Stroke Care during the COVID-19 Pandemic: International Expert Panel Review
Authors: Venketasubramanian Narayanaswamy , Anderson Craig , Ay Hakan , Aybek Selma , Brinjikji Waleed , de Freitas Gabriel R. , Del Brutto Oscar H. , Fassbender Klaus , Fujimura Miki , Goldstein Larry B. , Haberl Roman L. , Hankey Graeme J. , Heiss Wolf-Dieter , Lestro Henriques Isabel , Kase Carlos S. , Kim Jong S. , Koga Masatoshi , Kokubo Yoshihiro , Kuroda Satoshi , Lee Kiwon , Lee Tsong-Hai , Liebeskind David S. , Lip Gregory Y.H. , Meairs Stephen , Medvedev Roman , Mehndiratta Man Mohan , Mohr Jay P. , Nagayama Masao , Pantoni Leonardo , Papanagiotou Panagiotis , Parrilla Guillermo , Pastori Daniele , Pendlebury Sarah T. , Pettigrew Luther Creed , Renjen Pushpendra N. , Rundek Tatjana , Schminke Ulf , Shinohara Yukito , Tang Wai Kwong , Toyoda Kazunori , Wartenberg Katja E. , Wasay Mohammad , Hennerici Michael G. 
Published: March 2021

Background: 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.