Endovascular Therapy for Acute Ischemic Stroke During COVID-19 Pandemic

May 12, 2020
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Authors:
Smith MS, Bonomo J, Knight WA IV, et al.
Citation:
Endovascular Therapy for Patients With Acute Ischemic Stroke During the COVID-19 Pandemic: A Proposed Algorithm. Stroke 2020;Apr 30:[Epub ahead of print].
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • Acute stroke patients presenting to the ED who cannot be screened for symptoms of COVID-19 (e.g., because of encephalopathy or aphasia) should be assumed to have COVID-19.
  • In centers where resources are scarce, it may be reasonable to limit endovascular therapy (EVT) to patients in whom the largest benefit can be expected.
  • In ventilated COVID-19 patients, sedation should be weaned every 8 hours to assess for signs of large vessel occlusion.

Study Questions:

By applying consensus borne out of a multidisciplinary working group from a single institution, what is a reasonable algorithm for evaluation and treatment of acute ischemic stroke patients eligible for endovascular therapy (EVT) during the coronavirus disease 19 (COVID-19) pandemic?

Methods:

Recommendations are presented both for stroke patients presenting to the emergency department (ED) with unknown COVID status and for admitted COVID-positive stroke patients.

Results:

The following recommendations should be considered in the evaluation and treatment of stroke patients who are potential candidates for EVT during the COVID-19 pandemic:

  • Acute stroke patients presenting to the ED should be screened for fever 38° C (100° F), tachypnea, history of subjective fever/chills/myalgias/etc., and exposure to anyone with known or suspected COVID-19 in the prior 14 days. Patients who cannot be screened (e.g., because of encephalopathy or aphasia) should be assumed to have COVID-19.
  • If the above screening is negative, stroke patients should be treated per pre-COVID-19 protocols but should wear a surgical mask throughout their evaluation and treatment.
  • After they have undergone appropriate acute stroke imaging, patients with suspected or confirmed COVID-19 who require endotracheal intubation should undergo intubation (using either etomidate or ketamine to preserve cerebral perfusion pressure) in a negative airflow room by an experienced airway specialist before transport to the interventional neuroradiology suite for thrombectomy.
  • In centers where resources are scarce, it may be reasonable to limit EVT to patients in whom the largest benefit can be expected (e.g., patients with low pre-stroke disability, patients with proximal rather than distal arterial occlusions, patients with small ischemic cores on computed tomography perfusion imaging).
  • In hemodynamically stable COVID-19 patients undergoing mechanical ventilation, sedation should be weaned every 8 hours to assess for signs of large vessel occlusion (gaze deviation and focal weakness).
  • It is reasonable to withhold EVT from most COVID-19 patients undergoing extracorporeal membrane oxygenation or advanced ventilator management for acute respiratory distress syndrome due to high anticipated mortality.
  • At centers where intensive care unit (ICU) beds are limited, post-EVT patients may be admitted to step-down or floor beds following uncomplicated procedures. In addition, it may be reasonable to forego customary post-EVT Q1h neurologic exams (after the initial 2 hours) to conserve staff and PPE.

Conclusions:

The evaluation and treatment of acute large vessel occlusion stroke present many challenges during the COVID-19 era. It may be difficult to screen stroke patients for COVID-19 symptoms because of encephalopathy or aphasia. Stroke patients require transportation for emergent acute stroke imaging, which consumes PPE and risks exposing staff. Patients who undergo EVT often require intubation, an aerosol-generating procedure.

Perspective:

At some centers during the COVID-19 pandemic, performance of EVT may consume scarce medical resources (such as staff, ICU beds, PPE, and other equipment) that may be better directed toward other uses. It is ethical at these centers to limit EVT to stroke patients in whom the largest benefit can be expected.

Clinical Topics: Cardiac Surgery, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Imaging

Keywords: Aphasia, Brain Ischemia, Coronavirus, Coronavirus Infections, COVID-19, Diagnostic Imaging, Endovascular Procedures, Extracorporeal Membrane Oxygenation, Myalgia, Respiration, Artificial, Respiratory Distress Syndrome, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Stroke, Thrombectomy, Vascular Diseases


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