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Bill Klaproth: This UPMC Pinnacle podcast on COVID-19 recorded on May 20th. The major risk factors for stroke are hypertension, diabetes, cardiovascular disease, obesity, and being a male, which also happened to be the same high risk group for COVID-19 infected patients. So what is the COVID-19 in stroke connection? Let's find out what Dr. Elena Romero Dailey, Hospitalist Medical Director at UPMC Pinnacle. This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Dr. Dailey, thank you for your time. So the major risk factors for stroke also happened to be the same for COVID-19 infected patients. What's the correlation between the two?

Dr. Dailey: As we learn more about this infection, we're realizing that this virus really likes to attack the vasculature and it just so happens that that's the very problem in stroke victims. So those risk factors are diabetes, heart disease, morbid obesity. Those patients tend to have high blood pressure, which is a blood vessel disease. And that is the same thing that affects not only stroke patients, but also it seems that this virus really likes to infect these sorts of people that end up in the hospital.

Host: So the worry is for people with diabetes or who may have hypertension or who may be obese, for those people that contract COVID-19, they may be at a higher risk for stroke then?

Dr. Dailey: That's correct. It seems as we continue to learn more and more about this virus, the infection in people that end up in the hospital, that infection tends to cause more blood clots in the bloodstream, especially in the arterial blood stream, which is again the bloodstream that oxygenates the brain and those are the very blood vessels that can end up with clots that lead to the stroke.

Host: So then when it comes to caring for stroke patients, you're able to treat normally for stroke for patients with COVID-19?

Dr. Dailey: That is correct. There is no cure for COVID-19 so if you come in with a respiratory illness and are found to have COVID-19 we support you through that respiratory illness. If you have COVID-19 your respiratory illness and you also happen to stroke, we not only support you through your respiratory illness, but then we also treat you just like any other stroke because we know we have the science to support that. If we catch your stroke within a four and a half hour window and give you the clot Buster called TPA, we have a very good chance of saving brain tissue and correcting your symptoms, and improving your ability to recover from that stroke. If you present within 24 hours and we found find a blood clot in your brain and that's in the large vessel and we call that a large vessel occlusion, then we treat you just the same. Even if you're COVID-19 positive, we will not only get a CT angiogram, we will identify that clot and then we will make sure that you go to a center because Carlisle does not have neurosurgery here. We send you to a center where they can then remove that clot and we do that within a certain time period because we want to provide the best care here at UPMC Carlisle.

Host: For those patients that don't need to be transferred to a higher level of care, can you explain what additional therapies are provided for stroke patients, with or without Covid-19 at your facility?

Dr. Dailey: So once you have your stroke and you're outside the window for the clot Buster called CPA, there's two ways we approach a stroke patient. If you receive a clot Buster, TPA, you are brought into the ICU, you're monitored closely for 24 hours in our intensive care unit to make sure that there are no complications with using that clot Buster. We initiate physical therapy, occupational therapy, and speech therapy after 24 hours. We control your blood pressure, we address all of the risk factors and we progress you through those therapies because after you have a stroke, we try to mitigate the risk for the next stroke. If you are not a candidate for the blood clot Buster called TPA, then we send you to the floor where we initiate the physical therapy, occupational therapy, and speech therapies immediately and we interact with you, and those therapies on a daily basis trying to assess the need for further therapy after being stabilized in the hospital. Or if you are well enough to go home and continue outpatient therapy.

Host: And then considering that outpatient therapy. What about admission for rehab after a positive COVID-19 test?

Dr. Dailey: So again, as we continue to learn more about this infection and at this time we don't know how infectious you are after you have the respiratory illness of COVID-19 so understandably acute rehabs are extremely cautious. So if you test positive and are found to require further inpatient acute rehabilitation with physical therapy, occupational therapy and speech therapy, some rehabs are requiring two negative COVID PCR tests. And what that means is we're checking your respiratory airways to see if you have any virus in you. And that's what the PCR test is. It is not a blood test and we do not know if you're contagious at that point. But I understand why. I think we all understand in the medical community why acute rehabs want to be very cautious with patients until we know the contagion after recovering from the respiratory illness.

Host: So Dr. Dailey, let me ask you about medications, for someone who may be on cardiovascular medications, are there any indications that this may help prevent someone from contracting COVID-19?

Dr. Dailey: So again, patients who suffer stroke have cardiovascular disease and patients who suffer COVID may not have any of these diagnoses or may have these diagnoses. At this time, Physicians don't know is these cardiovascular medications prevent COVID-19. So we are not starting these medications to prevent this infection. In patients in the high risk group, we are continuing their medication, we're not stopping them and certainly if they come in to the hospital for stroke we continue them and in some instances we intensify them in order to prevent the next stroke.

Host: And when people talk about stroke we hear the term TIAs. Can you explain to us what a TIA is?

Dr. Dailey: Sure. TIAs are transient ischemic attacks. Basically we think that there might've been a delay in blood flow to the brain that was temporary that causes the same symptoms as stroke, and they go away. Usually within six hours, definitely within 24 hours. And that is what we call a sign that there is a stroke coming. Patients who suffer TIAs within the first 48 hours of that TIA, they are in about a 60 to 75% risk of having a full on stroke and that risk remains but kind of declines by the two week period. So by the end of the second week, your risk for a stroke levels off to that of your normal risk for a stroke for your age group. So it's crucial to present within that 48 hours to the hospital with those symptoms so that the medical team can assess the risk factors that led to that transient ischemic attack. It could be diabetes, you didn't know you had diabetes. It could be uncontrolled, high blood pressure. Actually, that's what we find the most common. It could be you're a smoker and you're starting to develop vascular disease. It could be the development of atrial fibrillation. And that's your presentation. So we hope to find those things, Institute the medical treatment for these things and hope that you are compliant. You leave the hospital and continue to work on reducing those risk factors.

Host: And that's the problem with people delaying care and not coming to the hospital. They're having these TIAs instead of going, Hey, I better go have this checked out. They're concerned about coming to the hospital because that's where the COVID is. And they're saying, I'm just going to tough it out. That's the problem. Right?

Dr. Dailey: Correct. That's the very problem we're facing.

Host: So tell us more about the consequences of delayed care, especially when it comes to stroke.

Dr. Dailey: Yes. Everybody has been very cautious, especially since Pennsylvania issued the stay at home order. Understandably, patients do not want to come to a place where there may be potential COVID patients waiting. And yes, that has caused a delay in presentations for TIA's. We in the medical community think that the TIA's are the early warning sign to full on stroke. So if you have a TIA, you have a chance to come into the hospital, have your risk factors evaluated and medications or therapies initiated to mitigate the actual stroke that you are at risk for. By not presenting to the hospital, you're basically not addressing those risk factors and there is a higher chance of you to develop that stroke within that two week time period of that TIA. So we have seen stroke, we've actually seen large vessel occlusions and I dare say we've seen more hemorrhagic stroke, which is a type of stroke that you see in uncontrolled high blood pressure, this year in April than we did last year in April. We've seen twice the amount of large vessel occlusions this year in April than we did last year in April. So the Langer presentation from a transient ischemic attack, that's what a TIA is, does not allow the person to have the risk factors evaluated and mitigated.

Host: Just a couple more questions. So people might be thinking, I'm in this high risk category, I better not catch COVID-19, can you share with us some tips that people can avoid getting COVID-19.

Dr. Dailey: Absolutely. Even though we know more and more about this virus, we still don't have a cure and we certainly don't know whether the antibodies that our body develops against this virus are even protective, until we find those answers and we hope to find them sooner rather than later. The best way to prevent getting infected with COVID-19, even as we enter the warm months of spring and summer is to physically distance. We know that this virus travels in respiratory droplets or water droplets in the air and really disinfecting the air is not going to help that, physical distance is truly the only way to prevent catching COVID-19.

Host: And then last question, Dr. Dailey, we should talk about the symptoms of a stroke. Can you go over those with us?

Dr. Dailey: So the American Heart Association has this wonderful word called fast F A S T, acting fast, and it really illustrates the most common symptoms of stroke. And it catches, I think about 86% of strokes. So when you act fast, you look at your face, F for face, you always ask the person to smile. And see if there's one side of the face that is drooping. Arms, A for arms. You ask the person to raise their arms and if one arm is drifting downward, that could be a symptom in association with that face droop. S for speech fast. As for speech, you ask the person to repeat a simple phrase. It could be as, Hey, my dog is walking and is that speech slurred? Is it strange? Or they're missing a word. Are they substituting a word when they try to repeat that phrase? That is also a symptom of stroke. And finally T, fast T, time. As soon as any of these symptoms show up, you should call 911 right away to try to get that patient to the hospital and get treatment to save brain tissue.

Host: So remember the acronym FAST, face, arms, speech time, Dr. Dailey. This has really been informative. Thank you so much for your time. We appreciate it.

Dr. Dailey: Thank you for having me.

Host: That's Dr. Elena Romero Dailey. And for more information, please visit UPMCpinnacle.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMCs Pinnacle. I'm Bill Klaproth. Thanks for listening.