key: cord-0992727-t9v1hng5
authors: Al Kasab, Sami; Almallouhi, Eyad; Spiotta, Alejandro M.
title: Acute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic: From Trough of Disillusionment to Slope of Enlightenment
date: 2020-06-03
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.04.153
sha: 74fbb36546d5d1809465fec90f7e1f68d2a82905
doc_id: 992727
cord_uid: t9v1hng5

nan

S ince the initial report of infection with the coronavirus disease 2019 in December 2019, the number of confirmed COVI-19 cases has exceeded 1.6 million globally. 1 Without a vaccine in sight and given the success of social distancing, we expect the outbreak to last longer than originally projected. Social distancing while at work remains a challenge of us all. Mid-March, we implemented separate call teams, so that each of us only comes into contact with 4 to 5 coworkers at maximum over the course of the pandemic. These changes are necessary to maintain the workforce required to continue to be able to provide mechanical thrombectomy (MT) for our patients. Every stroke care system must prepare for the worst-case scenario involving a surge that completely overwhelms the capacity of that system to function. Over the last several weeks, we have been learning from our colleagues around the nation-first, news out of Seattle and then New York City, and now most recently from Detroit, with greater than 800 providers testing positive for COVID-19 at Henry Ford. With approximately 25% of health care providers being infected with the virus, we are faced with the challenge of providing the care our patients desperately require while ensuring the safety of our health care providers. 2 We must be mindful that our selfless tendencies as dedicated frontline providers do not become our biggest vulnerability. This challenge requires that we adjust our mindset and also place at the forefront the safety of ourselves and our teams. We make up one of the smallest and most subspecialized units in our hospitals. As such, we are easily incapacitated with quarantine or illness; who will take care of our community then?

This safeguarding requires major changes to our pre-COVID-19 workflow, to which the current pandemic has added multiple layers of complexity. Engagement of multiple specialties, including emergency department (ED) physicians, stroke neurologists, anesthesiologists and neurointensivists, is required. Fears and anxieties are normal human responses to a pandemic, and each must be acknowledged and addressed, never dismissed. In the acute stroke setting, the stakes are greatest because every minute counts. Although it may seem that there is not enough time to get it right, we must remember that this is also no time to get it wrong. That could mean being placed on diversion and not having the capacity to continue to treat our patients with stroke.

It begins with not overly burdening an already-tenuous hospital system. In the current COVID-19 crisis, there is critical bed shortage at greater level of care hospitals. We must therefore reduce the number of "futile transfers" from community hospitals and ensure that only patients who are likely to receive MT are transferred to the thrombectomy-capable center. Turning down a transfer could be the difference between being able to accept the next. This will entail obtaining advanced imaging at spoke hospitals to confirm the presence of proximal large vessel occlusion (LVO) before transport. Patients ruled out for LVO can remain at the spoke for routine care, even those who receive intravenous thrombolysis, particularly those spokes that are primary stroke center certified.

Even for patients in whom an LVO is confirmed, the criteria for transfer to the thrombectomy capable center should be decided on by a multidisciplinary team. During a pandemic and in the context of bed shortages, plus the prospect of bringing in vulnerable patients into an environment in which they might have a greater likelihood of acquiring the virus, hard decisions must be made. Accept the hard truth that your center should be more stringent in your criteria for MT, particularly for patients who don't fall within the guideline recommendations. As a team, discuss how you will handle those falling outside the "trial criteria"-very elderly patients, patients with mild, yet disabling stroke symptoms, and patients with distal occlusions. Only patients with a high likelihood of receiving thrombectomy should be transferred.

Once the patient with LVO who is an MT candidate arrives to your ED, all teams must be in alignment. Pre-thrombectomy screening for COVID-19 is a major challenge; often these patients are unable to provide a history and collateral information is typically lacking. The Society of NeuroInterventional Surgery currently recommends that patients with unknown COVID-19 status should be screened for fever and respiratory symptoms. 3 Given that approximately 35% of patients with COVID-19 are asymptomatic and the growing awareness that asymptomatic patients are able to transmit the virus, this screening might not be sufficient. 4 It may therefore be prudent to consider is to obtain a computed tomography (CT) scan of the chest to evaluate for underlying infiltrates at the time of obtaining a CT angiogram and perfusion. Although extending the CT to capture the entire chest entails additional radiation, identifying a lung infiltrate suggestive of likely COVID-19 infection in an asymptomatic patient affords the health care team the ability to don the proper precautions before the procedure.

Another question that has sparked major debate is whether to intubate patients before MT. Some proponents of an "intubate-all" approach argue that it protects the small and highly specialized MT team from exposure. Although all valid points, this approach fails to consider the other facets and team members along the way. Thrombectomy in and of itself is a low-risk procedure for contracting the virus, whereas the intubation and extubation are by far the greatest-risk components and would incur additional risk to your ED and neuro-intensive care unit (ICU) colleagues, respectively. In addition, intubating an elderly patient adds morbidity, and the airway management would require negativepressure rooms in both the ED and the neuro-ICU. These are resources expected to be either in very short supply or not available at all during peak surge.

The lowest-risk pathway to the system as a whole is to get the LVO patient through the thrombectomy awake and cooperative without requiring pre-procedure intubation. However, the greatest potential risk to both the anesthesia and MT teams is in the event the thrombectomy unexpectedly transforms into an aerosolgenerating procedure. A patient coughing or vomiting mid-WORLD NEUROSURGERY -: ---, MONTH 2020 www.journals.elsevier.com/world-neurosurgery procedure, would entail the worse possible scenario not just by the greatest-risk exposure to the providers but also in the delay it would incur. Neuroangiography suites are positive-pressure rooms (exceptions would be hybrid angio/operating room suites), necessitating a clearing out of the room by personnel following an aerosol-generating procedure like an intubation. Thus, the "lowest-risk" pathway is not necessarily the safest.

Finding the balance of risk to patient versus provider and resource use (negative-pressure rooms and personal protective equipment [PPE]) is delicate, and the decision of which patient should undergo preprocedural intubation is not straightforward. The Society of NeuroInterventional Surgery recommends a lower threshold for intubation for patients with suspected COVID-19, however, without specific criteria for intubation. 3 We suggest that those patients at risk for converting an otherwise noneaerosolgenerating procedure (thrombectomy) to a greater-risk procedure due to airway compromise should be intubated before MT. These would include those with severe stroke symptoms, patients with receptive aphasia, any signs of respiratory distress, or vertebrobasilar occlusion should be intubated before MT. Intubation ideally takes place in a negative-pressure room in the ED. Patients should then be transferred to the ICU with the same ventilator so that a closed circuit can be maintained.

The emergence of a faster COVID-19 test that provide results within minutes will provide us with a more efficient and reliable way to rapidly triage patients with LVO and avoid unnecessary intubations. However, until that test becomes widely available, following vigilant screening and maximizing precautions will be of paramount importance to protect our health care providers.

Another consideration is modification to your angio-suites for team protection. At our center, we have designated one of the biplanar rooms a "COVID-19" room, in which patients with suspected or confirmed COVID-19 receive MT. The door to this room has been sealed off, making it impermeable to aerosolized particles to completely isolate it from the control room. We have rehearsed an elaborate protocol to deliver additional supplies and devices into that room should they be needed via the hallway, as well as donning/doffing of PPE for room entry/exit protocol. Due to staff and PPE shortages, only essential personnel should be allowed into the COVID room during the procedure. This means that only one nurse, one technologist, the interventionists, and anesthesiologist are the only staff member to be in the room. Once the procedure is finished, patients are transferred to the ICU, where they are extubated in a negative-pressure room.

Remarkable challenges lie ahead of us, but we remain optimistic knowing that our field is graced with tremendously devoted, talented, and innovative people. Our solutions may not always be perfect, but these are also imperfect times, and we may have to do the best with what we can. However, one certainty remains: on reflecting back on these unprecedented times, it will be known that we answered the call for our patients. 

World Health Organization. Coronavirus disease (COVID-2019) situation reports

Protecting health-care workers from subclinical coronavirus infection

Society of NeuroInterventional Surgery recommendations for the care of emergent neurointerventional patients in the setting of COVID-19

Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19)