This article is reproduced in part from a review published in the journal Cerebrovascular Diseases, with permission from S. Karger AG, Basel. (Venketasubramanian N, Anderson C, Ay H, Aybek S, Brinjikji W, de Freitas G, R, Del Brutto O, H, Fassbender K, Fujimura M, Goldstein L, B, Haberl R, L, Hankey G, J, Heiss W, -D, Lestro Henriques I, Kase C, S, Kim J, S, Koga M, Kokubo Y, Kuroda S, Lee K, Lee T, -H, Liebeskind D, S, Lip G, Y, H, Meairs S, Medvedev R, Mehndiratta M, M, Mohr J, P, Nagayama M, Pantoni L, Papanagiotou P, Parrilla G, Pastori D, Pendlebury S, T, Pettigrew L, C, Renjen P, N, Rundek T, Schminke U, Shinohara Y, Tang W, K, Toyoda K, Wartenberg K, E, Wasay M, Hennerici M, G: Stroke Care during the COVID-19 Pandemic: International Expert Panel Review. Cerebrovasc Dis 2021;50:245-261. doi: 10.1159/000514155)
Masao Nagayama, MD, PhD, FAAN, FACP, FNCS
Professor, Department of Neurology
International University of Health and Welfare Graduate School of Medicine, Japan
Katja Wartenberg, MD, PhD
Co-Director, Neurointensive Care Unit, Department of Neurology
University of Leipzig, Germany
The 2019 novel coronavirus disease (COVID-19) pandemic is taking many lives, and it poses great challenges to healthcare facilities in addition to its effects on individual people, families, communities, societies, economies, both regionally and globally. Neurological manifestations of COVID-19 are observed very frequently in at least one third of hospitalized COVID-19 patients.
In May, 2020, the Editor-in-Chief (Professor Michael G. Hennerici) of the journal Cerebrovascular Diseases, representative journal in the field of stroke, asked the Editorial Board to develop stroke care recommendations by expert panel review during the COVID-19 pandemic. The Editorial Board comprises eminent and renowned physicians from around the world and the expert panel review was published in March 2021 addressing stroke care in settings with potential or actual COVID-19 patients including management recommendations for the treatment of acute stroke patients with COVID-19 infection (Venketasubramanian N et al, Cerebrovasc Dis 2021). Many of the topics were an evidence-free zone, and thus expert opinion was described and the contributions were reviewed by the Editor-In-Chief and all the Editors.
A neurocritical care (NCC) chapter was included in this expert panel review and we contributed (personally, stroke review should be part of NCC review). Here we present the NCC chapter including those contents not included in the final draft due to the limited space (shown in blue).
Faced with new challenges in the absence of solid evidence, many critical care and neurological societies issued recommendations and statements to support and restructure neurocritical care during the COVID-19 pandemic in addition to conduction of surveys among neurocritical care providers (Rubin M et al, Neurology, 2020; Alhazzi W et al, Crit Care Med, 2020; Canelli R et al, N Engl J Med, 2020).
Neurological manifestations of the 2019 novel coronavirus disease (COVID-19) occur in 36.4%-69% of hospitalized COVID-19 patients (Mao L et al, JAMA Neurology, 2020; Helms J et al, NEJM, 2020; Brigham and Women’s Hospital, https://covidprotocols.org/, 2020).
Representation of COVID-19 in NCC include acute encephalopathy, qualitative and quantitative disturbance of consciousness, encephalitis, acute disseminated encephalomyelitis, seizures, cerebrovascular diseases, Guillain-Barré and Miller Fisher syndrome, skeletal muscle disorders, white matter and demyelinating lesions, smell and/or taste disturbances, headache, dizziness, and corticospinal tract signs (Romero-Sánchez CM et al, Neurology, 2020).
During the COVID-19 pandemic, there is an obligation to save as many lives as possible. Discussion of quality of life and goals of care remain important components of the management of patients requiring neurocritical care.
Triage in situations of scarce intensive care resources requires a specialized team of intensivists, nurses, pharmacists, other medical staff with neurocritical care expertise, including some not directly involved in patient care, and including clinical ethicists to ensure consistent and transparent decisions based on an individual patient’s situation and wishes that are independent of race, sex, ethnicity, socioeconomic, and social status. Risk stratification should be applied across all patients requiring intensive care and without relying exclusively on disease-specific prognostic scales (Rubin M et al, Neurology 2020). Triage should be performed at presentation to the ER.
Critically ill patients with stroke and COVID-19 should be cared for in a designated isolation unit. Patients with suspected COVID-19 should be kept in a designated unit or in a defined triage room with closed doors until the return of the test result.
For healthcare workers performing aerosol-generating procedures (e.g., endotracheal intubation, manual bag-valve-mask ventilation, and resuscitation) or in aerosol-generating situations (e.g., seizure, cough, and agitation) on patients with suspected or confirmed COVID-19, usage of fitted respirator masks (N95 respirators, FFP2, or equivalent) in addition to other PPE (i.e., gloves, gown, face shield, or safety goggles) is recommended (Alhazzi W, Crit Care Med, 2020).
Aerosol-generating procedures on ICU patients with COVID-19 should be performed in a negative pressure room (Brigham and Women’s Hospital, https://covidprotocols.org/, 2020). For endotracheal intubation of patients with COVID-19, video-guided laryngoscopy is recommended over direct laryngoscopy, where available, undertaken by those most experienced with the procedure (Alhazzi W et al, Crit Care Med, 2020).
Disturbance of consciousness
One of five patients (19.6%) hospitalized with COVID-19 developed disorders of consciousness (DOC) (Romero-Sánchez CM et al, Neurology, 2020). DOC were associated with severe COVID-19, older age, higher creatine kinase levels, and lower lymphocyte count (38.9% among patients with severe COVID-19, 14.9% delirium, 9.4% coma), mainly caused by severe hypoxemia. Because obtaining a history is often difficult, every patient with DOC should be screened for SARS-Cov-2 and treated with the respective contact precautions (surgical mask, gown, gloves, ocular PPE such as eye shield, goggles, face shield) by designated medical staff.
Procedures with aerosol production such as tracheal intubation, manual bag valve mask ventilation, and resuscitation require additional PPE and N95-/FFP-2/-3 masks.
End-tidal CO2 monitoring is recommended to identify alveolar hypoventilation.
The patient should wear a surgical mask until COVID-19 has been definitely ruled out.
The history should be obtained from the family over the phone. Personal contact should be kept at a minimum with the respective barriers and precautions.
If the patient presents with fever > 37.5℃, respiratory symptoms, travel history, contact with COVID-19 patients, or smell and/or taste abnormalities, the patient should be managed in a negative pressure room, if available. It is advisable to keep a triage room in the ER and the Neurointensive Care Unit.
The Full Outline of Unresponsiveness (FOUR) Score is useful for evaluation of the level of consciousness, even in intubated patients (Wijdicks EFM et al, Ann Neurol, 2005).
If a CT scan is obtained, a low dose chest CT scan should be added for additional screening for COVID-19 (Wang K et al, Clin Radiol, 2020).
Seizures and status epilepticus
New-onset seizures are presumed to be secondary to direct central nervous system effects of COVID-19 (Romero-Sánchez CM et al, Neurology, 2020; Saad M et al, Int J Infect Dis 2014; Addendum to Emory Healthcare’s Brain Death Determination Policy effective 04/17/2020, https://www.emoryhealthcare.org/ui/pdfs/covid/medical-professionals/Brain Death Testing in the Setting of COVID-19.pdf).
Infections and certain medications, e.g. imipenem can lower the seizure threshold (Sutter R et al, Neurology, 2015).
Nonconvulsive status epilepticus (NCSE) are frequent life-threatening conditions identifiable by continuous EEG monitoring, commonly caused by encephalopathy, acute stroke, central nervous system or systemic infections among others (Brophy G et al, Neurocrit Care 2012; Nagayama M, F1000Research 2017).
Convulsive seizure and agitation in the postictal period are considered aerosol generating. Appropriate PPE is recommended.
Head MRI and routine EEGs should be deferred until infection with SARS-Cov-2 is ruled out. If the patient is SARS-Cov-2 positive, these tests should be obtained after the infection is cleared unless the tests results are likely to change immediate management.
Diagnosing irreversible loss of brain function
Testing for SARS-CoV-2 prior to brain death examination is recommended, if results are available within 48 h (Addendum to Emory Healthcare’s Brain Death Determination Policy effective 04/17/2020, https://www.emoryhealthcare.org/ui/pdfs/covid/medical-professionals/Brain Death Testing in the Setting of COVID-19.pdf). If the SARSCoV-2-PCR is negative, the usual policy of determination of irreversible loss of brain function should be utilized.
Decisions must be guided by the principle of balancing the minimization of harm to healthcare colleagues with the benefit of establishing a diagnosis for the patient and family. If the SARS-CoV-2 infection cannot be excluded, appropriate PPE should be used with aerosol-generating procedures. Ancillary diagnostic tools to replace apnea testing are recommended for SARSCoV-2-positive patients (Brigham and Women’s Hospital, https://covidprotocols.org/, 2020).
Neurocritical care should continue to be provided for patients who may benefit from intensive care. Infection control measures must be strictly enforced. Aerosol-generating procedures on ICU patients with COVID-19 should be performed in a negative pressure room. Video-guided laryngoscopy is preferred over direct laryngoscopy for endotracheal intubation of patients with COVID-19.