Letter by Cerase et al Regarding Article, "Temporary Emergency Guidance to US Stroke Centers During the COVID-19 Pandemic".

Abstract

HomeStrokeVol. 51, No. 7Letter by Cerase et al Regarding Article, “Temporary Emergency Guidance to US Stroke Centers During the COVID-19 Pandemic” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Cerase et al Regarding Article, “Temporary Emergency Guidance to US Stroke Centers During the COVID-19 Pandemic” Alfonso Cerase, MD, Gianni Guazzi, MD and Maria Antonietta Mazzei, MD Alfonso CeraseAlfonso Cerase https://orcid.org/0000-0003-4753-6649 Unit of Neuroimaging, Diagnostic and Functional Neuroradiology, Department of Neurological and Movement Sciences Azienda ospedaliero-universitaria Senese Siena, Tuscany, Italy (A.C.). Search for more papers by this author , Gianni GuazziGianni Guazzi Unit of Emergency Radiology, Department of Emergency, Urgency, and Transplantation, Azienda ospedaliero-universitaria Senese Siena, Tuscany, Italy (G.G.). Search for more papers by this author and Maria Antonietta MazzeiMaria Antonietta Mazzei Unit of Diagnostic Imaging, Department of Radiological Sciences, Azienda ospedaliero-universitaria Senese Department of Medicine, Surgery and Neuroscience University of Siena Siena, Tuscany, Italy (M.A.M.). Search for more papers by this author Originally published13 May 2020https://doi.org/10.1161/STROKEAHA.120.030147Stroke. 2020;51:e139–e140Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 13, 2020: Ahead of Print To the Editor:As SARS-CoV-2 pandemia and coronavirus disease 2019 (COVID-19) largely spread, plans for emergency management of acute stroke treatment are developing worldwide. Stroke teams should try to continue to treat as many patients as possible. However, US regulatory authorities have been informed that major concerns are hindering full compliance to all guidelines all times everywhere.1 A protected code stroke algorithm has been suggested,2 whose application depends on local realities.1,3 The challenge is how to link best chance for recovery to prevention of infection transmission. Notably, such an extreme condition forces stroke teams to seek creative solutions.2,3 Radiology and neuroradiology units are also planning to both contain infection and ensure normal activity. American College of Radiology does not recommend chest imaging to diagnose COVID-19, since findings are not specific, with high resolution computed tomography (HRCT) more sensitive than chest x-rays.3,4 Viral testing confirmation by reverse transcription-polymerase chain reaction is required. However, reverse transcription-polymerase chain reaction is not always performed in all infected patients, above all if asymptomatic or paucisymptomatic. Furthermore, initial reverse transcription-polymerase chain reaction is not always positive in infected patients, and HRCT may be positive before positive reverse transcription-polymerase chain reaction in up to 69.8% of patients.4 Five categories for suspected patients have then been proposed: definitely COVID-19, very probably COVID-19, probably COVID-19, probably not COVID-19, and very probably not COVID-19.5 Other issues include sanitization of equipment and rooms, and sparing personal protective equipments. Thus, when chest imaging is considered necessary, the American College of Radiology recommends portable radiography units which can be easily cleaned, avoiding both x-rays/CT rooms and personnel/patients’ movement. CT should be reserved for hospitalized patients with specific clinical indications. Our institution follows these American College of Radiology recommendations.However, at the time we are writing, little has been discussed about emergency radiology and neuroradiology units pathways of those patients suspected or positive for COVID-19 requiring both chest imaging and time-based emergency care by priority CT, such as generally required in patients with stroke. These patients often present with unclear clinical scenarios or comorbidities, may be confused, aphasic, or otherwise unable to provide necessary information for screening. Additionally, in this sad era, patients are generally admitted alone without family members nor witnesses.2,3 Recently, in Italy allied societies against stroke addressed the need of chest imaging in patients presenting with stroke.3 We think that in these patients HRCT should be associated to the required CT, avoiding chest x-ray by portable radiography unit, despite increase of radiation exposure. Time, movements, and personal protective equipments would be spared. HRCT patterns may early allow better patients’ stratification, assisting rapid decision-making. We propose HRCT in patients undergoing CT for stroke and requiring chest imaging as one of the winning cards against COVID-19. This might likely prevent Trojan horses also in nontime-based emergency pathways requiring priority CT. Which is Authors’ opinion?DisclosuresNone.FootnotesFor Disclosures, see page e139.