key: cord-0784801-5jk3u9b8 authors: Pedicelli, Alessandro; Valente, Iacopo; Pilato, Fabio; Distefano, Marisa; Colosimo, Cesare title: Stroke priorities during COVID-19 outbreak: acting both fast and safe date: 2020-05-06 journal: J Stroke Cerebrovasc Dis DOI: 10.1016/j.jstrokecerebrovasdis.2020.104922 sha: 03ee0d55e072bf596d8c4479f599d97b5e8e102a doc_id: 784801 cord_uid: 5jk3u9b8 Abstract While the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) spreads all over the world, the healthcare systems are facing the dramatic challenge of simultaneously fight against the outbreak and life-threating emergencies. In this biological setting, emergency departments and neurovascular teams are exposed to high risk of infection and should therefore be prepared to deal with neurological emergencies safely. The purpose of this article is to analyze the current evidence on COVID-19 in the context of acute ischemic stroke and to describe the model of behavior we are putting into action to maintain the stroke pathway both rapid for the patient and safe for the healthcare professionals. We reserve a specific focus on personal protection equipment, dress code and healthcare professional behavior. In this biological setting, emergency departments and neurovascular teams are exposed to high risk of infection and should therefore be prepared to deal with neurological emergencies safely. The purpose of this article is to analyze the current evidence on COVID-19 in the context of acute ischemic stroke and to describe the model of behavior we are putting into action to maintain the stroke pathway both rapid for the patient and safe for the healthcare professionals. We reserve a specific focus on personal protection equipment, dress code and healthcare professional behavior. On March 11 2020, the World Health Organization (WHO) defined COVID-19 as a pandemic 1 . On April 02, 896,450 confirmed cases in 204 countries were reported 2 . Coronaviruses are not-segmented, enveloped, positive-sense, single-strand ribonucleic acid viruses, belonging to the Coronaviridae family 3 . Human-to-human transmission occurs primarily via direct contact, through surfaces touch 4 , air droplets or airways diffusion 5, 6 . The higher risk of transmission is within approximately 1 or 2 meters from the infected person but the minimum distance is still undetermined 7 . Evidences showed that 74% of asymptomatic SARS-CoV-2 positive patients may be infective 8 . Although this background makes healthcare professionals" job difficult and risky, patients with ischemic stroke still need fast intervention. Since five trials demonstrating the efficacy and safety of mechanical thrombectomy (MT) for the treatment of ischemic strokes due to large vessel occlusion (LVO) have been published 9-13 , the endovascular treatment is now the standard of care for patients presenting within 6 hours from symptoms onset. Also patients who arrives between 6 and 24 hours from symptoms onset can benefit from this treatment if they meet specific neuro-radiological criteria 14, 15 . The whole process of patient"s neurological evaluation, radiological examination and medical or interventional treatment should be carried out in the shortest time to reduce brain damage (the socalled "time-is-brain" concept) 16, 17 . Relying on our experience in a COVID-19-reference and tertiary stroke center, we analyze each step of the acute ischemic stroke (AIS) pathway in order to identify the phases at the highest risk of infection and to simplify, when possible, the diagnostic process. Consequently, we developed an intra-hospital protocol to balance the management of ischemic stroke patients (including the access to time-dependent procedures) and the risk of infection. A brief report claims the decreasing by 50% of mechanical thrombectomies in Shanghai since the end of January compared with the same period in 2019 18 . Data of our hospital shows no reduction in the number of mechanical thrombectomies performed during the outbreak; conversely, we noted an increase of 88,8% in mechanical thrombectomies when comparing the same period (1 th March -1 th April) with 2019. Although this increase could hide a bias due to a natural improvement of the stroke network performances, it goes against the trend of previous evidences. However, this trend is not surprising because ischemic stroke was reported as one of the possible complications to COVID-19 19 . The disease is associated with transiently raised serum concentrations of inflammatory cytokines 20 that cause endothelial dysfunction and increases the procoagulant activity of the blood, which can contribute to the formation of an occlusive thrombus over a ruptured arterial plaque 21 . Another proposed mechanism is cardioembolism from virusrelated cardiac injury 22 . Cohorts of patients from three Chinese hospitals showed up to 36% of neurological symptoms 23,24 that included dizziness, headache, encephalopathy, anosmia, dysgeusia, muscle injury (detected by elevated creatine kinase) and stroke. The impact of Covid-19 on ischemic stroke management: from TIA to LVO. Current acute stroke management guidelines recommend designing and implementing public education programs focused on stroke systems, referring acute stroke patients to emergency care and evaluating risk factors for patients presenting with TIA 14 . Since AIS is a time-dependent disease and the treatment effectiveness is mainly related to timely access to the therapy 25, 26 , current guidelines state that emergency therapy should be administrated quickly avoiding unnecessary and potentially time-consuming procedures 14, 27 . Before COVID-19 outbreak, stroke guidelines have been universally accepted by clinicians involved in acute stroke 14 . On March 09 2020, the Italian Government imposed national quarantine, restricting movement of population except for necessity, work, and health circumstances, in response to the growing pandemic of COVID-19 in the country 28 . Although healthcare system resources have been shifted towards COVID-19 pandemic, both stroke inpatients and outpatients keep requiring high standard of care. In the face of Covid-19, the need to reduce the exposure of doctors and patients is vital, as is ensuring the continuity of care for those who need it. Because hospitals are filling up by infected patients and health workers may be asymptomatic carriers, low risk patients should be discouraged to refer to hospitals whenever possible. To make matters even worse, reports that as many as 100 health care workers at a single institution have to be quarantined at home because of exposure to Covid-19 have raised concern about workforce capacity 29 . Telehealth can be a valuable help to solve these problems. It allows patients who have non-Covid-19 issues to receive consultations without the risk of exposure and quarantined doctors to continue to provide care 30 . A pivotal strategy for virus spreading control is forward triage that is the categorization of patients before they arrive in the emergency department (ED). However, such a strategy needs to be integrated into the actual stroke system hub-and-spoke model 31 . To overcome such a difficult situation, software solutions are being used in some regional healthcare systems, playing a key role in this emergency. Telehealth allows transmission of radiological images and video-assisted neurological examination, preventing unnecessary centralization and supporting spoke decisions ( Table 1) . The aims of the coming weeks is encouraging the diffusion of telehealth system in stilllacking centers enrolling more patients in our patient portals 30 . Due to COVID-19 outbreak, self-presentation in emergency room (ER) is highly discouraged because of a potential risk of infection; highly suspected for infection or COVID-19 positive (COVID+) patients should be pre-triaged in a separate box. The approach to patients referred to ER should focus on early recognition of suspected COVID-19 positive cases that require immediate isolation and infection control measures. Current WHO guidelines suggest that once COVID-19 infection is suspected, control measures should be immediately implemented and public health officials notified. However, following current public health official guidelines only a minority of population has already been tested for SARS-CoV-2, mainly due to the reduced availability of these tests 32, 33 3. Potential exposure through attendance at events where COVID-19 cases have been reported. In suspected cases, the epidemiological link to a probable or confirmed case may have occurred within a 14-day period before the symptoms onset 34 . According to WHO"s criteria, we developed a risk stratification table to assess infective risk of patients referred to ER ( Table 2) . The WHO has warned that the severe shortage of the global supply of PPEcaused by rising demand, panic buying, and misuseis putting lives at risk from the novel coronavirus. Then, although clinicians involved in management of AIS patients are at risk of infection and require specific PPE (Table 3) , they are requested to optimize PPE use and to avoid useless waste 35 . Common hygienic habits such as washing hands with soap and water or alcohol-based hand rub before and after all patient interaction, contact with potentially infectious sources, and before putting on and upon removal of PPE, have to be put into practice. Neurovascular team should wear opportune disposable equipment ( Table 4 ). According to the AHA / ASA 14 , patients with suspected stroke need brain computed tomography (CT), computed-tomography angiography (CTA) and, in selected cases, computed tomography perfusion (CTP). It is highly recommended to have a CT room dedicated to intermediate-to-high risk or COVID+ patients ( Table 2) . This room should have a dedicated access route separated from the other areas of the radiology unit and must have, on the ground of the entrance, a cloth soaked in sodium hypochlorite. Two radiologic technologists (RT) should be employed for the CT scanning of patients with intermediate-to-high risk or COVID+ patients. One RT (RT 1 ) uses PPE to set up the patient on the CT table while the other RT (RT 2 ) operates on the CT console 37 (Table 4) . CT examination should be performed following a previously described procedure 37 : RT 1 and the accompanying medical doctor (MD), both equipped with adequate PPE, set up the patient on the CT table and then remove their contaminated PPE and put them into a dedicated garbage inside the room. Then, they leave the CT room. While RT 2 operate on the CT scan, RT 1 and MD wear a new pair of PPE and, once the examination is over, they transfer the patient from the CT table to the bed. In patients referred from spoke center for LVO, this step could be avoided and the patient could be directly transferred to the angio suite, if all these conditions are satisfied: patient"s arrival time within 6 hours from symptoms onset. radiological imaging acquired within the previous two hours at the spoke center; availability of a CT-capable angiograph to rule out hemorrhage; This indication comes from the idea that patients who arrive to the hub center (following the drip-and-ship model) within 7.3 hours of time last seen well, the repetition of the brain imaging before angiography could be unnecessary, but it is still debated 38 . However, in these epidemiological setting, we follow this more rapid approach. A special mention is required for acute stroke patients who are confused, aphasic or unable to provide information for a comprehensive COVID-19 screening. Although these patients should be treated as potentially infected, such an approach is hardly possible due to shortage of PPE. In these cases, an extension of the CT examination to the chest should be taken into consideration to exclude signs of interstitial pneumonia 39 . If pulmonary CT scan exclude signs of interstitial pneumonia, patients could be identified as low-risk and all the remaining procedure could be performed with class A precautions ( Table 2) . Conversely, if pulmonary CT scan shows signs of interstitial pneumonia, the patient should be considered as high risk and PPE should be used accordingly (Table 4 ). The angiography suite is the place where mechanical thrombectomy is performed. This procedure should be performed in an adequately ventilated room: natural ventilation with air flow of at least 160 L/s per patient or in negative-pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation 40 . Since mechanical thrombectomy may require patient intubation (that is classified as an aerosol-producing procedure), intermediate-to-high risk patients need airborne precautions 36, 41 and all healthcare workers must wear proper protection (Tables 4) . The access to the angio suite should be allowed only through one door ("Patient" in Figure 1 ); in front of this door, on the ground, a cloth soaked in sodium hypochlorite should be placed (CL in Figure 1 ). Both the ray tube and the detector should be covered with a single-use plastic coverage. In many hospitals, not all the medical devices required for mechanical thrombectomy are stored inside the angio suite: devices that are rarely used are kept in depots outside the room. Before patient arrival, the availability of the necessary devices should be checked. However, devices needed to do a mechanical thrombectomy can vary from case to case; therefore, it is not possible to foresee (and prepare) all the devices needed before starting the procedure and a behavioral model is needed to allow quick and safe access to all the necessary tools. Following the scheme illustrated in Figure 1 , we hypothesized a way of working that involves two nurses: N 1 and N 2 . N 1 is intended to be inside the angio suite, wearing appropriate PPE. When a device (D 1 ) is needed, N 1 wears a third pair of gloves and takes it from the cupboard; after delivering the material to the first operator, the third pair of gloves will be removed. If the requested device is in the depot (D 2 ), N 2 put it on a cart (C) placed outside the entrance door and N 1 repeats the above-mentioned procedure. At the end of the intervention, the undressing of the staff must take place inside the angio suite and near an exit door (preferably a different door from the one used for the patient"s exit) ("Staff" in Figure 1) ; near this door, a dedicated garbage (G) must be set up for the collection of contaminated waste. At the end of acute treatment, patient is admitted to a dedicated ward, according to clinical conditions and infective risk. In our hospital, to limit virus diffusion and provide adequate level of care, we have provided separate wards dedicated to COVID+ and non-COVID+ patients both for those who need intensive care and for those who need sub intensive care. A particular evaluation should be done for patients with extensive middle cerebral artery (MCA) territory infarct. MCA occlusion can produce a large brain injury and swelling that may increase intracranial pressure causing malignant brain edema and brain herniation [42] [43] [44] . Some studies demonstrated that early decompressive hemicraniectomy (DHC) in patients up to 60 years reduces mortality and improves functional outcome [45] [46] [47] [48] ; however, several surviving patients remain severely dependent [45] [46] [47] [48] and the ideal candidate for DHC and timing of DHC is still a matter of debate 49 . After COVID-19 outbreak, due to the shortage of intensive care units beds and the allocation of the intensive care resources 50 , DHC should be thoughtfully weighted on a case by case basis. Having regard to the rapid spreading of the COVID-19, many hospitals will soon have to develop internal protocols to deal with this emergency and to cope with the associated challenging circumstances. 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