Acute Stroke Treatment Preparedness and COVID-19: A Perfect Storm of Challenges

By Murali K. Kolikonda, MBBS; M. Shazam Hussain, MD; and Ken Uchino, MD

Management of acute stroke is challenging under normal circumstances, but a confluence of factors related to the COVID-19 pandemic has made it particularly challenging in recent weeks in the United States.

Beyond affecting more than 1.2 million people worldwide as of this writing, the COVID-19 pandemic is exerting real but poorly understood impacts on the treatment of other medical emergencies, including acute stroke. Some of these effects are illustrated by two cases managed by Cleveland Clinic’s Cerebrovascular Center in the first weeks after the pandemic’s emergence in Northeast Ohio.

Case 1. One patient called emergency medical services after nine days of experiencing symptoms of aphasia and right hemiparesis. During evaluation on our mobile stroke treatment unit, the patient was asked about the long delay in seeking care and responded that it was due to being “afraid to come out due to the coronavirus.”

Case 2. A second patient was transferred to Cleveland Clinic for mechanical thrombectomy after presenting with right middle cerebral artery syndrome. She had a history of flu-like symptoms over the prior 10 days. In view of these symptoms, the patient was managed as if she had possible COVID-19 and precautionary measures were taken, which included intubation prior to thrombectomy, to prevent aerosol spread, and the use of personal protective equipment (N95 respirators, surgical masks, gowns and protective eyewear) for all providers in the procedure room. As a result, treatment initiation was delayed.

These cases echo reports from other centers, which include instances where members of stroke care teams have had to be quarantined and/or have tested positive for the virus that causes COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), after exposure to stroke patients infected with the virus.

Indeed, a number of factors related to the COVID-19 pandemic are resulting in potential delays to the swift treatment that is essential to optimal stroke outcomes:

• Reluctance to promptly seek medical attention among some patients with stroke symptoms, due to fear of exposure to SARS-CoV-2, as in Case 1 above.
• Delays in initiation of stroke evaluation and treatment due to (1) the need for precautionary measures to prevent exposure of providers to stroke patients with confirmed or suspected COVID-19, or (2) potential stroke team workforce depletion resulting from provider quarantines and/or infections.1
• A possible increase in stroke rate among COVID-19 patients. While this requires further confirmation, a single-center report from Wuhan, China, revealed a 5% incidence of acute ischemic stroke among the center’s 221 patients hospitalized with COVID-19, with 12 days into the illness being the median time to stroke.2

These factors collectively represent a perfect storm that may make acute stroke management more challenging — and optimal patient outcomes more difficult to achieve — as long as the COVID-19 pandemic persists.

As healthcare organizations tend to the surge of COVID-19 cases, we must be vigilant about preserving the quality of care for stroke and other acute illnesses and also about striking the right balance between patient care and protection of healthcare workers. We must recognize that some treatment delays will be inevitable to ensure the proper protection and safety of providers treating patients with acute disease. And we must continue to educate the public about the importance of seeking immediate medical attention for symptoms suggesting stroke or other acute medical emergencies.

Cleveland Clinic’s Cerebrovascular Center has developed a strategic plan to triage and prescreen patients for COVID-19 symptoms, alert the necessary teams and have personal protective equipment readily available when the patient hits the door. However, we remain mindful of the priority that must be given to provider safety in order to avoid depleting the healthcare workforce during a crisis when our communities need providers more than ever.

For a more detailed take on the issues discussed here, see the authors’ commentary on Neurology® Blogs.

References

1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648
2. Li Y, Wang M, Shou Y, et al. Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study (3/3/2020). Available on SSRN: ssrn.com/abstract=3550025.

Dr. Kolikonda is a vascular neurology fellow at Cleveland Clinic. Dr. Hussain is Director of Cleveland Clinic’s Cerebrovascular Center, and Dr. Uchino is Head of Research and Education in the Cerebrovascular Center.