Skip to Main Content
It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.
Login
hse hli logo

Covid-19 HSE Clinical Guidance and Evidence

* Phone users, please scroll down to view content. Queries to: clinicaldesign@hse.ie

Acute / Maternity, Paediatric Hospital Information Navigation

Acute Stroke TIA Admissions and COVID-19

Acute Stroke / TIA Admissions and COVID-19 – update recommendations from the National Stroke Programme (CD19-167-002 / 06.01.21)


  • There may be an increased risk of stroke with COVID-19 infection and case reports of younger people with large-vessel ischaemic stroke and SARS-Cov-2 (COVID-19), without other apparent risk factors have been reported (1). Case series suggests a 3% risk of stroke among COVID-19 patients (2, 3) but the incidence of stroke is also known to rise during outbreaks of viral infections such as influenza.
  • While a possible link with SARS-Cov-2 and stroke is being reported, it has not been confirmed and remains under study. However we need to be vigilant. In addition many patients with stroke symptoms may not be presenting to hospital or presenting too late for effective early treatment, due to lack of stroke awareness or fear of infection.
  • Patients with mild stroke symptoms or TIAs may not be consulting GPs or initiating the FAST response pathway due to lack of stroke awareness or fear of infection and this may result in greater numbers of stroke eventually.
  • Stroke patients appear particularly susceptible to the effects of COVID-19 (4) and every effort must be made to ensure safe and effective acute stroke unit care of patients presenting with stroke. 
  • The following are a set of principles agreed by the clinical advisory group of National Stroke Programme. They do not replace the clinical judgement of stroke services locally. Comprehensive Infection Prevention and Control Guidance is available at the following link: https://bit.ly/2SloLf4

 

Principles
  • Standard infection prevention and control precautions (in particular hand hygiene) and use of properly applied surgical mask should be applied by all healthcare workers caring for all patients at all times.
  • All acute stroke patients should be assessed for clinical features suggestive of COVID-19 both at the time of presentation and for reported symptoms suggestive of COVID-19 in the weeks preceding the stroke.
  • A history of contacts with confirmed COVID-19 cases recently should be sought in all cases.
  • Stroke is a medical emergency and outcome is dependent on time-sensitive decision making, which requires urgent neuro-imaging and sometimes transfer to the thrombectomy centre. Patient imaging, hyper-acute treatment or transfer for thrombectomy should NOT be delayed on the basis that a laboratory test report for COVID-19 is positive or is pending.
  • All acute stroke patients should have a surveillance swab for COVID-19 as standard. The test should be prioritised and processed as urgent (with rapid turnaround where available) to facilitate appropriate patient placement. This is particularly important where admission to an acute stroke unit care, on an open ward setting, is planned. 
  • Where Contact and Droplet precautions are applied, the requirement for continued Contact and Droplet precautions should be reviewed in the overall clinical context when the laboratory test result is available.  It is important to emphasize that a sample reported as ‘not-detected’ is not of itself a sufficient basis for removal of Contact and Droplet Precautions in a patient where there is strong clinical suspicion of COVID-19.
  • Patients should be admitted to an appropriately monitored and staffed side room, as part of the acute the stroke unit, wherever possible until their COVID status is known. Where this is not possible and patients are admitted to an open bay/multi-bed room stroke unit setting they should be advised to stay in their own bed space as much as possible and to avoid sharing items with other patients until their COVID status is known. Patients should be advised to wear a mask and where tolerated and appropriate, until their COVID-19 status is known. If /when Contact and Droplet precautions are lifted the patient is advised to wear a mask, if tolerated, when outside of their bed space and when another person is in their bed space. Those patients who may choose to wear a mask in their bed space should be facilitated in this choice.
  • All those with clinical features suggestive of COVID-19 (fever, dyspnoea, cough, hypoxia, lymphopenia, or infiltrates on chest x-ray) should be managed from the outset as per national infection prevention and control guidance for people with suspected or confirmed COVID-19 (appropriate patient placement and Contact and Droplet Precautions, see link above).
  • For this purpose thromboembolic stroke* (suspected or confirmed) in those who do not have recognisable risk factors for stroke maybe considered as a clinical feature suggestive of COVID-19. (* haemorrhagic encephalopathy in patients with no risk for intracerebral haemorrhage has also been rarely reported in association with COVID-19). (6)
  • Stroke patients identified as COVID-19 Contacts should be managed from the outset as per national infection prevention and control guidance for people with suspected or confirmed COVID-19 (appropriate patient placement and Contact and Droplet Precautions, see link above).
     
High COVID Risk Stroke Patients

If any stroke patient

  • has any of the common symptoms or clinical indicators suggestive of active COVID-19  infection (fever, dyspnoea, cough, Hypoxia,  lymphopenia, or infiltrates on chest x-ray)

                                                          OR

  • has been diagnosed with COVID-19 and is still in the infectious period *   

                                                          OR

  • has had recent contact with a case COVID-19

                                                          OR

  • has thromboembolic stroke with no clear risk factor for same

                                                          OR        

  • is a front-line healthcare worker (5)

* The infectious period for COVID-19 is

  • 10 days from the date of onset of symptoms in people who do not require hospitalisation and do not reside in a long-term residential care facility.
  • 14 days for those who require hospitalisation or reside in a long-term residential care.

Stroke patients in this category should be

  • provided with and encouraged to wear a face mask as above.
  • admitted to a single patient room (as part of the acute stroke unit where possible) with appropriate contact and droplet precautions until they are no longer considered as representing a specific infectious risk. 
  • Application of contact and droplet precautions are as per national guidance and include maintaining distance where practical to do so, hand hygiene and use of appropriate PPE. These measures should continue until a decision has been taken by a senior clinician that contact and droplet precautions are no longer required.

N.B. Clinical decisions to remove contact and droplet precautions should not then be based solely on a ‘not detected’ result but on the clinical picture and advice from the infection prevention and control team if required.

Vitals and oxygen saturations should be carefully monitored.

If isolation facilities on the acute stroke unit are not available, high COVID-19 risk stroke patients should be admitted to an area with suitable isolation facilities for example a ‘COVID-19 sorting ward’ under the care of the admitting Stroke Physician or Vascular Neurologist, with access to appropriate nursing care, monitoring and assessment & treatment by members of the Stroke MDT. Joint care with another specialist may be appropriate in these circumstances as per local hospital protocol or as clinical condition dictates.

 

All other stroke Patients
  • Stroke Patients with no clinical features or a history suggestive of COVID-19 / COVID-19 contacts should have a surveillance swab taken as soon as possible after presentation.
  • Where possible patients transferred to a stroke unit should be accommodated in a single room until (dedicated ‘receiving’ room) until COVID-19 status is known.
  • Transfer from the Emergency Department to an inpatient area need not be delayed pending receipt of the result however where possible their COVID-19 status should be known prior to transfer to an open ward with other stroke patients however. If patients are of necessity placed in multi-bed area pending test result that contact with other patients is limited as much as possible and they should be supported in use of a surgical mask as above.
  • Patients with no clinical features suggestive of COVID-19 should be managed for infection prevention and control purposes with Standard Precautions plus all healthcare workers should wear a surgical mask and pay particular attention to hand hygiene as per national guidance for all patient care encounters.
  • In the event of a positive swab result in a low COVID-19 risk stroke patient (no recent infection or exposure, no symptoms or clinical signs of COVID-19) the patient should be placed in a single room with contact and droplet precautions immediately if not already in a single room. The local infection control team and occupational health service should be contacted for further management of patients and staff potentially exposed.   
  • Detailed National guidance on Infection Prevention and Control Requirements for COVID-19 are available at https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/ppe/


Guidance Development Group

  • Prof. Ronan Collins - Clinical Lead of National Stroke Programme

(on behalf of the clinical advisory group – see appendix for CAG membership)

Appendix

  • Riona Mulcahy - Chair
  • Gerald Wyse
  • Michael Marnane
  • Ronan Collins
  • Glen Arrigan
  • Niamh Hannon
  • Desmond O Neill
  • Joan McCormack
  • Paul Brennan
  • Joe Harbison
  • John Mcmanus
  • Racheal Doyle
  • George Pope
  • John Thornton
  • Sarah Power
  • Barry Moynihan
  • Karl Boyle
  • Sean Murphy
  • Dan Ryan
  • Ken Mulpeter
  • Simon Cronin
  • Trish Galvin
  • David Bradley
  • Clare Fallon
  • Paul Cotter
  • Liam Healy
  • Peter Kelly
  • Martin Mulroy
  • John C. Corrigan
  • Tom O Malley
  • Paula Hickey
  • Christina Donnellan
  • Donnelly, Teresa
  • Rory McGovern
  • Eithne Harkin
  • Richard Liston
  • Margaret O'Connor
  • Eamon Dolan
  • Kieran O'Connor
  • Cathal O'Donnell
  • Eugene Wallace
  • Tim Cassidy
  • David Williams
  • Dominick McCabe
  • Catherine O'Sullivan

References
  1. Oxyley T et al. Large-Vessel Stroke as a Presenting Feature of COVID-19 in the Young. NEJM 2020;382: Apr 28.
  2. Rothstein A et al. Acute Cerebrovascular Events in Hospitalized COVID-19 Patients. Stroke 2020:51(9); DOI: 10.1161/STROKEAHA.120.030995.
  3. Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, Chang J, Hong C, Zhou Y, Wang D, et al.. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020; 77:1–9. doi: 10.1001/jamaneurol.2020.1127.
  4. Aggarwal G, Lippi G and Henry BM. Cerebrovascular disease is associated with an increased disease severity in patients with coronavirus disease 2019 (COVID-19): a pooled analysis of published literature. Int J Stoke 2020; 15(4): 385–389.
  5. Nguyen et al.  Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health 2020:5(9):e475-e483.
  6. Hernandez et al COVID-19-related intracranial imaging findings: a large single-centre experience. Brain 2020;143(10): 3089–3103.

Health Library Ireland, Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: hli@hse.ie

Disclaimer