key: cord-0787030-du9lzlji authors: Baracchini, C.; Pieroni, A.; Kneihsl, M.; Azevedo, E.; Diomedi, M.; Pascazio, L.; Wojczal, J.; Lucas, C.; Bartels, E.; Bornstein, NM.; Csiba, L.; Valdueza, J.; Tsvigoulis, G.; Malojcic, B. title: Practice recommendations for the neurovascular ultrasound investigations of acute stroke patients in the setting of COVID‐19 pandemic: an expert consensus from the European Society of Neurosonology and Cerebral Hemodynamics date: 2020-05-19 journal: Eur J Neurol DOI: 10.1111/ene.14334 sha: 630dbdbe55cc7c09fa7e4801c08ad2716b55bd5d doc_id: 787030 cord_uid: du9lzlji Since the COVID‐19 pandemic stormed into the healthcare systems worldwide, protected stroke pathways have been suggested, in order not to spread the viral infection and ensure hyper‐acute treatment. Noteworthy, patients with acute ischemic stroke are at high‐risk for contracting SARS‐CoV‐2 virus, particularly the severe form, because COVID‐19 and cerebrovascular diseases share common risk factors. Conversely, among patients hospitalized with SARS‐CoV‐2 respiratory distress, about 5% might suffer a stroke. During the acute stages of the pandemic, thousands of healthcare professionals have already contracted COVID‐19 infection, although the actual number is likely to be higher because healthcare workers are not always tested and protection measures at hospitals are not always readily available. This is the setting in which neurovascular ultrasound providers (physicians, sonographers) should expect to be involved in the care of stroke patients. Since the COVID-19 pandemic stormed into the healthcare systems worldwide, protected stroke pathways have been suggested, in order not to spread the viral infection and ensure hyper-acute treatment. [1] [2] Noteworthy, patients with acute ischemic stroke are at high-risk for contracting SARS-CoV-2 virus, particularly the severe form, because COVID-19 and cerebrovascular diseases share common risk factors. 3 Conversely, among patients hospitalized with SARS-CoV-2 respiratory distress, about 5% might suffer a stroke. 4 During the acute stages of the pandemic, thousands of healthcare professionals have already contracted COVID-19 infection, [5] [6] [7] although the actual number is likely to be higher because healthcare This article is protected by copyright. All rights reserved workers are not always tested and protection measures at hospitals are not always readily available. This is the setting in which neurovascular ultrasound providers (physicians, sonographers) should expect to be involved in the care of stroke patients. In light of this situation, effective safety and prevention strategies need to be implemented not only during the lockdown period, but especially afterwards when healthcare workers and patients will tend to let their guard down. Therefore, the European Society of Neurosonology and Cerebral Hemodynamics (ESNCH) is providing the following recommendations for the performance of neurovascular ultrasound investigations with the aim of protecting both patients and ultrasound providers. To develop this document, members of the "ultrasound in acute stroke working group" of the ESNCH examined literature articles and reviews using the following key words: "corona virus" or "COVID-19" or "SARS-CoV-2 virus", and "acute stroke" or "cerebrovascular disease", and "ultrasound". World Health Organization (WHO) and Center for Disease Control and Prevention (CDC) recommendations on COVID-19 pandemic were also consulted. After a thorough discussion with the "education and guidelines working group" of the ESNCH, a final consensus was reached (Table 1 and Figure 1 ). The successful care of COVID-19 positive or presumed positive stroke patients will depend also on these prevention strategies. 8 Field personnel should screen all patients for COVID-19 infection using standardized checklists of clinical signs and symptoms (i.e., fever, cough, chest pain, dyspnea, anosmia, ageusia, headache, myalgias, and gastrointestinal symptoms including vomiting and diarrhea) or history of close contact exposure with a COVID-positive patient, and immediately dispatch these data to the emergency operations center for preparedness. Stroke patients might not be able to provide a full history due to neurologic impairment; in this case, close relatives should be asked for clinical signs and symptoms, possible contacts with COVID-19 infected persons or risky social behaviour over the past two weeks. If the screening is positive or medical history is not available, patients should be considered as possibly COVID-19 infected. For safety reasons, a COVID-19 known positive or presumed positive patient should wear a surgical mask, while healthcare providers should use appropriate protection according to COVID status (see below). Furthermore, clinically-oriented extracranial and intracranial ultrasound evaluation, if available, should be performed during transport to reveal large vessel occlusion (LVO) strokes and indicate the most suitable destination for the patient. 9-10 Eligibility for hyper-acute therapies is not modified by the COVID-19 pandemic, consequently current guidelines should be implemented [11] [12] as a denial of these therapies might increase the social burden of stroke, creating also a greater drain on healthcare resources. 13 This article is protected by copyright. All rights reserved If resources are available, all stroke patients should undergo a fast track COVID-19 nasopharyngeal test in order to prevent in-hospital transmission and indicate the most appropriate safety measures for ultrasound providers. As the sensitivity of nasopharyngeal swabs is about 70%, the ESNCH recommends wearing standard personal protective equipment (PPE): surgical mask, latex-free disposable gloves and a disposable gown. Before and after direct patient contact, appropriate hand hygiene, even with a sanitizer, is imperative. Since many patients who undergo neurovascular ultrasound will be COVID-19-positive or presumed positive in the current environment, effective cleaning of ultrasound equipment is compulsory. This article is protected by copyright. All rights reserved Transducers and ultrasound equipment must be cleaned with a compatible disinfectant after each patient, also in accordance with local guidelines. For external procedures, such as extracranial and intracranial ultrasound, low-level disinfection (LLD) is effective in agreement with CDC guidelines. 15 Common LLD agents include quaternary ammonium compounds, alcohols, and phenols available as sprays and disinfectant wipes. Ultrasound providers should ensure that the chosen LLD method is compatible with the transducer; for example, alcohols are often contraindicated due to material incompatibility. If LLD agents are depleted, soap and water are a valid alternative. Noteworthy, external transducers that come into contact with contaminated skin, such as skin infections, should be covered with a single-use transducer cover. If transducer covers are not available, medical gloves or other physical barriers as compatible medical dressings should be used. If the transducer comes in contact with mucous membranes or any body fluids, or a transducer cover is required and becomes compromised, the transducer must undergo high-level disinfection (HLD). HLD agents include hydrogen peroxide, hypochlorite/hypochlorous acid, glutaraldehyde, peracetic acid, phenol/phenolate, chlorhexidine gluconate. 16 At the end of the day, the ultrasound room should also undergo appropriate cleaning and disinfection. For hospitals with multiple neurovascular ultrasound laboratories, it is recommended to have one laboratory designated as a 'COVID room', stocked with enhanced PPE to minimize risk and with at least one dedicated ultrasound machine for COVID-19-positive or presumed positive patients, since COVID-19 can survive on plastic surfaces for up to 72 hours. 17 Concerning post-thrombectomy ultrasound monitoring, [18] [19] [20] [21] if possible, a room adjacent to the angiography suite should be designated for this purpose, to minimize exposure of any at-risk group of patients to potential COVID-19 contact in the hospital environment. Data sharing is not applicable to this article as no new data were created or analyzed in this study. 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All rights reserved 12 Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee Relationship between functional disability and costs one and two years post stroke Yield and accuracy of urgent combined carotid/transcranial ultrasound testing in acute cerebral ischemia Disinfectants for Use Against SARS-CoV-2 Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Diagnostic criteria and yield of real-time transcranial Doppler monitoring of intra-arterial reperfusion procedures Increased middle cerebral artery mean blood flow velocity index after stroke thrombectomy indicates increased risk for intracranial hemorrhage Early hemodynamic predictors of good outcome and reperfusion injury after endovascular treatment Microemboli After Successful Thrombectomy Do Not Affect Outcome but Predict New Embolic Events This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved  All stroke patients should undergo a fast track COVID-19 nasopharyngeal test.  the ESNCH recommends that all ultrasound providers wear standard PPE: surgical mask, latex-free disposable gloves and a disposable gown.