key: cord-0835551-8yjxpb5e authors: Khanna, Omaditya; Hafazalla, Karim; Saiegh, Fadi Al; Tahir, Rizwan; Schunemann, Victoria; Theofanis, Thana N; Mouchtouris, Nikolaos; Gooch, M. Reid; Tjoumakaris, Stavropoula; Rosenwasser, Robert H.; Jabbour, Pascal M title: Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19 date: 2021-05-13 journal: Clin Neurol Neurosurg DOI: 10.1016/j.clineuro.2021.106677 sha: 9c05055b731b50bcfcc4695f3a2b5f958b5c8ee9 doc_id: 835551 cord_uid: 8yjxpb5e Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions. Patients presenting with acute stroke owing to bilateral large vessel occlusions (LVO) is a rare entity, with only a handful of reported cases in the literature. (1, 2) Underlying medical conditions that result in a hypercoagulable, pro-thrombotic state may predispose patients to more extensive thrombo-embolic events. The SARS-CoV-2 virus has been implicated in an increased incidence of cryptogenic stroke, particularly amongst young patients without any known risk factors. This phenomenon is thought to be a result of the hypercoagulable state owing to systemic inflammation from cytokine storm, and direct viral injury causing endotheliopathy leading to vessel thrombosis. (3) Herein, we present a case report of a patient who presented with bilateral anterior circulation large vessel occlusions, who was incidentally found to be COVID-19 positive upon emergent admission screening but otherwise asymptomatic, and was successfully treated via simultaneous mechanical thrombectomy with excellent clinical outcome. J o u r n a l P r e -p r o o f The patient is a 67-year-old female non-smoker with a past medical history of hypertension who presented with acute onset of aphasia and right-sided hemiparesis. Upon arrival of emergency medical services, she was found to be unresponsive, and was intubated for airway protection and Upon transfer to our institution, the patient's neurological exam was poor: she was globally aphasic, with a complete right-sided hemiplegia, withdrawing to pain minimally on the left side. Given the patients clinical and radiographic findings, the decision was made to take her for emergent mechanical thrombectomy. The patient was taken to Interventional radiology suite and bilateral femoral sites were accessed for bilateral mechanical thrombectomy with the attending neurosurgeon and endovascular fellow working in conjunction on each side. Each femoral artery was catheterized with an 8F sheath, and a 5F Berenstein catheter within a 90-cm Neuronmax sheath (Penumbra, Alameda, CA) was used to simultaneously catheterize the bilateral internal carotid arteries ( Figure 2 ). The bilateral occlusions were addressed at the same time, and fluoroscopy used throughout the procedure visualized both sides. A left internal carotid artery (ICA) run showed an ICA terminus occlusion. A one pass aspiration with a React 71 catheter and Riptide pump (Medtronic, Fridley, MN) was performed at the same with a right sided one pass aspiration with a React 071 too. TICI 3 recanalization was achieved after a single pass on both sides ( Figure 2 ). The patient was transferred to the neurological intensive care unit (NICU). The patient was extubated without incident the following morning, and was found to be neurologically intact, without any impaired prosody of speech or residual hemiparesis. A post-thrombectomy MRI showed bilateral scattered FLAIR hyperintensity suggestive of microangiopathy, albeit no evidence of acute infarction. The patient's stroke work-up was unremarkable: she had a normal lipid panel and HbA1c (5.6%). Trans-thoracic echocardiogram (TTE) was unremarkable for any wall-motion abnormalities, or valvular thrombi, and the patient is being considered for a LINQ device as an outpatient. The patient was started on 81 mg Aspirin daily for secondary stroke prevention. Post-procedural lab work was also relatively unremarkable for widespread inflammatory or infectious markers. The patient had a normal CBC (WBC count of 10.5, with 85% neutrophils), and mildly elevated C-reactive protein (2.5 mg/dL) and procalcitonin (0.18 ng/mL) levels, which may represent post-procedural inflammation and sequelae of her transient ischemic attack. Hematologic work-up was significant only for an elevated D-dimer (436 ng/mL) with normal fibrinogen level (418 mg/dL). Lower extremity ultrasound was negative for evidence of any deep vein thrombosis. The incidence of patients presenting with bilateral LVO's is relatively rare, and a few cases reported in the literature have implicated underlying medical conditions that render a patient into a pro-inflammatory, pro-thrombotic state as being at especially increased risk. This past year, several case reports have shown an association between COVID-19 and risk of ischemic stroke, particularly in patients without any other known cardiovascular risk factors. Stroke has also been reported to be the presenting symptom in patients with previously unknown COVID-19 infection.(4) Although the pathophysiologic causation between COVID-19 and ischemic stroke has yet to be elucidated, it is thought that a systemic pro-inflammatory cascade coupled with direct injury of blood vessels renders patients at increased risk of thromboembolic injury. Patients with multifocal vessel occlusions are likely to present with high NIHSS scores, highlighting the severity morbidity and mortality associated with this condition. It is imperative to pursue a treatment strategy that facilitates reperfusion. In patients with concomitant anterior and posterior circulation (e.g. basilar occlusion) thrombi, it may be prudent to focus initial attention on the latter given its critical blood supply to the brainstem. In patients with concomitant anterior circulation occlusions, simultaneous thrombectomy via bilateral access should be considered in order to give the patient the best chance of achieving a functional recovery. Our study, as well as several others that have described this technique, gives credence to the treatment paradigm of simultaneous bilateral thrombectomy as a safe and efficacious way of patients presenting with multifocal large vessel occlusions. In patients presenting with bilateral large vessel occlusions, simultaneous treatment via bilateral arterial cannulation should be considered to achieve faster time to recanalization. At institutions where two neuroendovascular practitioners are available, each can work on either side to achieve arterial access and selectively catheterize vessels of interest. In our case, bilateral mechanical thrombectomy was performed simultaneously to try to maximize chances of recovery, this Endovascular treatment in two cases of bilateral ischemic stroke Acute Bilateral Internal Carotid Artery Occlusion Presenting with Symmetric Cortical Infarctions Exhibits Dramatic Improvement After Mechanical Thrombectomy Endothelial cell infection and endotheliitis in COVID-19 Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young Battle-Tested Guidelines and Operational Protocols for Neurosurgical Practice in Times of a Pandemic: Lessons Learned from COVID-19 The authors report no competing interests.