UC Irvine

Early in the Coronavirus disease-2019 (COVID-19) pandemic, frontline clinicians provided anecdotal observations there was an increase in the number of individuals presenting with a stroke who did not have traditional stroke factors. Current tools to evaluate stroke risks are based on decades of research-all conducted prior to COVID-19 pandemic and before the SARS-CoV-2 was in existence or circulating widely. Accurate stroke assessment is predicated on accurate identification of stroke risk factors. Little attention has been paid to re-examining stroke risk tools to consider the influence of COVID-19. This Quality Improvement (QI) project aimed to answer the question: Do established stroke tools capture factors that increase stroke risk during COVID and post-COVID illness? First, a review of literature was conducted to identify stroke risk assessment tools. Second, emerging risk factors for stroke related to COVID-19 were extracted from a literature search. Third, a survey, which included traditional and non-traditional risk factors found in the literature review, was developed and administered to 35 front-line clinical experts; this survey aimed to understand the reliability and content validity of stroke risk factors as they occur within the context of COVID-19. The clinical experts identified 23 traditional and 29 non-traditional risk factors as being highly associated with increased odds of stroke. The top traditional risk factors were atrial fibrillation, smoking (current or history), 2nd TIA in less than seven days, age >74, hypertension (>140/90 mmHg or SBP >140 or DBP >90). Non-traditional risk factors were metabolic syndrome, ipsilateral >50% carotid stenosis of the internal carotid artery and/or major cerebral artery, active COVID-19 infection that has lasted more than eight days, D-dimer >920 ng/m, and C-reactive protein >10.0 mg/L. This project provides a foundation for future QI projects and research with the goal of reducing risk for stroke within the context of COVID-19.