The document discusses COVID-19 and its relationship to stroke. It notes that while 80% of COVID-19 cases are non-hospitalized, the virus can cause neurological symptoms that may precede other symptoms. Studies found higher rates of stroke in COVID-19 patients with risk factors like hypertension and diabetes. Severe COVID-19 patients commonly had neurological issues like stroke and impaired consciousness. Those with a history of cerebrovascular disease had higher mortality when infected. The challenges of stroke care during the pandemic include using protective equipment and establishing centralized treatment centers to continue high-quality emergency stroke care while managing COVID-19 risks.

1. COVID-19 and STROKE

2. COVID-19 & Cerebrovascular Disease
 COVID-19 is a severe acute respiratory syndrome caused by a novel coronavirus now named
Severe Acute Respiratory Syndrome (SARS) CoV-21.
 80% of patients infected with the virus remain non-hospitalized.
 Patients infected with the SARS-CoV-2 virus may present in a number of ways, including
neurological symptoms that may coincide with, or could potentially precede, pulmonary
symptoms and fever.
 To date, no comprehensive survey of neurological manifestations of coronavirus viremia has been
published.
10.1161/STROKEAHA.120.030023

3. Clinical Evidence

4. Study Patients Based on Baseline Characteristics
(36 patients required ICU care)
Clinical Characteristics of
138 Hospitalized Patients
With 2019 Novel
Coronavirus–Infected
Pneumonia in Wuhan,
China
N=138  Hypertension 58.3%
 Diabetes 22.2%,
 Cardiovascular disease 25.0%
 16.7% Cerebrovascular Disease
patients required ICU care
JAMA. 2020;323(11):1061-1069. doi:10.1001/jama.2020.1585

5. Study:
 Of 221 patients with
confirmed SARS-
CoV-2, 13 (5·9%)
developed new
onset of CVD
following COVID
infection.
 11 (84·6%) were
diagnosed as
Ischemic stroke.
Conclusions: Older patients with risk factors are more likely to develop CVD.
 Development of CVD is an important negative prognostic factor, which require further study to identify optimal
management strategy to combat the COVID-19 outbreak.
Li Y, et al. Acute Cerebrovascular Disease Following COVID-19: A Single center, Retrospective, Observational Study, 2020
Clinical
characteris
tics of
COVID-19
patients
with or
without
new onset
CVD

6. Study: N= 214 hospitalized patients with laboratory confirmed diagnosis of severe acute respiratory syndrome from
coronavirus 2 (SARS-CoV-2) infection were enrolled.
Interpretation: Compared with non-severe patients with COVID-19, severe patients commonly had neurologic symptoms
manifested as acute cerebrovascular diseases, impaired consciousness and skeletal muscle injury.
Clinical
characteristics of
patients with
COVID-19.
 36.4% patients had
neurologic
manifestations.
 More severe
patients were likely
to have neurologic
symptoms 45.5%
Symptoms Total
Patients
Severe
COVID
Non-severe
COVID
P value
Mao L, et al. Neurological Manifestations of Hospitalized Patients with COVID-19 in Wuhan, China: a retrospective case series study. medRxiv.

7. Interpretation:
 The mortality of critically ill patients with SARS-CoV-2 pneumonia is considerable.
 As previously reported, patients with a history of cerebrovascular disease are at increased
risk of becoming critically ill or dying if they have SARS-CoV-2 infection.
Study: 52 critically ill adult patients were included. The mean age of the 52 patients was 59·7 (SD 13·3) years
Findings:
21 (40%) patients had chronic diseases, including cerebrovascular diseases in seven (13·5%)
patients, all of whom died at 28 days.
Lancet Respir Med 2020. https://doi.org/10.1016/S2213-2600(20)30079-5

8. What we should be aware of ?
Patients with stroke were:
 Older
 More cardiovascular comorbidities
 More severe pneumonia.
Stroke mechanisms may vary and could include:
 Hypercoagulability from critical illness and
 Cardio-embolism from virus-related cardiac injury
10.1161/STROKEAHA.120.030023

9. Challenges and Potential Solutions of Stroke
Care During the Coronavirus Disease 2019 (COVID-19)
Outbreak
The establishment of stroke networks and care systems able to deliver high-quality emergency stroke
care at all times but particularly at times of crisis.
The establishment of centralized stroke treatment centers where sufficient stroke care resource can be
secured. Although there is a strong case for such centers to be the system of care at all times, it is
particularly important at times of medical crisis to have services that can continue to function.
Inform the emergency medical system and the public that these centers will be protected and will
remain fully operational even during crises.
Stroke. 2020;51:00-00

10. Challenges and Potential Solutions of Stroke
Improve education of health professionals and the public, especially those who are at high risk of
stroke, to recognize stroke and call emergency medical services immediately to be taken to one of the
designated stroke centers so as to avoid significant delay in transferring patient from one hospital to the
other.
During the community, lockdown time use online resources to educate and perform consultation for
acute and chronically ill patients to improve stroke prevention awareness and the knowledge of
infection prevention.
Stroke. 2020;51:00-00

11. Temporary Emergency Guidance: Provisional Guidance
Guideline Adherence. Continue treating stroke patients as appropriate. Full adherence to guidelines may be challenging but needed
treatment should be offered to the extent possible.
PPE. Seek ways to minimize the use of scarce PPE in your medical center. Send fewest possible team members to see Code Stroke
patients, and into rooms for follow up visits.
Telemedicine. Telemedicine began with telestroke. The NIHSS can be performed efficiently via telemedicine.
Health and Safety. Take care of yourselves, your families, and your teammates. Follow protocol (local, CDC and WHO), including
guidelines for hand washing, PPE use, COVID-19 testing and evaluation, and self-quarantine as needed.
Teamwork. Stroke care has always been a multispecialty, collaborative effort among EMS, physicians and nurses from the Emergency
Departments to the Stroke Units, ICUs and Rehabilitation Centers. A true sense of a unified Stroke System of Care is needed now more
than ever.
10.1161/STROKEAHA.120.030023

12. Protected Code Stroke: Hyperacute Stroke Management During
the Coronavirus Disease 2019 (COVID-19) Pandemic
Screening Prior to Code Stroke
Khosravani et al Protected Code Stroke During the COVID-19 Pandemic

13. **Protected Stroke Code**
Use of Personal Protective Equipment(PPE) and Place a mask on the patient.
1. Use Droplet/Contact PPE: Full sleeve gown, surgical mask, eye protection and gloves.(Ideal to use extended cuff gloves)
 Is there Aerosolization? (Eg Oropharynx/Nasal (open) suctioning, intubation, Non-invasive Ventilation, Code Blue and/or CPR.
• Yes to Aerosolization? Use Airborne/Contact/Droplet PPE: Full sleeve gown, N95 Mask, eye protection and gloves (Ideal to use
extended cuff gloves)
2. Place a surgical mask over the non-intubated patient: (After securing your own PPE)
 Mask should stay on the patient during transport to and from imaging.
Is the patient obtunded? Needing high FiO2 (>0.5)? Needing CPAP, BiPAP, Nasal High Flow Therapy or Bag-Valve-Mask
Ventilation?
 Yes to Any? Consider EARLY Intubation, Consult ED/ICU Physician for airway management prior to transport to imaging.
3. Use crisis resource management:
• Do not rush inside the resuscitation room, “slow-down when you should”
• Designate a Safety Leader to monitor PPE donning/doffing
• Role designate your team and avoid crowding (Ideally perform a pre-brief)
• Ensure PPE is donned by all team members before starting PCS
• Avoid contamination of other hospital environments en route to imaging and back.

14. Protected code stroke (PCS) framework
Khosravani et al Protected Code Stroke During the COVID-19 Pandemic

15. Summary
 There is no previous experience that can be used to develop plans for the emergency management
of acute stroke treatment in COVID-19 pandemic.
 Although the control of the COVID-19 is very important, at the same time, the management of
stroke must not be neglected.
 The world needs to act quickly to have plans ready to deal with the challenges of continuing to
deliver high-quality stroke care.

16. THANK YOU