Acute Neurological Care in the COVID-19 Era: The Pandemic Health System RE silience PROGRAM (REPROGRAM) Consortium Pathway

Abstract

The management of acute neurological conditions, particularly acute ischemic stroke, in the context of Coronavirus disease 2019 (COVID-19), is of importance, considering the risk of infection to the healthcare workers and patients and emerging evidence of the neuroinvasive potential of the virus. There are variations in expert guidelines further complicating the picture for clinicians in acute settings. In this light, there is a compelling need for further formulation of recommendations that compile these variations seen in the numerous guidelines present. Health system protocols for managing ongoing acute neurological care and intervention need consideration of safety and well-being of the frontline healthcare workers and the patients. We examine existing pathways and their efficacy to mitigate viral exposure to the healthcare workers and patients and synthesize a systemic approach to manage patients with acute neurological conditions in the COVID-19 scenario. Early experiences with a COVID-19 positive stroke patient treated with endovascular thrombectomy is presented to highlight the urgent need for adequate personal protective equipment (PPE) during acute neuro-interventional procedures.

Keywords: Coronavirus disease 2019 (COVID-19); Personal Protective Equipment (PPE); acute stroke; guidelines; neurointervention; reperfusion; safety; surgery.

Figure 1

Proposed acute stroke pathway in the setting of the coronavirus 2019 (COVID-19) pandemic. Notably, there are 3 different suite options recommended: Non-COVID, Suspected COVID and Confirmed COVID. EMS, Emergency Medical Services; NPA, Nasopharyngeal Aspirate; PPE, Personal Protective Equipment; IVT, Intravenous Thrombolysis; EVT, Endovascular Therapy; ICU, Intensive Care Unit; CT, Computed Tomography.

Figure 2

Illustration of an acute stroke reperfusion work-up in a COVID-19 positive case. A patient in the age-group of 65–75 years, with a history of atrial fibrillation and on anticoagulation, presented to an outside facility with difficulty breathing (dyspnea), high temperature and severe cough. COVID-19 work-up was followed and the patient tested positive for COVID-19. Chest computed tomography (CT) revealed bilateral infiltrates (A). The patient was intubated and sedated a day later. On Day 3, the nurse noticed that she was not moving the left side to painful stimuli; given the time of onset could not be determined (unknown), intravenous thrombolysis was not given. Baseline non-contrast computed tomography (NCCT) head was normal; the patient was transferred to the comprehensive stroke center. CT angiography (CTA) showed the right M1 and A2 occlusions. Pre-intervention digital subtraction angiography (DSA) confirmed occlusion in the right M1 and A2 arteries (B). Endovascular thrombectomy (EVT) was performed successfully with complete angiographic reperfusion (thrombolysis in cerebral infarction (TICI) score of 3). The patient was still intubated by the time the manuscript was written. (C) Post-intervention DSA imaging demonstrated good reperfusion outcome (TICI3). A clinician with 3M™ Versaflo™ TR-600 Powered Air Purifying Respirator (PAPr) – personal protective equipment (PPE) for protection against the air-borne virus is shown (D). The interventional neuroradiology (INR) team doing the EVT procedure while wearing their full PPEs (sterile gown, gloves and PAPr) is shown (E). Post-procedure, all INR suite equipment including anesthesia machines and pyxis are secured using surgical drapes and equipment covers (F). COVID-19, Coronavirus 2019; NCCT, Non-contrast computed tomography angiography; CTA, CT angiography; EVT, Endovascular thrombectomy; TICI, Thrombolysis in cerebral infarction score; DSA, Digital subtraction angiography; PAPr, Powered Air Purifying Respirator; PPE, Personal protective equipment; INR, Interventional neuroradiology.