key: cord-0770754-45n5kfsi
authors: Lee, Woong Jae; Byun, Jun Soo
title: Neurointervention in the Era of COVID-19: Korean Nationwide Survey, Literature Review, and Recommendations
date: 2021-09-01
journal: Neurointervention
DOI: 10.5469/neuroint.2021.00304
sha: 63f44d8ced78fdfb67b5400cad903f4cac2aa395
doc_id: 770754
cord_uid: 45n5kfsi

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a tremendous impact on healthcare systems worldwide. Although the most common presentation of COVID-19 is respiratory illness, neurologic manifestations are increasing and the pandemic may have consequential effects on urgent conditions such as acute ischemic stroke. In this document, we describe the current status of neurointervention in Korea affected by COVID-19 based on a nationwide survey and review relevant literature from other countries and professional societies.

Currently, Korea is in the era of its 4th pandemic with the coronavirus disease 2019 (COVID- 19) . As of August 6, 2021, the cumulative number of confirmed patients in Korea is 207,406, with more than 1,500 confirmed cases per day, resulting in 2,113 deaths. However, according to the Healthcare Bigdata Hub of Health Insurance Review and Assessment Service (HIRA), there was a mild increase in the number of aneurysm coilings in 2019 and 2020 (14, 384 in 2019 and 15,348 in 2020) and mechanical thrombectomy for acute stroke (4,954 in 2019 and 5,420 in 2020).

Screening for fever and respiratory symptoms should be part of the screening of all potential neurointervention patients. The reverse-transcription polymerase chain reaction testing (RT-PCR) with a nasal and pharyngeal swab is the current diagnostic gold standard for confirming infection with COVID-19. However, since this test takes several hours, many stroke patients tend to receive a rapid antigen test and chest computed tomography (CT) for emergency neurointervention, which can give results within minutes to tens of minutes.

Patients with suspected or confirmed COVID-19 must always wear a mask. It is recommended to use a dedicated route (including elevators) from the emergency department to the angiography suite for patients with suspected or confirmed COVID-19. 1 The physical and mental stress of healthcare workers during the COVID-19 pandemic is a substantial problem. A recent study to assess mental health problems in healthcare workers treating COVID-19 patients reported symptoms of depression, anxiety, insomnia, and distress. 2 For safe and efficient treatment of patients in the COVID-19 era, we describe the current status of neurointervention in Korea affected by COVID-19 based on a nationwide survey and review the literature from other countries and professional societies of neurointervention.

An online survey of Korean Society of Interventional Neuroradiology (KSIN) members was conducted from 14 September 2020 to 14 October 2020 using Google Forms. A total of 62 members (including 31 institutions) participated in the survey. Seventy-three percent of respondents were working at a tertiary medical institution, and 27% of respondents were working at a secondary medical institution. Topics covered included COVID-19 screening, healthcare worker precaution, neurointervention practice, clinical trial, and mental health (Supplementary Material).

To ensure safety from exposure and minimize the treatment delay of large vessel occlusion (LVO)-stroke patients, several professional societies have provided recommendations for decision-making regarding specific steps of management in patients requiring mechanical thrombectomy (MT) during the COVID-19 pandemic. 1, [3] [4] [5] [6] [7] Table 1 summarizes the recommendations of the latest publications for MT during the COVID-19 pandemic.

Review Screening for fever and respiratory symptoms should be part of the screening of all potential neurointervention patients. RT-PCR using a nasal and pharyngeal swab is the current diagnostic gold standard for confirming infection with COVID-19. However, since this test takes 4 to 24 hours depending on the institution, many stroke patients tend to receive a rapid antigen test and chest CT for emergency neurointervention, which can give results within minutes to tens of minutes. The rapid antigen test is relatively cheaper than the RT-PCR test (5.7 vs. 10.8 USD) 8 , and the sensitivity is reported to be 60.5-72. 1%, and the specificity is 98.7-99.5%. 8, 9 Survey results At the time of the survey, more than half of respondents (54.8%, 34 of 62) conducted an RT-PCR test in patients for emergent neurointervention, and 45.2% (28 of 62) were selectively performed in patients with suspicious COVID-19 symptoms. The time duration of COVID-19 test results for emergency procedures required 2-24 hours in 85.5% of respondents (53 of 62), 1-2 hours in 8. 1% (5 of 62), less than 1 hour in 1.6% (1 of 62), and more than 24 hours in 4.8% (3 of 62). Currently, it is mandatory for all patients to have an RT-PCR test in most institutions, and rapid tests can be selectively performed.

▶ Although the results of RT-PCR for a patient with suspected COVID-19 are not received until the end of the neurointervention procedure, 40.3% of respondents (25 of 62) immediately performed other tasks without waiting for a prophylactic quarantine, and 41.9% (26 of 62) of respondents stopped their work with a temporal quarantine until the test result was available. ▶ Only 1.6% (1 of 62) of physicians reported having an experience of treating a COVID-19 positive patient. There was no evidence of COVID-19 infection in the medical staff associated with the neurointervention service.

Review Initial chest radiography demonstrated 69-73% sensitivity in COVID-19 positive patients, but the sensitivity may decrease below 55% within 2 days of symptoms. 10, 11 Chest CT has substantially improved diagnostic performance over chest radiographs for COVID-19. Typical CT findings of COVID-19 pneumonia include (1) peripheral, bilateral, ground-glass opacities (GGO) (with or without consolidation or visible intralobular lines), (2) multifocal GGOs of rounded morphology (with or without consolidation or visible intralobular lines), and (3) reverse halo signs or other findings of organizing pneumonia (seen in a later stage of disease). 12 The chest CT sensitivity for COVID-19 relative to RT-PCR was 97-100%. 13, 14 Usually, it is not a suitable screening modality because the proportion of confirmed COVID-19 patients with normal chest CT was relatively high (30.8%). 15 However, in emergency neurointervention (including mechanical thrombectomy for acute ischemic stroke), chest CT could be a practical and rapid additional tool (mean acquisition time, 184±65.5 seconds; mean radiation dose, 2.47±1.03 mSv) for COVID-19 risk stratification prior to RT-PCR results. 13 Survey results In our survey, most respondents (83.9%, 52 of 62) underwent chest radiography regardless of COVID-19 symptoms when emergency neurointervention procedures were performed. Only 11.3% of respondents (7 of 62) underwent chest CT simultaneously with brain CT in all patients regardless of COVID-19 symptoms, and 74.2% of respondents (46 of 62) underwent chest CT simultaneously when COVID-19 symptoms were suspected.

Patients with suspected or confirmed COVID-19 must always wear a mask. It is recommended to use a dedicated route (including elevators) from the emergency department to the angiography suite for patients with suspected or confirmed COVID-19. For patients with suspected or confirmed COVID-19 who require intubation before mechanical thrombectomy, it is recommended to intubate them before going to the angiography suite. Performing intubation, extubation, and suction within the angiography suite may increase the risk of viral spread. 1 A single-use policy is recommended, but multiple dental masks overlapped on an N95 may be reasonable (given the shortage of equipment). 4 Limit the number of medical staff within the angiography suite to minimize the exposure from patients. If possible, the neurointervention team should be divided into 2 groups or rotated. 3, 5 Before patient arrival, the preparation of all equipment (e.g., thrombectomy kit) should be completed. Only selected essential equipment should be brought into the angiography suite. Doors must be closed during the procedure. 

Review Access to the current status of an angiography suite ventilation system (positive, negative, filtered, or recirculating air) may assist in the development of a specific workflow to limit viral spread. Isolation of COVID-19 in an angiography suite may not require an extra-ventilation system. However, a dedicated high-efficiency particulate air filtration system may be the best method, and a dedicated negative-pressure system (rather than positive-pressure) with air filtration may be ideal for protecting physicians. [3] [4] [5] After the procedure, cleaning and ventilation of the angiography suite must be ensured. All exposed surfaces within the angiography suite must be cleaned, ventilated for at least 30 minutes, and then it is recommended to wait for 30 minutes with the door closed before the next patient enters. 5, 16 Designating a COVID-19 room is necessary to protect other patients. 4 Survey results Only 16. 1% of respondents (5 of 62) had an available dedicated negative-pressure system in the angiography suite and most (83.9%, 57 of 62) did not. Most respondents (93.5%, 58 of 62) performed cleaning and ventilation of the angiography suite with the door closed after the treatment of a suspected or confirmed COVID-19 patient. Time of ventilation and disinfection after treatment of a suspected or confirmed COVID-19 patient was (1) more than 1 hour 30 minutes (47.5%), (2) 1 hour (23%), (3) 30 minutes (23%), or (4) not performed (6.6%).

Review MT for LVO stroke is highly time-dependent, and rapid initiation of treatment is crucial. Several studies observed a reduction in the number of MT procedures (28-48%), [17] [18] [19] [20] [21] [22] as well as delayed hospital presentation (last-known well time, increased by 54-160 minutes) 19, 20, 22 and delayed door-to-groin puncture time 18, 20, 23, 24 during the COVID-19 pandemic.

Two studies 20,24 demonstrated no significant difference in the rate of successful reperfusion during the pandemic, and another 2 studies 25,26 observed increased mortality despite successful reperfusion.

In our survey, 30.5% (18 of 59, ischemic stroke) and 26.7% (16 of 60, hemorrhagic stroke) of respondents reported a reduction (>25%) in emergency procedures during the pandemic compared with pre-pandemic levels. Only 5.1% (3 of 59, ischemic stroke) and 5.0% (3 of 60, hemorrhagic stroke) of respondents indicated an increase in emergency procedures. ▶ General anesthesia for mechanical thrombectomy was not performed (93.5%, 58 of 62) or rarely performed (3.2%, 2 of 62) in most respondents before the COVID-19 pandemic, and the practice of general anesthesia for mechanical thrombectomy was not changed after the COVID-19 pandemic in all respondents. ▶ Procedural details and outcomes of mechanical thrombectomy (delayed presentation, in-hospital delay, reperfusion rate, patient outcome) were not a component of the current survey.

Review Clinical trials of neurointervention have been disrupted following COVID-19 according to the survey by Rai et al. 27 (65 institutions included). They reported most respondents (78%) had suspended enrollment for clinical trials (32% completely or 46% partially) due to missed trial-related clinics (42%), missed imaging follow-up (37%), and protocol deviation (42%). New clinical trials were also halted in most sites (75%). Remote consent was available for some studies in 52% of sites and for all studies in 8% of sites. They suggested increased use of virtual consent and platform trials may increase enrollment during the pandemic. 

Review The physical and mental stress of healthcare workers during the COVID-19 pandemic may be substantial. A recent study to assess mental health problems in healthcare workers treating COVID-19 patients in China (1,257 individuals) reported symptoms of depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%). 2

In our survey, half of physicians (48.4%, 30 of 62) revealed mental and psychological problems including (multiple responses) depression (32.3%), anxiety (27.4%), and insomnia (3.2%).

We found a variety of workflow in various institutions during the COVID-19 pandemic. Full adherence to guidelines against COVID-19 may be challenging. However, specific steps of workflow with individualization according to specific patient conditions and institution circumstances could minimize the risk of COVID-19 spread during neurointervention.

Supplementary materials related to this article can be found online at https://doi.org/10.5469/neuroint.2021.00304.

This study was supported by the Korean Society of Interventional Neuroradiology (KSIN) research grant 2020.

Ethical approval for this study was obtained from the Chung-Ang University Hospital Institutional Review Board. This survey study did not involve patients, and all medical staff members of the survey agreed to participate in the study.

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