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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 ana-
lyzed medical records of 5 patients with positive reverse transcription polymerase chain reac-
tion 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 alveo-
lar concentration; MODS = multiple organ dysfunction syndrome; OSA = obstructive sleep apnea;
SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; Spo2 = 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 may worsen with disease progression. Severe coughing,
medical conditions, perioperative course, complications, high oxygen requirements, or altered mental status may or
and outcomes in 5 patients with coronavirus disease may not be apparent when a patient presents with stroke.
2019 (COVID-19) with large vessel obstruction strokes. Other factors possibly associated with COVID-19 infection,
Our study was approved by the Columbia University including clot fragmentation and migration, can complicate
Institutional Review Board, and written informed consent the procedure, causing acute changes in mental status or
was obtained from all subjects or their legal surrogates. This hemodynamic lability.
article adheres to the applicable guidelines for case reports.
The Society for Neuroscience in Anesthesiology and CASE DESCRIPTIONS
Critical Care recognizes that the threshold for the use of We included patients who had interventions for ischemic
general anesthesia for endovascular treatment may be stroke in the neuroradiology suite between March 1 and
reduced during the COVID-19 pandemic.1 They describe June 14, 2020, and who tested positive for severe acute
suitable candidates for monitored anesthesia care during respiratory syndrome coronavirus 2 (SARS-CoV-2). All
the COVID-19 pandemic as those who (a) have an ante- patients underwent general anesthesia for angiography and
rior circulation or nondominant hemispheric stroke and mechanical thrombectomy. Clinical data and the anesthetic
a National Institutes of Health Stroke Scale <15, Glasgow management of the 5 patients who consented are outlined
Coma Scale >9, (b) do not have hypoxemia requiring high- in a tabular format (Tables 1, 2).
flow oxygen, and (c) are not actively coughing or vomit- Ischemic stroke is frequently accompanied by hyperten-
ing, and are able to protect their airways. Patients with sion, but all 5 of our patients presented with systolic blood
COVID-19 have multiple physiologic derangements that 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 pul-
From the Department of Anesthesiology, Columbia University Medical
Center, NewYork-Presbyterian Hospital, New York, New York. monary symptoms, and 2 presented with oxygen saturation
Accepted for publication March 23, 2021. <92%. Two patients had concurrent major arterial throm-
Funding: None. botic events (myocardial infarction and pulmonary embo-
The authors declare no conflicts of interest. lism). Clot fragmentation during mechanical thrombectomy
Address correspondence to Richa Sharma, MBBS, Department of was common, and available pathology described the clots
Anesthesiology, Columbia University Medical Center, NewYork- as friable. Two patients had a hemorrhagic conversion.
Presbyterian Hospital, 622 W 168 St PH-5, New York, NY 10032. Address
e-mail to ris9075@nyp.org.
Although interventions for many strokes in our hospital
Copyright © 2021 International Anesthesia Research Society.
are frequently performed with monitored anesthesia care,
DOI: 10.1213/XAA.0000000000001458 general anesthesia was selected in all 5 of these patients.
Several factors contributed to this decision: the inabil- time. The patients were maintained with sevoflurane with
ity of the patient to cooperate, tenuous respiratory status, inspired oxygen concentration titrated to a pulse oximetry
hemodynamic lability, or expectation of a long procedural goal of 100%. All patients showed at least some need for
2
cases-anesthesia-analgesia.org A & A PRACTICE
Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Table 2. Summaries of Anesthetic Management
Patient 1 2 3 4 5
Anesthetic General anesthesia General anesthesia General anesthesia General anesthesia General anesthesia
Site of intubation Outside hospital Emergency department Arrived intubated from intensive Neuroradiology suite Emergency depart-
care unit ment
Team performing Unknown team Anesthesiology Anesthesiology Anesthesiology Emergency medicine
intubation
Rapid sequence Unknown Yes - (electively intubated for Yes No
intubation cardiac surgery in a prior
encounter)
Airborne precautions Unknown Yes No Yes Yes
Induction drugs given Arrived on fentanyl Midazolam 10 mg, Off sedation and Fentanyl 50 mg, propofol, 180 Etomidate and
at the time of and propofol propofol 50 mg, suc- unresponsive when mg, succinylcholine 300 rocuronium
intubation drips. Induction cinylcholine 160 mg, stroke suspected. mg, rocuronium 100 mg
drugs unknown rocuronium 50 mg Emergency transfer to
(intubation record neurointervention suite
unavailable)
Periprocedural On arrival had Desaturation to Spo2 60% Continual titration between Required multiple attempts by None
anesthesia Spo2 50%–60%. during transfer between vasopressors and vaso- different anesthesiologists,
complications Possible gurney and intensive dilators to maintain brain failed ventilation by
bronchospasm. care unit bed and Spo2 perfusion and coronary supraglottic airway,
Saturation increased with positive vasodilation in the setting failed videolaryngoscope
improved with pressure of his recent coronary intubation. Final airway
positive pres- arterial bypass grafting by direct laryngoscopy.
sure and dilute surgery and postoperative Right main-stem intubation
epinephrine myocardial ischemia requiring 2 adjustments
Procedural anes- Fentanyl and pro- Fentanyl infusion was Sevoflurane ~0.5 MAC in the Maintained on sevoflurane - Propofol infusion and
thesia pofol infusions continued along with first half of the case and 0.5–1 MAC and intermittent rocuronium
were continued ~0.5–1 MAC sevoflu- later on a low dose propo- boluses of fentanyl
along with ~0.4 rane fol infusion. Rocuronium as
MAC sevoflurane needed
Vasopressors admin- Phenylephrine infu- Phenylephrine infusion Norepinephrine (12 μg/ Phenylephrine boluses (80 µg) Phenylephrine infu-
istered (maximum sion (180 µg/ (250 µg/min) min), vasopressin (6 U/h) sion (80 µg/min)
dose) min) infusions
Systolic blood pres- 125–155 mm Hg 125–175 mm Hg 125–180 mm Hg 125–200 mm Hg 125–160 mm Hg
sure range
Spo2 range 72%–100% 100% 99%–100% Low 90s 96%–100%
Fraction of inspired 100% 100% 68%–97% 50%–100% 60%–70%
oxygen
Tissue plasminogen Yes Yes Yes Yes Yes
activator admin-
istered
Neurointervention 3 attempts were 3 attempts using stent- Combination of stent- Initial thrombectomy by “A The previously
performed for aspiration combination aspiration thrombectomy direct aspiration first pass” observed clot in
clot retrieval. therapy were made. used. Despite 2 attempts, technique and the “stent the dominant mid-
Each attempt Clot fragmentation clot fragmentation and retriever with simultane- dle cerebral artery
resulted in distal with distal emboli into distal emboli to bilateral ous aspiration technique” branch was no
clot fragmenta- a new territory, the posterior cerebral arteries were unsuccessful. Primary longer observed,
tion and eventual anterior cerebral artery, was seen suction aspiration was then consistent with
downstream and into downstream performed recanalization
migration into the middle cerebral artery after tissue plas-
cortical segment branches was seen minogen activator
of middle cere- administration
bral artery
TICI grade 2A 2B 3 (anterior circulation), 2B 3 No
revascularization (basilar occlusion)
Hemorrhagic conver- ~12 h from ~12 h from endovascular No No No
sion of infarct endovascular treatment
treatment
Postoperative course Increasing need Vasopressor require- Failure of neurologic examina- Uncomplicated recovery Uncomplicated
for vasopressor ment decreased with tion to improve, fever, recovery
and inotropic sedation wean but persistent hypoxia. Further
support; neurologic examination investigation revealed
increasing failed to improve positive COVID-19 (was not
leukocyte counts tested preprocedure). Later
developed MODS
Outcome Comfort care Comfort care Death Rehabilitation Rehabilitation
Abbreviations: COVID-19, coronavirus disease 2019; MAC, minimum alveolar concentration; MODS, multiple organ dysfunction syndrome; Spo2, pulse oxygen
saturation; TICI, thrombolysis in cerebral infarction.
4
cases-anesthesia-analgesia.org A & A PRACTICE
Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
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