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      Call for Papers: Extracellular Vesicles: Broadening Horizons in Neurodegenerative Diseases

      Submit here by September 30, 2025

      About Neurodegenerative Diseases: 1.9 Impact Factor I 5.9 CiteScore I 0.648 Scimago Journal & Country Rank (SJR)

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      Stroke Care during the COVID-19 Pandemic: International Expert Panel Review

      review-article
      Author(s): a , * , b , c , d , e , f , g , h , i , j , k , l , m , n , o , p , q , r , s , t , u , v , w , x , y , z , A , B , C , D , E , F , G , H , I , J , K , L , M , N , O , P , Q , R , S , T , U , V , W
      Publication date (Electronic):
      Journal: Cerebrovascular Diseases (Basel, Switzerland)
      Publisher: S. Karger AG
      Keywords: Stroke, Coronavirus disease 2019, Management

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          Abstract

          Background

          Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions.

          Summary

          The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one.

          Key Messages

          Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

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          Most cited references118

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          Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

          Chaolin Huang, Yeming Wang, Xingwang Li … (2020)
          Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
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            Clinical Characteristics of Coronavirus Disease 2019 in China

            Wei-jie Guan, Zheng-yi Ni, Yu Hu … (2020)
            Abstract Background Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)
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              Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

              Fei Zhou, Ting Yu, Ronghui Du … (2020)
              Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
              Article 0 comments Cited 14082 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cerebrovasc Dis
                Journal ID (iso-abbrev): Cerebrovasc Dis
                Journal ID (publisher-id): CED
                Title: Cerebrovascular Diseases (Basel, Switzerland)
                Publisher: S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                ISSN (Print): 1015-9770
                ISSN (Electronic): 1421-9786
                Publication date (Electronic): 23 March 2021
                Pages: 1-17
                Affiliations
                [1] aRaffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore
                [2] bThe George Institute for Global Health, Camperdown, Washington, Australia
                [3] cDepartments of Neurology and Radiology, Massachusetts General Hospital, Harvard School of Medicine, Boston, Massachusetts, USA
                [4] dTakeda Pharmaceutical Co. Limited, Cambridge, Massachusetts, USA
                [5] eDepartment of Neurology, University Hospital Inselspital, Bern University, Bern, Switzerland
                [6] fDepartment of Radiology, Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
                [7] gInstituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
                [8] hDepartment of Neurology, Universidade Federal Fluminense (UFF), Niterói, Brazil
                [9] iSchool of Medicine, Universidad Espiritu Santo-Ecuador, Samborondón, Ecuador
                [10] jDepartment of Neurology, Saarland University Medical Centre, Homburg, Germany
                [11] kDepartment of Neurosurgery, Kohnan Hospital, Sendai, Japan
                [12] lDivision of Advanced Cerebrovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
                [13] mDepartment of Neurology, University of Kentucky, Lexington, Kentucky, USA
                [14] nDepartment of Neurology and Neurological Intensive Medicine, Munich Clinic gGmbH, Academic Teaching Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
                [15] oMedical School, The University of Western Australia, Perth, Washington, Australia
                [16] pMax-Planck-Institut für Neurologische Forschung, Cologne, Germany
                [17] qDepartment of Neurosciences, Neurology Service, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
                [18] rDepartment of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
                [19] sAsan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
                [20] tDepartment of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
                [21] uDepartment of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
                [22] vDepartment of Neurosurgery, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
                [23] wRutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
                [24] xDepartment of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
                [25] yDepartment of Neurology, University of California, Los Angeles, Los Angeles, California, USA
                [26] zLiverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
                [27] ADepartment of Clinical Medicine, Aalborg University, Aalborg, Denmark
                [28] BDepartment of Neurology, Universitätsmedizin Mannheim, Mannheim, Germany
                [29] CResearch Center of Neurology, Moscow, Russian Federation
                [30] DDepartment of Neurology, Janakpuri Super Speciality Hospital, New Delhi, India
                [31] ETananbaum Stroke Center, New York, New York, USA
                [32] FDepartment of Neurology, International University of Health and Welfare(IUHW), Graduate School of Medicine, Tokyo, Japan
                [33] GDepartment of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
                [34] HDepartment of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte, Germany
                [35] IAretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
                [36] JDepartment of Neurology, Interventional Neuroradiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
                [37] KDepartment of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
                [38] LDepartments of Internal Medicine and Geratology, John Radcliffe Hospital, Oxford, United Kingdom
                [39] MCentre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
                [40] NDepartment of Neurology, University of Kentucky, Lexington, Kentucky, USA
                [41] ODepartment of Neurosciences, Indraprastha Apollo Hospital, New Delhi, India
                [42] PDepartment of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, USA
                [43] QDepartment of Neurology, University Medicine, Greifswald, Germany
                [44] RTachikawa Hospital, Tokyo, Japan
                [45] SDepartment of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong, China
                [46] TDepartment of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
                [47] UDepartment of Neurology, University of Leipzig, Leipzig, Germany
                [48] VDepartment of Medicine, Aga Khan University, Karachi, Pakistan
                [49] WDepartment of Neurology, Medical Faculty, Mannheim University of Heidelberg, Mannheim, Germany
                Author notes
                *Narayanaswamy Venketasubramanian, Raffles Neuroscience Centre, Raffles Hospital, 585 North Bridge Road, Singapore 188770 (Singapore), drnvramani@ 123456gmail.com
                Article
                Publisher ID: ced-0001
                DOI: 10.1159/000514155
                PMC ID: 8089455
                PubMed ID: 33756459
                SO-VID: f0b099e7-51a3-4812-962c-171192128aee
                Copyright © Copyright © 2021 by S. Karger AG, Basel
                License:

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                Date received : 9 September 2020
                Date accepted : 16 December 2020
                Page count
                Figures: 3, References: 119, Pages: 17
                Categories
                Subject: Review

                ScienceOpen disciplines: Neurology
                Keywords: stroke,coronavirus disease 2019,management
                Data availability:
                ScienceOpen disciplines: Neurology
                Keywords: stroke, coronavirus disease 2019, management

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