440 https://doi.org/10.1590/0004-282X20200053 VIEW AND REVIEW Management of acute stroke and urgent neurointerventional procedures during COVID-19 pandemic: recommendations on the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, Brazilian Society of Cerebrovascular Diseases and Brazilian Society of Neuroradiology Tratamento do acidente vascular cerebral agudo e realização de procedimentos de neurointervenção urgentes durante a pandemia de COVID-19: recomendações do Departamento Científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia, Sociedade Brasileira de Doenças Cerebrovasculares e Sociedade Brasileira de Neurorradiologia Francisco José Arruda MONT’ALVERNE1, Fabrício Oliveira LIMA2, Raul Gomes NOGUEIRA3, Carlos Clayton Macedo de FREITAS4, Octávio Marques Pontes NETO5, Gisele Sampaio SILVA6, Maura Salaroli de OLIVEIRA7, Michel FRUDIT8, Jose Guilherme Mendes Pereira CALDAS9, Daniel Giansante ABUD10, Adriana Bastos CONFORTO11, Fernanda Martins Maia CARVALHO12, Francisco Antunes DIAS5, Rodrigo BAZAN13, Wagner Mauad AVELAR14, Carla Heloísa Cabral MORO15, Pedro Silva Correa de MAGALHÃES15, Maramelia MIRANDA16, Leandro de Assis BARBOSA17, José Antonio FIOROT JUNIOR18, Fabrício Buchdid CARDOSO2, Leticia Costa REBELLO19, Bruno de Sousa Mendes PARENTE19, Mário de Barros FARIA20, Gabriel Rodriguez de FREITAS21, Viviane de Hiroki Flumignan ZÉTOLA22, Jamary OLIVEIRA-FILHO23, Daniel da Cruz BEZERRA24, Jorge Luis Nobre RODRIGUES25, Gustavo KUSTER26, Sheila MARTINS27, João José Freitas de CARVALHO2 1Hospital Geral de Fortaleza, Departamento de Neurorradiologia Intervencionista, Fortaleza CE, Brazil. 2Hospital Geral de Fortaleza, Unidade de AVC, Fortaleza CE, Brazil. 3Emory University School of Medicine, Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, United States. 4Universidade Estadual Paulista “Júlio de Mesquita Filho”, Faculdade de Medicina de Botucatu, Departamento de Neurologia e Psiquiatria, Botucatu SP, Brazil. 5Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Ribeirão Preto SP, Brazil. 6Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo SP, Brazil. 7Universidade de São Paulo, Departamento de Doenças Infecciosas, São Paulo SP, Brazil. 8Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neuroradiologia Intervencionista, São Paulo SP, Brazil. 9Universidade de São Paulo, Faculdade de Medicina, Departamento de Neuroradiologia Intervencionista, São Paulo SP, Brazil. 10Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Ribeirão Preto SP, Brazil. 11Universidade de São Paulo, Hospital das Clínicas, Divisão de Neurologia Clínica, São Paulo SP, Brazil. 12Universidade de Fortaleza, Curso de Medicina, Programa de Pós-Graduação em Ciências Médicas, Fortaleza CE, Brazil. 13Universidade Estadual Paulista, Campus de Botucatu, Departamento de Neurologia, Botucatu SP, Brazil. 14Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil. 15Hospital Municipal de Joinville, Neurológica, Joinville SC, Brazil. 16Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil. 17Hospital Estadual Central de Vitória, Departamento de Neuroradiologia Intervencionista, Vitória ES, Brazil. 18Hospital Estadual Central de Vitória, Departamento de Neurologia, Vitória ES, Brazil. 19Instituto Hospital de Base do Distrito Federal, Departamento de Neuroradiologia, Brasília DF, Brazil. 20Universidade Federal do Rio Grande do Sul, Hospital de Clínicas, Departamento de Neuroradiologia Intervencionista, Porto Alegre RS, Brazil. 21Universidade Federal Fluminense, Departamento de Neurologia, Niterói RJ, Brazil. 22Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil. 23Universidade Federal da Bahia, Serviço de Neurologia, Salvador BA, Brazil. 24Hospital Pro-Cardíaco, Departamento de Neurologia, Rio de Janeiro RJ, Brazil. 25Universidade Federal do Ceará, Departamento de Doenças Infecciosas, Fortaleza CE, Brazil. 26United Health Group, National Neurology Board, São Paulo SP, Brazil. 27Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil. Francisco José Arruda MONT’ALVERNE https://orcid.org/0000-0002-1761-2674; Fabrício Oliveira LIMA https://orcid.org/0000-0002-0383-4145; Raul Gomes NOGUEIRA https://orcid.org/0000-0003-4532-153X; Carlos Clayton Macedo de FREITAS https://orcid.org/0000-0001-5210-4336; Octávio Marques Pontes NETO https://orcid.org/0000-0003-0317-843X; Gisele Sampaio SILVA https://orcid.org/0000-0002-3247-3123; Maura Salaroli de OLIVEIRA https://orcid.org/0000-0001-8508-2612; Michel FRUDIT https://orcid.org/0000-0003-3882-0226; Jose Guilherme Mendes Pereira CALDAS https://orcid.org/0000-0002-1916-7121; Daniel Giansante ABUD https://orcid.org/0000-0002-9648-3195; Adriana Bastos CONFORTO https://orcid.org/0000-0001-7869-3490; Fernanda Martins Maia CARVALHO https://orcid.org/0000-0001-6548-7268; Francisco Antunes DIAS https://orcid.org/0000-0003-1932-4550; Rodrigo BAZAN https://orcid.org/0000-0003-3872-308X; Wagner Mauad AVELAR https://orcid.org/0000-0002-0025-4225; Carla Heloísa Cabral MORO https://orcid.org/0000-0001-6346-939X; Pedro Silva Correa de MAGALHÃES https://orcid.org/0000-0001-7297-1381; Maramelia MIRANDA https://orcid.org/0000-0002-8284-1991; Leandro de Assis BARBOSA https://orcid.org/0000-0002-9762-1078; José Antonio FIOROT JUNIOR https://orcid.org/0000-0001-6894-8517; Fabrício Buchdid CARDOSO https://orcid.org/0000-0001-6185-4622; Leticia Costa REBELLO https://orcid.org/0000-0002-7254-6710; Bruno de Sousa Mendes PARENTE https://orcid.org/0000-0002-7182-9276; Mário de Barros FARIA https://orcid.org/0000-0003-0175-7905; Gabriel Rodriguez de FREITAS https://orcid.org/0000-0003-3178-0460; Viviane de Hiroki Flumignan ZÉTOLA https://orcid.org/0000-0001-8464-9488; Jamary OLIVEIRA-FILHO https://orcid.org/0000-0003-1915-0423; Daniel da Cruz BEZERRA https://orcid.org/0000-0002-2530-4970; Jorge Luis Nobre RODRIGUES https://orcid.org/0000-0001-6836-4327; Gustavo KUSTER https://orcid.org/0000-0002-2203-9024; Sheila MARTINS https://orcid.org/0000-0002-8452-712X; João José Freitas de CARVALHO https://orcid.org/0000-0002-1070-5552 Correspondence: João José Freitas de Carvalho; E-mail: jjcarvalho@gmail.com Conflict of interest: There is no conflict of interest to declare. Received on May 3, 2020; Received in its final form on May 12, 2020; Accepted on May 13, 2020. https://doi.org/10.1590/0004-282X20200053 https://orcid.org/0000-0002-1761-2674 https://orcid.org/0000-0002-0383-4145 https://orcid.org/0000-0003-4532-153X https://orcid.org/0000-0001-5210-4336 https://orcid.org/0000-0003-0317-843X https://orcid.org/0000-0002-3247-3123 https://orcid.org/0000-0001-8508-2612 https://orcid.org/0000-0003-3882-0226 https://orcid.org/0000-0002-1916-7121 https://orcid.org/0000-0002-9648-3195 https://orcid.org/0000-0001-7869-3490 https://orcid.org/0000-0001-6548-7268 https://orcid.org/0000-0003-1932-4550 https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100233&lng=en&nrm=iso&tlng=en https://orcid.org/0000-0002-0025-4225 https://orcid.org/0000-0001-6346-939X https://orcid.org/0000-0001-7297-1381 https://orcid.org/0000-0002-8284-1991 https://orcid.org/0000-0002-9762-1078 https://orcid.org/0000-0001-6894-8517 https://orcid.org/0000-0001-6185-4622 https://orcid.org/0000-0002-7254-6710 https://orcid.org/0000-0002-7182-9276 https://orcid.org/0000-0003-0175-7905 https://orcid.org/0000-0003-3178-0460 https://orcid.org/0000-0001-8464-9488 https://orcid.org/0000-0003-1915-0423 https://orcid.org/0000-0002-2530-4970 https://orcid.org/0000-0001-6836-4327 https://orcid.org/0000-0002-2203-9024 https://orcid.org/0000-0002-8452-712X https://orcid.org/0000-0002-1070-5552 mailto:jjcarvalho@gmail.com 441Mont’Alverne FJA et al. Acute stroke and neurointervention in COVID-19 INTRODUCTION The recent outbreak caused by the severe acute respi- ratory syndrome coronavirus 2 infection (SARS-CoV-2) and its high transmission rates resulted in a situation that was officially declared as pandemic by the World Health Organization (WHO) on March 11, 20201. Presently, there have been over 3 million confirmed cases and over 200,000 deaths from SARS-CoV-2 Coronavirus Disease 2019 (COVID- 19) worldwide1. According to the Brazilian Department of Health, the first case of COVID-19 in Brazil was confirmed on February 26, 2020, and reached the community transmis- sion stage on March 20, 2020. The epidemic peak in Brazil has been estimated for late April and early May 20202. All regions of Brazil have been affected, leading to new challenges to ensure adequate care for suspected or con- firmed cases of COVID-19 and the safety of health profession- als and other patients, reducing their exposure to the risk of infection and safeguarding the care of other potentially life- threatening conditions2. While the pandemic poses new challenges to the health- care system to provide support for thousands of COVID- 19 cases (often requiring hospitalization and intensive care admission), common medical emergencies, such as stroke, should also be considered, because they will continue to occur and require adequate treatment. The allocation of both material and human resources to fight the pandemic cannot overshadow the care for those time-sensitive emergencies, because in the event of inefficient treatment, they will further increase mortality, long-term disability, and costs. ABSTRACT Introduction: Although the 2019 severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2, COVID-19) pandemic poses new challenges to the healthcare system to provide support for thousands of patients, there is special concern about common medical emergencies, such as stroke, that will continue to occur and will require adequate treatment. The allocation of both material and human resources to fight the pandemic cannot overshadow the care for acute stroke, a time-sensitive emergency that with an inefficient treatment will further increase mortality and long-term disability. Objective: This paper summarizes the recommendations from the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Society of Cerebrovascular Diseases and the Brazilian Society of Neuroradiology for management of acute stroke and urgent neuro-interventional procedures during the COVID-19 pandemic, including proper use of screening tools, personal protective equipment (for patients and health professionals), and patient allocation. Keywords: neurointerventional treatment; coronavirus infections; stroke. RESUMO Introdução: A pandemia causada pelo novo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2, COVID-19) apresenta novos e importantes desafios à gestão de saúde no Brasil. Além da difícil missão de prestar atendimento aos milhares de pacientes infectados pelo COVID-19, os sistemas de saúde têm que manter a assistência às emergências médicas comuns em períodos sem pandemia, tais como o acidente vascular cerebral (AVC), que continuam ocorrendo e requerem tratamento com presteza e eficiência. A alocação de recursos materiais e humanos para o enfrentamento à pandemia não pode comprometer o atendimento ao AVC agudo, uma emergência cujo tratamento é tempo-dependente e se não realizado implica em importante impacto na mortalidade e incapacitação a longo prazo. Objetivo: Este trabalho resume as recomendações do Departamento Científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia, da Sociedade Brasileira de Doenças Cerebrovasculares e da Sociedade Brasileira de Neurorradiologia para o tratamento do AVC agudo e para a realização de procedimentos de neurointervenção urgentes durante a pandemia de COVID-19, incluindo o uso adequado de ferramentas de triagem e equipamentos de proteção pessoal (para pacientes e profissionais de saúde), além da alocação apropriada de pacientes. Palavras-chave: neurointervenção; infecções por coronavirus; acidente vascular cerebral. Although we have few data to develop a robust and con- sistent guideline and acknowledging that recommendations may need to be adapted according to the pandemic evolu- tion and each healthcare facility specificities, the purpose of this expert joint consensus of the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Society of Cerebrovascular Diseases and The Brazilian Society of Neuroradiology is to provide an organization framework for acute stroke patients’ healthcare and those who require urgent neuro-interventional proce- dures in the COVID-19 pandemic setting. COVID-19 AND THE NERVOUS SYSTEM Typical symptoms of COVID-19 ( fever, cough, sore throat, dyspnea, anorexia, nausea, vomiting, diarrhea, abdominal pain) have been well described in the literature, and neu- rological symptoms may be seen in about one-third of the cases3,4,5,6,7. Neurologic involvement may be presented as cen- tral nervous system manifestations (dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system manifesta- tions (anosmia, ageusia, vision impairment, nerve pain, and Guillain Barré Syndrome), and myopathies3,4,5,6,8. Focal neurological deficits due to cerebrovascular dis- ease are less frequent (2.8%) in the course of COVID-19, but they might occur more often amongst those who develop a more severe form of the disease (5.7%)5. However, they can be an initial manifestation of the disease, and early 442 Arq Neuropsiquiatr 2020;78(7):440-449 recognition of infection will significantly impact the line of care of these patients conciliating healthcare profession- al’s protection and proper treatment strategies, especially in time-sensitive therapies like reperfusion for acute isch- emic stroke3,4,5,6. COVID-19 might increase the risk of cerebrovascular disease by several mechanisms. It may predispose to both venous and arterial thromboembolic disease due to exces- sive inflammation, hypoxia, immobilization, and dissemi- nated intravascular coagulation. The serum D-dimer level is generally increased, which could be a marker of embolic vascular events9. Despite systematic thrombosis prophy- laxis, the incidence of thrombotic complications in intensive care unit (ICU) patients with COVID-19 was remarkably high (31%) in one report10. Middle East Respiratory Syndrome (MERS- CoV) can cause acute myocarditis and heart failure, and since COVID-19 has a similar pathogenicity may also predispose to brain embolism from cardiac sources11. PATIENT CARE IN THE ISCHEMIC STROKE ACUTE PHASE Triage Patient-specific considerations should be balanced in conjunction with the safety of healthcare professionals who are engaged in the triage, assessment, and treatment of patients during the acute stroke phase. Besides the cur- rent screening and triage for stroke, healthcare professionals should further examine the COVID-19 pandemic and include an infection control screen, which should check for recent signs and symptoms listed in Table 13,5. As community trans- mission started to be established, screening for recent trips became irrelevant. However, history of contact with a con- firmed case during the previous 14 days might be beneficial for screening COVID-19 infected individuals, especially in areas with a limited number of infected subjects. This rec- ommended screening may not always be feasible as patients may not be able to communicate reliably due to stroke symp- toms (such as aphasia, severe dysarthria, and decreased level of consciousness), and family members may not be on the scene. In such cases, we recommend proceeding with usual COVID-19 safety precautions until the screening can be reliably completed or infection is excluded by formal test- ing. Screening should be completed during the emergency department (ED) stay using all available sources of informa- tion (including telephone contact) to provide the adequate patient transfer. Patients might be admitted as a spontaneous demand or as a referral from other centers, requiring a reliable triage per- formed upfront by pre-hospital healthcare professionals and the hospital triage staff. Communication across sites before patient transfer and consistent implementation of local screening protocols are paramount. Ideally, every stroke patient admitted should be tested for COVID-19 through the reverse transcription poly- merase chain reaction (RT-PCR) or rapid serological tests. However,  considering the limitation of tests in under- resourced countries, only symptomatic cases have been tested. It is noteworthy that massive testing has not been feasible in our reality, so there is a high proportion of asymp- tomatic patients or patients with seasonal flu-like symptoms who have been infected by SARS-CoV-2. Recent data esti- mate that the percentage of pre-symptomatic transmission ranged from 46 to 55%, and infectiousness peaks at zero to two days before symptom onset12,13. Consequently, the pro- posed screening is not able to effectively exclude COVID- 19, and protective measures are advisable for every stroke patient. Furthermore, the triage, as mentioned (Table 1, Figure 1), may be useful to guide patient transfer to the most appropriate clinical unit (COVID unit or stroke/ICU). Protected code stroke Code stroke is a well-known term used to prioritize hyperacute assessment and care of patients with a suspected stroke. The word ‘code’ promotes efficient multi-player, tiered communication among healthcare professionals setting up a process of measured urgent actions during the hyperacute management of a patient with stroke signs and symptoms14. In the COVID-19 pandemic, code stroke (along with similar medical emergencies) is being modified to the protected des- ignation (Protected Code Stroke — PCS) to provide an extra layer of protection for healthcare professionals and patients. The appropriate use of personal protective equipment (PPE) by all team members is essential in the PCS. After com- munity transmission, routine PCS should include contact and droplet precautions for all patients. Proper protection requires a full-sleeved gown, eye protection ( face shield), gloves, and head covering (Table 2). Since aerosol-generating events might occur in acute stroke, we recommend the use of N95 or KN95 face masks for all stroke team members directly involved in patient’s care at the ED. Aerosol-generating medical procedures during a code stroke include oropharyngeal/nasal (open) suctioning, bag- valve-mask ventilation, nebulization, high flow oxygen masks, Table 1. Initial infectious screening for COVID-19 infection. Potential indicators of COVID-19 infection Common initial symptoms of COVID-19 Fever Headache Cough/Sneezing Anorexia/Adynamia/Myalgias Sore throat Gastrointestinal symptoms (including vomiting and diarrhea). Chest pain Anosmia Dyspnea Ageusia Contact with a confirmed case during the previous 14 days* *: areas with a limited number of infected subjects. 443Mont’Alverne FJA et al. Acute stroke and neurointervention in COVID-19 and noninvasive positive pressure ventilation. As such, these events should be avoided or minimized as much as possi- ble. Highly aerosol-generating procedures, such as intuba- tion and chest compressions, should be performed in the appropriate setting according to local/regional protocols15. Placement of a surgical mask in non-intubated patients is also recommended16. After initial triage, patients should be referred to the most appropriate location in the ED (ED of COVID unit or regular ED) for urgent neurological assessment, laboratory collection (including rapid serological tests or RT-PCR), and early stabilization. When patients present signs of respiratory dis- tress, are obtunded or require high fractions of oxygen (FiO2>0.5), we recommend early consultation with an emergency care or intensive care physician for proper airway management. High flow oxygen masks and non- invasive positive pressure ventilation should be avoided; therefore, early orotracheal intubation should be consid- ered for those patients. Figure 1. Protected Code Stroke during the COVID-19 pandemic (flowchart). REFER COVID UNIT (ELECTIVE) + Surgical mask for patient + NEUROLOGY TEAM* (labs; include COVID-19 rapid test /RT- PCR)) NO PRE-HOSPITAL ASSESSMENT (SAMU) AND HOSPITAL TRIAGE • ACTIVE checking of symptoms compatible with COVID-19 in ALL PATIENTS SYMPTONS COMPATIBLE WITH COVID-19 (ANY NEW SYMPTONS WITHIN 14 days) • Cough OR Fever OR Dyspnea OR Sore throat • Anosmia (loss of smell) OU Ageusia (loss of taste) with acute onset • Vomiting OR other Gastrointestinal symptoms Suspected Stroke YES SYMPTOMS COMPATIBLE WITH COVID-19 OR CONTACT WITH CONFIRMED CASE IN THE LAST 14 DAYS? ACUTE STROKE (LSW < 24 hours)? YES NO CLINICAL STABILIZATION PERFORM Non-contrast head CT + High resolution Thorax CT PERFORM Stroke Protocol - Management COVID UNIT SIGNS OF RESPIRATORY DISTRESS? YES • Nasal cannula oxygen up to 6l/min if Sat O2 < 94%) or face mask with reservoir bag • Avoid non-invasive ventilation or Venturi mask • Consider early Orotracheal intubation (OTI) NO FOLLOW USUAL INSTITUTIONAL STROKE PROTOCOL* + Surgical mask for patient REFER TO COVID UNIT Emergency Department + Surgical mask for patient + PROTECTED CODE STROKE (Neurology Team*, labs; include COVID-19 rapid test /RT- PCR) ELIGLBLE FOR IV rt-PA? PERFORM Intravenous rt-PA rt-PA 0,9 mg/kg (10% bolus and remainder in 1h) YES PERFORM Head and Neck Angio-CT ± CT-perfusion ELIGIBLE FOR MECHANICAL THROMBECTOMY? Proper Donning + PERFORM Mechanical Thrombectomy Favor OTI in case of early sings of respiratory distress *PPE: surgical mask (in case of aerosolization of secretions use N95), surgical cap, gloves, gown, face shield. Proper Doffing REFER * Appropriate COVID UNIT based on clinical history, signs and lab results CLINICAL STABILIZATION YES Figure 1. Protected Code Stroke during the COVID-19 pandemic (flowchart). 444 Arq Neuropsiquiatr 2020;78(7):440-449 The COVID-19 should not change the indications for acute ischemic stroke reperfusion therapies. In patients eli- gible for IV thrombolysis and/or mechanical thrombectomy, usual care should be taken following local/regional proto- cols17,18. An individual with COVID-19 can be asymptomatic, but be a significant source of infection13,14,15. Clinical settings Emergency Room Scenarios Staff in the room (e.g. neurologist, nurse) Suspected/confirmed COVID-19 patient OR Asymptomatic patients in whom an aerosol-generating procedurea will be performed (open suctioning of airways, manual ventilation, intubation, among others) N95 Face shield Non-sterile, disposable, full-sleeved isolation gown Two pairs of gloves Surgical cap Shoe covers Asymptomatic patients in whom an aerosol-generatinga procedure will NOT be performed Surgical maskb Goggles or face shield Sterile, disposable, full-sleeved isolation gown One pair of gloves Surgical cap Shoe covers Angiographic Suite Scenarios Staff in the room (e.g. anesthesiologist, neuroradiologist, nurse) Suspected/confirmed COVID-19 patient OR Asymptomatic patients that will undergo a neurointerventional procedure under general anesthesia or an aerosol-generating procedurea (e.g. open suctioning of airways, manual ventilation) N95 Face shield Sterile, disposable, full-sleeved waterproof gown 02 pairs of gloves Surgical cap Shoe covers Asymptomatic patients that will undergo a neurointerventional procedure, but an aerosol- generating procedurea will NOT be performed Surgical maskb Goggles or face shield Sterile, disposable, full-sleeved isolation gown One pair of gloves Surgical cap Shoe covers Stroke Unit Scenarios Staff in the room (e.g. neurologist, nurse, physiotherapist) Suspected/confirmed COVID-19 patient OR Asymptomatic patients in whom aerosol-generating procedurea will be performed (open suctioning of airways, manual ventilation, intubation) N95 Face shield Non-sterile, disposable, full-sleeved isolation gown Two pairs of gloves Surgical cap Shoe covers Asymptomatic patients in whom an aerosol-generating procedurea will NOT be performed Surgical maskb Face shield Sterile, disposable, full-sleeved isolation gown One pair of gloves Surgical cap Shoe covers Table 2. Personal protective equipment for the assistance of patients with stroke and confirmed/suspected cases of COVID-19. aProcedures at high risk for generating aerosol: tracheal intubation (OR=6.6 (2.3, 18.9); 39.6%), manual ventilation before intubation (OR=2.8 (1.3, 6.4), manipulation of oxygen mask (OR=4.6 (0.6, 32.5); 64.8%), non-invasive ventilation (OR=3.1 (1.4, 6.8); 0%), defibrillation (OR=2.5 (0.1, 43.9); 55.3%), suction before intubation (OR=3.5 (0.5, 24.6); 59.2%), collection of sputum sample (OR=2.7 (0.9, 8.2), manipulation of BiPAP mask (OR=6.2 (2.2, 18.1), chest compressions (one case-control study) 4.5 (1.5, 13.8). For further details: Tran et al.15. bIt is reasonable to always use a N95 mask in areas of high incidence of COVID-19. 445Mont’Alverne FJA et al. Acute stroke and neurointervention in COVID-19 Changes in high-resolution chest computed tomography (HRCCT) before viral symptoms can be detected in about 20% of the patients16. Thus, a HRCCT may be recommended after an initial non-contrast head computed tomography (NCCT) assessment for patients with a suspected stroke. Nonetheless, the feasibility of this recommendation should be assessed by each institution, weighing the availability of resources and the potential risk of silent COVID-19 spread- ers. In the event of a positive HRCCT, the patient should be considered a suspected case of COVID-19 infection, and the appropriate protocol should be followed19. The  HRCCT findings will be more frequent in the intermediate (three to six days) and late ( from seven days) phases from symp- toms onset17. If the HRCCT is negative, COVID-19 cannot be excluded, particularly in pre-symptomatic and early phases, but it may help to guide the transfer of the patient to an appropriate unit (COVID or non-COVID units). Definition criteria for COVID-19 disease According to the WHO, a COVID-19 case may be defined as suspected, probable, or confirmed (Table 3)20. For acute stroke management, the decision-making process should be very expeditious, but sometimes a full triage is not feasible. Therefore, we adapted the WHO classification, and patients should be considered at low risk for COVID-19 infection if the screening for COVID-19 is negative (Table 1). Patients should be considered a suspected case of COVID-19 in case of: • Positive screening for COVID-19 (Table 1). • HRCCT with findings compatible with COVID-19. • Inability to answer COVID-19 screening questions, due to neurological impairment of patients (e.g. coma, aphasia) or in case of non-availability of family members. Patients should be considered a possible case of COVID-19 if: • A suspect case in which the COVID-19 virus testing is inconclusive (description of “inconclusive” reported by the laboratory). • A suspect case in which the testing could not be per- formed for whatsoever reason. Patients should be considered a confirmed case of COVID-19 infection if: • A RT- PCR for COVID-19 was positive in less than 21 days after the onset of symptoms (or laboratory confirmation for asymptomatic patients), which is considered the gold standard method of diagnosis in clinical practice3. • A serological test for COVID-19 is positive less than 21 days after the onset of symptoms (or laboratory confir- mation for asymptomatic patients). Medical management of acute ischemic stroke in COVID-19 patients Patients with transient ischemic attack that do not nec- essarily require hospital admission may be appropriately managed at an outpatient level if the appropriate etiological investigation and secondary prevention can be performed in a timely fashion. Careful assessment needs to balance the risk/benefit ratio21. Patient evaluation with extended acute CT angiography protocols (angio-CT), including great vessels and cardiac CT, might help to expedite the assessment of stroke etiology and decrease the risk of infections associated with additional in-hospitals transfers for exams, such as carotid ultrasonog- raphy and echocardiography22. However, based on current evidence, cardiac CT is not routinely recommended for the evaluation of intracardiac structures in stroke patients. It is noteworthy that the appropriate use of PPE by all team members (including stroke unit/ICU physicians, nurs- ing staff, physical therapists, and speech therapists) involved in patient care is critical (Table 2). Table 3. World Health Organization definition criteria for the COVID-19 disease. Suspected case Scenario 1 A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath, AND a history of travel to or residence in a location reported community transmission of COVID-19 disease during the 14 days prior to symptom onset. Scenario 2 A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case (see definition of contact) in the last 14 days prior to symptom onset. Scenario 3 A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath, AND requiring hospitalization, AND in the absence of an alternative diagnosis that fully explains the clinical presentation. Probable case Scenario 1 A suspect case for whom testing for the COVID-19 virus is inconclusive. Inconclusive is the test result reported by the laboratory. Scenario 2 A suspect case for whom testing could not be performed for any reason. Confirmed case Scenario 1 A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms. 446 Arq Neuropsiquiatr 2020;78(7):440-449 Stroke telemedicine Telemedicine has a great potential for triage and man- agement of stroke patients during the COVID-10 pandemic, and its implementation at a pre-hospital and outpatient level should be encouraged. Stroke teleconsultations might spare the use of PPE, avoid unnecessary inter-facility transfers, and reduce exposure risk for the stroke team21. The current avail- able evidence supports the use of a modified neurological examination and reliable National Institutes of Health Stroke Scale (NIHSS) assessment using telemedicine23,24. A low-cost smartphone-based teleconsultation system for acute stroke has been validated in Brazil25. NEUROINTERVENTION PROCEDURES DURING THE PANDEMIC Mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion is a well-established pro- cedure for the early and late time window26,27,28. COVID-19 should not modify inclusion and exclusion criteria for endo- vascular reperfusion. As a time-sensitive procedure, MT pro- tocols should be reorganized to minimize the exposure risk of patients and healthcare professionals, but without com- promising the speed of evaluation and treatment. The neurointervention team should define if the pro- cedure is elective (e.g. unruptured cerebral aneurysm) or urgent, considering the risks/benefits of the procedure in relation to the likelihood of contamination and/or activation of the viral infection in asymptomatic individuals. It is a con- sensus among several Societies and Organizations, such as WHO, American College of Surgeons, Society of Vascular and Interventional Neurology, Society of Neurointerventional Surgery, French Society of Neuroradiology, Brazilian College of Surgeons, National Agency for Supplementary Health Service and the Brazilian Department of Health, that elec- tive surgeries should be temporarily postponed during the COVID-19 pandemic, concentrating material resources, spe- cialized teams, and ICU beds for the most severe cases8-12. There are only a few articles regarding elective surgery with COVID-19 related complications in asymptomatic patients29. Lei et al. reported 34 patients that underwent different surgeries, of whom 15 (44.1%) developed respira- tory insufficiency requiring intensive care assistance and 7 (20.5%) died30. In such retrospective report, the authors attri- bute the decreased cell-mediated immunological response to surgical stress, leading to accelerated viral replication, as demonstrated by the shorter incubation time of the disease (average of 2.5 days). Older age, prolonged surgical time, pro- cedure complexity, high blood pressure, diabetes, and cardiac disease were associated with a worse prognosis. On the other hand, an elective procedure can evolve into an emergency, depending on the type of vascular brain lesion and waiting time. Physicians are responsible for deciding the most appropriate moment for intervention. According to the National Agency of Supplementary Health, doctor and patient must keep a communication channel, using new technologies that allow non-presential evaluation and fol- low-up during the new coronavirus pandemic. Thus, even though there is a growing number of confirmed cases and deaths, the following urgent/emergency procedures are recommended in case of cerebrovascular diseases: • Endovascular treatment of acute ischemic stroke (MT). • Endovascular treatment of ruptured brain aneurysms. • Endovascular treatment of symptomatic carotid stenosis associated with a recent ischemic event. • Endovascular treatment of ruptured cerebral arteriove- nous malformations (AVMs), if the multidisciplinary team (Neurosurgery, Vascular Neurology, and Neuroradiology) identifies a high risk of rebleeding. • Endovascular treatment of posttraumatic, post-surgical or tumor bleeding. • Endovascular treatment of carotid-cavernous fistulas. • Cerebral angiography to determine the etiology of non-hyper- tensive hemorrhagic stroke or subarachnoid hemorrhage. RECOMMENDATIONS FOR NEUROINTERVENTIONAL PROCEDURES IN PATIENTS AT LOW RISK FOR COVID-19 A patient is considered at low risk for COVID-19 infection if the screening for COVID-19 is negative (Table 1). In such situation, individuals should undergo the procedure in the angiography room for patients without COVID-19 (if appli- cable) and wear a surgical mask during the entire hospitaliza- tion. Usual care, including protective measures for COVID- 19, should be adapted according to the procedure, local standards, and aerosolization risk (Table 2). After the proce- dure, the patient should be admitted to the most appropriate unit of care (Stroke Unit or ICU), based on local protocols. RECOMMENDATIONS FOR PROCEDURES IN PATIENTS WITH SUSPECTED, POSSIBLE, AND CONFIRMED COVID-19 Patients should be placed on contact and droplet precau- tions. During procedures, chiefly those generating aerosols, healthcare personnel should wear full protection (Table 2). It is crucial to follow the items below when dealing with patients with suspected/documented COVID-19. Pre-procedure • Patients should wear a surgical mask during the entire hospitalization. • Initial care should be taken in areas allocated for COVID- 19 patients (local protocols should be followed). • A swab sample for SARS-CoV-2 RT-PCR should be collected. 447Mont’Alverne FJA et al. Acute stroke and neurointervention in COVID-19 Table 4. Operational Manual for Doffing and Donning of personal protective equipment in a COVID-19 patient for neurointerventional procedures. Sequence for donning PPE 1. Wash hands or use an alcohol-based hand sanitizer. 2. Put on lead gown and accessories (radiation protection eyewear). 3. Wash hands or use an alcohol-based hand sanitizer. 4. We recommend N95 (ffp2) surgical cap, or powered air-purifying respirator (PAPR) and face shield, not only glasses. 5. Scrub hands for surgical procedures. 6. In the angiography suite, put on gloves (first gloves). 7. Surgical waterproof gown and gloves (second) extend to cover the wrist of isolation gown. After that, the procedure can be started. 8. Wash hands or use an alcohol-based hand sanitizer. 9. Put on lead gown and accessories (radiation protection eyewear). 10. Wash hands or use an alcohol-based hand sanitizer. Sequence for doffing PPE 1. Inside of the angiography suite, take out the gown and gloves. 2. Wash hands or use an alcohol-based hand sanitizer. 3. Take out the X-ray lead apron. 4. Wash hands or use an alcohol-based hand sanitizer. 5. Remove goggles and face shield from the back by lifting head band or earpieces and surgical cap. 6. Wash hands or use an alcohol-based hand sanitizer. 7. Get out from the angiography suite and take out the radiation protection eyewear. 8. Wash hands or use an alcohol-based hand sanitizer. 9. Grasp bottom ties or elastics of the N95 mask/respirator, then the ones at the top, and remove them without touching the front. 10. Wash hands or use an alcohol-based hand sanitizer. PPE: personal protective equipment. • A rapid serological test may also be used for suspected cases requiring procedures that are not time-sensitive and can wait for the result (e.g. carotid artery stenting), to guide appropriate use of PPE and cleaning process: • Indications for Interventional Neuroradiology proce- dures should follow the usual recommendations and should not be delayed, especially in time-sensitive cases, such as acute ischemic stroke. In the angiography suite • In institutions with more than one angiography suite, one must be dedicated specifically to patients with COVID-19. • The angiographic room should contain only essential equipment, furniture, and medicines to simplify cleaning. • The anesthesia workstation, monitors, and equipment should be covered with plastic wrap to reduce the risk of contamination and simplify cleaning. • All medications and materials required for the procedure should remain outside the room. If necessary, their deliv- ery can be done by outside healthcare personnel who should not go inside the angiographic suite. • Personal items should be kept outside the room. If neces- sary, cell phones can be protected in plastic bags. • The angiographic suite must be kept closed during the entire procedure. • Recommended warnings for precautions must be visible at the door of the angiographic suite. • Only the required number of professionals should be in the room. • Healthcare personnel directly involved in the procedure should wear N95 protective masks. • Healthcare personnel should follow a strict checklist for PPE donning and doffing (Table 4). • Face shield, waterproof gown, surgical cap, and two gloves should be provided for the physician in direct contact with the patient’s fluids (local protocols should be followed). • In cases when orotracheal intubation is considered nec- essary for the procedure, it should ideally be performed in a dedicated room before transport, which should be per- formed with a closed ventilator circuit. • In cases of MT, consider early orotracheal intubation if the patient shows at least one of the following conditions: • Acute respiratory distress/hypoxemia/high oxygen requirement. • Inability of airway/low Glasgow Coma Scale – GCS (<9) protection. • Agitation, no cooperation. • Active vomiting. • Active cough. • Posterior circulation occlusions with poor handling of secretions/airway. 448 Arq Neuropsiquiatr 2020;78(7):440-449 Notably, some authors have suggested that patients with dominant cerebral hemisphere occlusions and/or aphasia, as well as those with high NIHSS (>15), be considered for early intubation18. However, no reliable evidence supports this suggestion, as none of these factors have been demon- strated to be predictors of conversion from sedation to gen- eral anesthesia. Therefore, we discourage the preemptive intubation of these patients in the absence of agitation or any of the other aforementioned conditions, as this would lead to a high number of unnecessary intubations during a time of crisis when we should strive to optimize the use of our resources. The main idea behind the recommenda- tions for early intubation is to minimize the risk of intra- procedural intubation, considering it is a less controlled intervention and, as such, carries a higher risk of contam- ination. However, this needs to be balanced against the higher exposure of medical teams that intubate and extu- bate these patients, as well as to the additional use of time and resources. Thus, teams are encouraged to consider their local experiences in these decisions. Post-procedure • Confirmed and suspect COVID-19 patients should be transferred to a COVID unit. • Institutions are encouraged to divide these COVID units into confirmed/high- and low-risk COVID patients. When this is not feasible, low-risk COVID patients should be transferred to the stroke unit or ICU ( following institu- tional guidelines). • Patients should not be extubated in the angiography suite. Instead, they should be transported to an appropri- ate ICU room for planned extubation. • Transport of these patients should be limited as much as possible, and follow-up imaging should be restricted to cases with neurological deterioration. • Patients that are not under mechanical ventilation dur- ing transport should wear a surgical mask. Oxygen can be administered through a nasal cannula under the mask during transport. • If the patient is intubated, a closed ventilatory circuit must be used. • Full PPE must be worn by the transport team in case of direct contact with the patient or contaminated equipment. • A member of the transport team, without direct contact with the patient or contaminated equipment, should not wear PPE to interact with the environment (e.g. touch ele- vator buttons). • After the procedure, the ventilatory circuit and contents of the soda-lime container must be discarded. • After the procedure, perform terminal cleaning of the angiographic room as recommended, but it is manda- tory that the cleaning staff wears respiratory and contact PPE. Details on disinfectants for use against SARS-CoV-2 should be consulted elsewhere. • Since there is no precise data on how long the air inside a room occupied by someone with confirmed COVID-19 remains potentially infectious, the decision on how long a room used by a COVID-19 patient should be closed-off will depend on the evaluation of room size, the ventila- tion system design, and if the procedure generated aero- sol or not. Nevertheless, it is currently accepted that the room should remain with the doors closed for at least three hours if they are not working under negative pres- sure before another patient is admitted or personnel is allowed to enter without PPE. INFORMED CONSENT The risk of COVID-19 contamination is higher in hospital- ization, and this additional risk factor should be made explicit in the consent form, especially in cases where urgency/emer- gency is not undoubtedly characterized, as for example in unruptured aneurysms. TRAINING During care of COVID-19 patients, many protocol violations are possible in doffing and donning of PPE. Additionally,  health professionals may not be familiar with the required procedures and use of the equipment (such as fogging of the “face shield” impairing visibility). In this setting, training with on-site simulation is highly recommended to ensure proper execution of protocols and to avoid unnecessary stress, especially among professionals involved in aerosol-generating procedures, such as orotra- cheal intubation, nasogastric tube insertion, among oth- ers. All healthcare professionals should be fit-tested for N95 masks, especially those who deal directly with aerosol-gener- ating procedures. The N95 masks used in aerosol-generating procedures or contaminated with blood, respiratory or nasal secretions should be preferably discarded, although this recommen- dation might be impractical in most centers due to limited availability of resources. 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