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With COVID-19, Stroke Guidelines Now a 'Goal, Not an Expectation'

A CT scan stylized to show absence of blood flow to left brain

A CT scan stylized to show absence of blood flow to left brain

To protect stroke team members and patients during the ongoing COVID-19 pandemic, hospitals should aim to follow current guidelines while rethinking resource allocation, according to temporary guidance from the American Heart Association (AHA) and the American Stroke Association (ASA).

"Ordinarily, national recommendations go through a rigorous process of development, refinement, peer review, and thoughtful promulgation. None of that is possible at this time, yet we believe there is a substantial need for a broad policy statement that reflects both the commonality of the pandemic across the U.S. and the individual variability necessary at local sites," according to Patrick Lyden, MD, of Cedars-Sinai Medical Center in Los Angeles, and colleagues of the AHA/ASA Stroke Council. Their temporary guidance was published online in Stroke.

Existing stroke guidelines regarding patient selection for therapy, treatment times, and post-recanalization monitoring should continue to be adhered to, the authors said.

"However, we wish to inform regulatory authorities -- and we wish to reassure stroke teams -- that in the setting of the pandemic full compliance has become a goal, not an expectation. Across the wide variety of health care delivery systems in our country, full compliance with all guidelines cannot happen at all times in every locality," they emphasized.

The AHA/ASA Stroke Council recommended several ways to manage acute stroke treatment in the face of a shortage of staff, personal protective equipment (PPE), and medical equipment.

For example, to minimize PPE use, send the "fewest possible team members to see Code Stroke patients, and into rooms for follow up visits," the group urged, citing some centers' creative solutions with 3D printing and telemedicine.

There should be a discussion among all intensive care specialties about how ICU resource allocation can be handled differently during the COVID-19 pandemic, Lyden and colleagues added.

"In the U.S., stroke patients may be observed in an ICU setting for 24 hours after thrombolysis or thrombectomy, regardless of their status, with rigid intervals for regular vital signs and neurological assessments. There is no evidence base underlying this practice," they said.

The Council suggested moving Stable stroke patients to step-down or other units if an ICU bed is needed.

"Our recommendations and anecdotal advice are offered to the general stroke community in the context of the gravest public health threat in our country's recent history. Nothing in this document has been submitted to the normal guideline development and peer review, although we will begin such a process immediately and update this statement continuously during the crisis," according to the group.

To date, there is still no comprehensive survey of the neurological manifestations of COVID-19.

From two case series that have been posted without peer review on preprint servers, it appears that up to 36% of COVID-19 patients have neurological symptoms, the most common being dizziness, headache, and encephalopathy. Stroke complicated COVID-19 infection in 5.9% of patients at a median 10 days after symptom onset, Lyden's team noted.

Disclosures

Authors listed no disclosures.

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Monday, 01 June 2020

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