Interventional Stroke Care in the Era of COVID-19

'Care' immediately tells me these people are infected with the tyranny of low expectations. We DEMAND RESULTS AND 100% RECOVERY.  When the hell will you get there? 

Interventional Stroke Care in the Era of COVID-19

Hisham Salahuddin¹, Alicia C. Castonguay¹, Syed F. Zaidi^1,2, Richard Burgess¹, Ashutosh P. Jadhav³ and Mouhammad A. Jumaa^1,2*

• ¹Department of Neurology, University of Toledo, Toledo, OH, United States
• ²Promedica Neurosciences Center, Toledo, OH, United States
• ³Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States

The current coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to immense strain on healthcare systems and workers. Patients with severe symptoms of COVID-19 may also present with acute neurological emergencies such as ischemic stroke. Ischemic stroke in these patients may result from COVID-19 related complications or decompensation of previously asymptomatic cerebrovascular disorders, or concurrent ischemic stroke from common stroke risk factors in a patient with COVID-19. Acute ischemic stroke patients with large vessel occlusions require emergent triage, intensive care, and mechanical thrombectomy. Management of patients with large vessel occlusions (LVO) requires special considerations in the current pandemic. Physicians must now account for prognosis of severe COVID-19, resource utilization, and risk of infection to healthcare workers when determining eligibility for mechanical thrombectomy (MT). Here, we describe important prognostic factors including age, laboratory, and imaging findings to consider for MT selection and provide suggestions for taking care of patients with LVO and possible or confirmed COVID-19. It is recommended to perform MT in patients within the established guidelines, and consider a conservative approach in cases where there is clinical equipoise to minimize futile reperfusion. Lastly, we describe an illustrative case of a patient with ischemic stroke and COVID-19.

Introduction

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China (1). High rates of transmissibility, primarily through airborne droplets and aerosols and international travel, have led to a worldwide pandemic. The United States (US) leads the world in the number of COVID-19 cases, and there are growing concerns regarding the potential strain on its healthcare systems due to the intensive care needed for critically ill COVID-19 patients (2). Initial reports from other countries have already highlighted the stress of COVID-19 on their intensive care units (ICU) and resources (3). A recent case series of critically ill COVID-19 patients in Seattle, Washington reported a median ICU stay of 14 days and a median duration of mechanical ventilation of 10 days (4). With emergency departments and ICUs triaging and caring for increasing numbers of COVID-19 patients, there is little doubt that the COVID-19 pandemic will have a tremendous impact on available resources for the triage and treatment of acute ischemic stroke (AIS). Here, we present an overview of COVID-19, recommendations for acute stroke care and treatment, and provide an illustrative case study of stroke in a COVID-19 positive patient.