Challenges of Stroke Treatment during the COVID-19 Pandemic

Abstract

The Corona Virus Disease 2019 (COVID-19) pandemic
is creating new challenges in treating acute ischemic
stroke with intravenous (IV) recombinant tissue plasmi‐
nogen activator (rt-PA) and mechanical thrombectomy
[1–4]. The time interval between symptom onset and
presentation to emergency department (ED) for stroke
patients has increased in some centers [1,4] Stroke neu‐
rologists must inquire about the presence of respiratory
symptoms, such as cough and dyspnea, before entering

patients’ rooms to determine their eligibility for IV rt-
PA. The reliability of acquiring an accurate history of

respiratory symptoms may be challenging in acute
stroke patients due to underlying aphasia and cognitive
deficits [1]. Family (who are not allowed to enter the
ED) are often not immediately available to provide rele‐
vant information by telephone about respiratory symp‐
toms which increases the risk for treating stroke neurol‐
ogists. An accurate assessment of respiratory symptoms
may identify COVID-19 infected patients and thereby
permit the stroke neurologist to use personal protective
equipment, including a particulate filtering mask. How‐
ever, additional delays may occur while ensuring appro‐
priate protection against transmission of COVID-19
infection [4]. Patients, who are fearful of infection, are
wearing face masks to the ED, which makes it more dif‐
ficult to communicate and identify neurological signs,
such as facial weakness and dysarthria while in the ED.
Another challenge is the rapid acquisition of magnetic
resonance imaging (MRI). For example, a middle-aged
man who presented to one of our hospitals with a minor
stroke, later suffered a middle cerebral artery (M1 seg‐
ment) occlusion while admitted in the hospital and
required a MRI because more than 24 hours had elapsed
since the onset of his symptoms. The patient who was in
the MRI before him was infected with COVID-19 and it
took 1 hour to disinfect the MRI scanner with ultraviolet
light. This disinfection protocol led to a delay in per‐
forming mechanical thrombectomy. Mobile computed
tomographic (CT) scanners capable of performing CT
angiography and CT perfusion and dedicated for

COVID-19 infected patients with acute stroke have been
suggested as a way of reducing the risk of contamination
to uninfected patients [4]. However, the expense and
logistics associated with acquiring additional MRI
machines makes it impossible for some hospitals to ded‐
icate a separate MRI scanner for COVID-19 infected
patients.
Other challenges include the need for a designated
angiography suite for patients with COVID-19 infection
in the event that infected patients require mechanical
thrombectomy. The designated monoplane machine in
one of our institutions is not the usual machine used for
performing mechanical thrombectomy and has larger
detectors for electrophysiology procedures that are more
difficult to maneuver around the patient’s head.
We have experienced a reduction in the volume of
patients with strokes in our ED, and this trend has been
observed both inside and outside United States [3,4]. We
suspect that many patients with minor but potentially
disabling symptoms such as hand weakness are reluctant
to come to hospitals because they fear being exposed to
hospitalized COVID-19 patients [1–4]. One patient in
our institution suffered a minor stroke and was advised
to go to an inpatient rehabilitation center because she
was considered at high risk for falls. However, she opted
instead to go home because she was afraid of acquiring
COVID-19 infection in a rehabilitation center. Stroke
patients frequently develop pneumonia and fever due to
aspiration which may pose challenges in differentiating
symptoms due to COVID-19 infection. Given the high
infectious potential of COVID-19, early and rapid iden‐
tification of infected patients is important.
However, hospitals have only a limited number of
COVID-19 screening tests available.
There are new challenges to nursing care of stroke
patients. Intensive care unit (ICU) nurses are often over‐
whelmed by taking care of patients with COVID-19
infection which requires a multistep process of putting

Vol. 11, No. 2, pp. 77–78. Published Jul, 2020.
All Rights Reserved by JVIN. Unauthorized reproduction of this article is prohibited
*Corresponding Author: Nicholas Tarlov MD, Community Memorial Hospital, Ventura, CA, USA. (000) 00000. tarlov@gmail.com.
Journal of Vascular and Interventional Neurology, Vol. 11

on and taking off personal protective equipment. The
time required to remove personal protective equipment
after leaving an isolation room to care for a stroke
patient in an adjacent ICU room makes it more difficult
to simultaneously attend to uninfected stroke patients.
The physical barriers in place to reduce transmission of
COVID-19 infection within the ICUs also result in hin‐
drances to care of stroke patients.