Amid the coronavirus disease 2019 (COVID-19) pandemic, neurologists have been confronted with unprecedented situations, among which acute stroke management in COVID-19 patients. To the best of our knowledge, this is the first report of protected code stroke in Belgium.

A 74-year-old patient, while hospitalized for a COVID-19 pneumonia, experienced sudden-onset left-sided hemiplegia and aphasia. Two hours after symptom onset, an in-hospital code stroke was activated. A neurologist in personal protection equipment (PPE) consisting of mask, goggles, gown and gloves [1], evaluated the patient and documented a National Institutes of Health Stroke Scale (NIHSS) of 16, rapidly deteriorating to 25. Neuroimaging in the COVID-19 section of the radiology department showed no abnormality on the non-contrast computed tomography (NCCT) of the brain but CT angiography revealed a right carotid T occlusion. Intravenous thrombolysis with alteplase was administered within 3 h of symptom onset. The patient was then promptly transferred to the interventional radiology suite dedicated to COVID-19 patients to undergo endovascular thrombectomy (EVT). EVT by thrombus aspiration was performed under general anesthesia, using a Cello 9F balloon guide catheter for proximal flow control and a Sofia 6F catheter for distal aspiration. Complete recanalization of the carotid artery (modified treatment in cerebral ischemia (mTICI) grade 3) by first-pass thrombus aspiration was achieved 4 h and 30 min after symptom onset (Fig. 1). The patient was closely monitored in a COVID-19 Intensive Care unit. The neurological symptoms resolved as reflected by a NIHSS of 1 at 72 h after symptom onset.

Fig. 1
figure 1

a Persistent right carotid T occlusion despite initiation of intravenous alteplase, with no visualization of the middle and anterior cerebral arteries. b Complete recanalization of the right carotid artery (mTICI grade 3) after first-pass thrombus aspiration

In a health care system overwhelmed by COVID-19 patients, acute stroke management represents a major challenge. Awareness of stroke symptoms may be reduced, patients are experiencing fear of hospitals and stay at home, although they require urgent medical attention, while in-hospital logistical pathways have changed. For instance, PPE regulations have been implemented to reduce nosocomial infection rate, which has been reported to be as high as 41.3% [2]. However necessary, they may prove to be time-consuming in a code stroke setting. Despite these difficulties, successful outcome may be achieved, such as in our case. Since cerebrovascular disease has been observed in 5.9% of COVID-19 patients [3], this situation will not be infrequent. The implementation of protected code stroke is, therefore, essential [1, 4, 5]. Treating patients early after symptom onset remains the cornerstone of stroke management and stroke physicians should continue to pursue this goal during the COVID-19 pandemic.