key: cord-0905409-je21hl28
authors: Sharma, Richa; Yim, Peter D.; García, Paul S.
title: Anesthetic Management for Endovascular Treatment of Stroke in Patients With Coronavirus Disease 2019: A Case Series
date: 2021-05-07
journal: A A Pract
DOI: 10.1213/xaa.0000000000001458
sha: 04b167dc4086aa53ed844dc7aeda27b8b62930bb
doc_id: 905409
cord_uid: je21hl28

A significant number of patients with coronavirus disease 2019 develop strokes with large vessel obstructions that may require endovascular treatment for revascularization. Our series focuses on periprocedural issues and the anesthetic management of these patients. We analyzed medical records of 5 patients with positive reverse transcription polymerase chain reaction tests for severe acute respiratory syndrome coronavirus 2 during their hospitalization who underwent endovascular treatment at our hospital between March and mid-June 2020. We found that our patients were different from the typical patients with ischemic stroke in that they had signs of hypercoagulability, hypoxia, and a lack of hypertension at presentation.

Richa Sharma, MBBS, Peter D. Yim, MD, and Paul S. García, MD, PhD A significant number of patients with coronavirus disease 2019 develop strokes with large vessel obstructions that may require endovascular treatment for revascularization. Our series focuses on periprocedural issues and the anesthetic management of these patients. We analyzed medical records of 5 patients with positive reverse transcription polymerase chain reaction tests for severe acute respiratory syndrome coronavirus 2 during their hospitalization who underwent endovascular treatment at our hospital between March and mid-June 2020. We found that our patients were different from the typical patients with ischemic stroke in that they had signs of hypercoagulability, hypoxia, and a lack of hypertension at presentation. (A&A Practice. 2021;15:e01458.) GLOSSARY ACE-2 = angiotensin-converting enzyme 2; BiPAP = bilevel positive airway pressure; CABG = coronary artery bypass graft; CAD = coronary artery disease; COVID-19 = coronavirus disease 2019; M1, M2 = horizontal and Sylvian segment of middle cerebral artery; MAC = minimum alveolar concentration; MODS = multiple organ dysfunction syndrome; OSA = obstructive sleep apnea; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; Spo 2 = pulse oxygen saturation; TICI = thrombolysis in cerebral infarction; tPA = tissue-type plasminogen activator; WBC = white blood cells I n this retrospective case series, we outline the underlying medical conditions, perioperative course, complications, and outcomes in 5 patients with coronavirus disease 2019 (COVID-19) with large vessel obstruction strokes. Our study was approved by the Columbia University Institutional Review Board, and written informed consent was obtained from all subjects or their legal surrogates. This article adheres to the applicable guidelines for case reports.

The Society for Neuroscience in Anesthesiology and Critical Care recognizes that the threshold for the use of general anesthesia for endovascular treatment may be reduced during the COVID-19 pandemic. 1 They describe suitable candidates for monitored anesthesia care during the COVID-19 pandemic as those who (a) have an anterior circulation or nondominant hemispheric stroke and a National Institutes of Health Stroke Scale <15, Glasgow Coma Scale >9, (b) do not have hypoxemia requiring highflow oxygen, and (c) are not actively coughing or vomiting, and are able to protect their airways. Patients with COVID-19 have multiple physiologic derangements that may worsen with disease progression. Severe coughing, high oxygen requirements, or altered mental status may or may not be apparent when a patient presents with stroke. Other factors possibly associated with COVID-19 infection, including clot fragmentation and migration, can complicate the procedure, causing acute changes in mental status or hemodynamic lability.

We included patients who had interventions for ischemic stroke in the neuroradiology suite between March 1 and June 14, 2020, and who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). All patients underwent general anesthesia for angiography and mechanical thrombectomy. Clinical data and the anesthetic management of the 5 patients who consented are outlined in a tabular format (Tables 1, 2).

Ischemic stroke is frequently accompanied by hypertension, but all 5 of our patients presented with systolic blood pressure <140 mm Hg and required vasopressor support during general anesthesia. Hypoxia is common in patients with COVID-19. All our patients had a history of recent pulmonary symptoms, and 2 presented with oxygen saturation <92%. Two patients had concurrent major arterial thrombotic events (myocardial infarction and pulmonary embolism). Clot fragmentation during mechanical thrombectomy was common, and available pathology described the clots as friable. Two patients had a hemorrhagic conversion.

Although interventions for many strokes in our hospital are frequently performed with monitored anesthesia care, general anesthesia was selected in all 5 of these patients.

cases-anesthesia-analgesia.org

Several factors contributed to this decision: the inability of the patient to cooperate, tenuous respiratory status, hemodynamic lability, or expectation of a long procedural time. The patients were maintained with sevoflurane with inspired oxygen concentration titrated to a pulse oximetry goal of 100%. All patients showed at least some need for 

Although respiratory complications are commonly associated with COVID-19, our case series highlights some other systemic complications of coronavirus infection. Approximately 70% of acute ischemic stroke patients present with hypertension (systolic blood pressure >140 mm Hg). 2 Neurogenic hypertension occurs shortly after an ischemic insult to maintain cerebral perfusion pressure. 3 It is mediated by an increased excitatory drive of the rostral ventrolateral medulla sympathoexcitatory neurons. 4 It is possible that ventrolateral medulla neuronal dysfunction through viral infection could result in blunting of the sympathetic nervous response to cerebral ischemia. We cautiously speculate that this mechanism, which could provide some scientific rationale, should be investigated further. Neuroinvasiveness and transsynaptic retrograde axonal transfer are common properties of coronaviruses 5 -phenomena that have been exemplified in studies where mice infected with severe acute respiratory syndrome coronavirus demonstrated virus in their thalami, cerebrum, and brainstem. 6 The SARS-CoV-2 spike protein has a high binding affinity to the angiotensin-converting enzyme 2 (ACE-2) receptor. 7 The rostral ventrolateral medulla has been demonstrated to express these receptors, where their overexpression augments the baroreceptor reflex and decreases blood pressure. 8 Viral docking on these ACE-2 receptors is one mechanism by which SARS-CoV-2 may cause a lack of hypertensive response in ischemic stroke patients. Other mechanisms by which SARS-CoV-2 may cause a lack of hypertensive response include ischemia from capillary endothelial damage and direct cytopathic damage to neurons. 9, 10 Our case series describes clot fragmentation and distal migration of the clot to various vascular territories. It is not known if clot composition is different in patients with COVID-19. Our patients' clots were dark red to tan in color, suggesting an erythrocyte-rich, friable composition. Clots with more red blood cells than white blood cells and fibrin are associated with higher chances of breakage and migration. 11 Tissue-type plasminogen activator (tPA) may further increase their fragility and migration, making them too distal to be approached by endovascular treatment. 12 Clots with lower leukocyte counts and fibrin are associated with noncardioembolic origin. 13 While 1 patient had risk factors for a thrombus of cardioembolic origin, it is conceivable that our patients' clots formed in situ in a prothrombotic and hyperinflammatory milieu, as evidenced by the high D-dimer levels, hypercoagulable rotational thromboelastometry profiles, and high levels of interleukin-6 and C-reactive protein. Systemic inflammatory responses heighten the risk of intracranial hemorrhage with tPA administered for ischemic stroke. 14 Therefore, further investigations into the hemorrhagic conversion of stroke in patients with COVID-19 who received tPA are warranted. In our study, all patients received tPA. Patient 5 had complete resolution of the clot with tPA only, but patients 1 and 2 developed hemorrhagic conversions after the endovascular treatment.

Some patients with ischemic stroke who undergo mechanical thrombectomy may have compelling reasons for systemic anticoagulation. Examples in our patients include main pulmonary artery embolism, brachial artery obstruction, myocardial ischemia, and severe hypoxemia, which is associated with a hypercoagulable state in the lungs of patients with COVID-19. Patients with COVID-19 with elevated D-dimer or sepsis-induced coagulopathy scores had lower mortality when treated with heparin compared with those not treated with heparin. 15 Superlative caution must be exercised when starting heparin in patients with COVID-19 who are status postendovascular treatment. If heparin is administered, the patient must be followed closely with clinical and imaging examinations.

In our institution, we routinely perform endovascular treatment under either general anesthesia or monitored anesthesia care depending on individual patient considerations. For all of the 5 patients, general anesthesia was deemed to be the best choice, especially to prevent emergency intubation and exposure of personnel to an aerosolizing procedure. In retrospect, 4 patients in our case series had distal clot fragment migration. Thrombus migration, embolism, or development of new cerebrovascular thrombi due to a prothrombotic state may make endovascular treatment technically challenging, necessitating general anesthesia. However, patients with COVID-19 may need significant amounts of vasopressor support when under general anesthesia. Unless a difficult airway is encountered (as in patient 4), general anesthesia did not significantly delay intervention in our group of patients.

Patients with COVID-19 and ischemic stroke may have poor mental status at presentation or as a result of complications of their clot fragmentation, migration, or hemorrhagic conversion after thrombectomy. This may be confounded by deep sedation, and intubation is often needed for adequate ventilation. Therefore, daily sedation wean and awakening trials are of paramount importance. They would facilitate early detection of a new stroke or postprocedural complications.

In summary, ischemic stroke patients with COVID-19 have atypical features. They usually have some degree of pulmonary compromise, with many requiring high inspired oxygen and positive pressure for adequate blood oxygen saturation (>94%). The procedure may be prolonged and technically challenging due to abnormal coagulability. Starting the case with general anesthesia may be a better choice compared to monitored anesthesia care to prevent the emergency conversion from the latter to the former. Maintaining normal to high blood pressure (systolic blood pressure 140-180 mm Hg) in patients with COVID-19 under general anesthesia frequently requires vasopressors due to atypical hemodynamic parameters. E DISCLOSURES Name: Richa Sharma, MBBS. Contribution: This author made substantial contributions to the conception of the work, the acquisition, analysis, and interpretation of data for the work; and drafting the work, revising it critically for important intellectual content; and final approval of the version to be published. Name: Peter D. Yim, MD. Contribution: This author made substantial contributions to the design of the work; the interpretation of data for the work, revising it critically for important intellectual content, final approval of the version to be published. Name: Paul S. García, MD, PhD. Contribution: This author made substantial contributions to the design of the work; the interpretation of data for the work, revising it critically for important intellectual content, final approval of the version to be published. This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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