've seen recently with stroke and COVID, and we're finding it's quite abnormal. We're finding that not only the numbers are abnormal, but patients clinically seem to respond better to earlier use of blood-thinning medications and sometimes even clot-buster medicines to clear up some of these clotting issues that we'll see.”
 
“How that all shakes out, I think, is going to be very interesting and is actually going to teach us some important lessons about how blood clotting works and how vascular biology works. There are things to be learned there,” Payne added. 

The entirety of Russman et al.'s recommendations can be viewed by clicking here.
REFERENCES
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. Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. Published online April 28, 2020. doi: 10.1056/NEJMc2009787
3. Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. Published online April 10, 2020. doi: 10.1016/j.thromres.2020.04.013.
4. 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