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E  Case Series

Anesthetic Management for Endovascular Treatment


of Stroke in Patients With Coronavirus Disease 2019:
A Case Series
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 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.

May 2021 • Volume 15 • Number 5 cases-anesthesia-analgesia.org 1


Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Table 1. Summaries of Patient Presentations
Patient 1 2 3 4 5
Age/sex 58/male 64/male 57/male 37/female 71/female
Diabetes No No Yes Yes Yes
Body mass index 25 43 30 46 39
Hypertension No No Yes Yes Yes
Comorbidities Chronic obstructive Recent prostate Hyperlipidemia, CAD Empty sella turcica OSA on home BiPAP,
pulmonary disease cancer diag- status post percuta- syndrome, chronic Restrictive lung dis-
and lung cancer, status nosis, status neous intervention headaches, recent ease, hyperlipidemia,
post partial lobectomy; post radiation with bare metal pregnancy status previous mitral valve
CAD, status post-CABG; stent 11 y ago post dilation and repair, hypothyroid-
thymoma with pericar- curettage 2 mo ism. New dilated
dial involvement, status ago nonischemic cardio-
post-thoracotomy myopathy severe left
atrial enlargement
Other manifestations of No Pulmonary Brachial artery occlu- No No
hypercoagulability embolism sion, ST-elevation
myocardial infarction
Acute respiratory distress Yes Yes Yes No No
syndrome
Agitation, lack of coopera- Unknown Yes Yes Yes Yes
tion or aphasia
Symptoms of COVID-19 Yes Yes Yes Yes Yes
Days between first symp- 11 2 6 d between 14 d between first 7
toms of experiencing starting empiric
COVID-19 and stroke unstable angina treatment for
symptoms which was the first presumed
manifestation of bronchitis and
COVID-19 and stroke stroke
Initial blood pressure 120/80 mm Hg (sedated, 120/70 mm Hg 118/81 mm Hg 133/90 mm Hg 130/76 mm Hg
no pressor)
Initial oxygen saturation Unknown 98% 96% (intubated) 90% 83%
WBC count (109/L) 20.5 11.6 11.2 7.8 6.9
Platelet count (109/L) 437 273 140 359 242
C-reactive protein (normal 79.89 282.35 250.65 (6 d after 8.68 5.62
≤0.00–10.00 mg/L) stroke)
D-dimer (normal ≤0.80 >20 >20 9.93 (13 d after stroke) 15.87 >20 (after tissue plas-
μg/mL) minogen activator)
Procalcitonin (ng/mL) 0.26 0.78 3.21 (13 d after stroke) 0.04 0.12
Fibrinogen (mg/dL) 497 Not applicable 549 (16 d after stroke) 79 <60
Interleukin-6 (normal ≤5.0 Not applicable 65.2 18 (6 d after stroke) 8.9 32.2
pg/mL)
Creatinine (peak) (mg/dL) 1.29 1.08 1.55 0.45 1.49
Time to thrombectomy 120 min 265 min 183 min 263 min Not performed
Prestroke National Insti- 27 29 23 9 18
tutes of
Health stroke scale
score
Thrombus location Left middle cerebral artery, Left internal Right vertebral 4, proxi- Distal right internal Short segment occlu-
left internal carotid carotid artery/ mal left vertebral 4 carotid artery clot, sion of the perisyl-
artery (proximal) left middle and proximal/mid right M1 cutoff with vian M2
cerebral artery basilar components reconstitution of
vessels distally
Time to tissue plasmino- 48 min 85 min 92 min 95 min 125 min
gen activator
Clot pathology Multiple, irregular soft, Path not avail- Multiple, irregular soft, 5 irregular pieces of No clot retrieved
tan-brown to dark red able tan-brown to dark soft, tan-brown to
subcentimetric red subcentimet- dark red tissue
-<2 cm pieces ric-<2 cm pieces measuring from
0.4 × 0.4 × 0.1 cm
to 0.9 × 0.8 ×
0.2 cm
Abbreviations: 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; OSA, obstructive sleep apnea; WBC, white blood cells.

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

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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.

May 2021 • Volume 15 • Number 5 cases-anesthesia-analgesia.org 3


Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
vasopressor administration. Three patients died, and 2 systemic anticoagulation. Examples in our patients include
patients were discharged to rehabilitation facilities. main pulmonary artery embolism, brachial artery obstruc-
tion, myocardial ischemia, and severe hypoxemia, which
DISCUSSION is associated with a hypercoagulable state in the lungs of
Although respiratory complications are commonly associated patients with COVID-19. Patients with COVID-19 with ele-
with COVID-19, our case series highlights some other sys- vated D-dimer or sepsis-induced coagulopathy scores had
temic complications of coronavirus infection. Approximately lower mortality when treated with heparin compared with
70% of acute ischemic stroke patients present with hyper- those not treated with heparin.15 Superlative caution must
tension (systolic blood pressure >140 mm Hg).2 Neurogenic be exercised when starting heparin in patients with COVID-
hypertension occurs shortly after an ischemic insult to 19 who are status postendovascular treatment. If heparin is
maintain cerebral perfusion pressure.3 It is mediated by an administered, the patient must be followed closely with
increased excitatory drive of the rostral ventrolateral medulla clinical and imaging examinations.
sympathoexcitatory neurons.4 It is possible that ventrolateral In our institution, we routinely perform endovascular
medulla neuronal dysfunction through viral infection could treatment under either general anesthesia or monitored anes-
result in blunting of the sympathetic nervous response to thesia care depending on individual patient considerations.
cerebral ischemia. We cautiously speculate that this mecha- For all of the 5 patients, general anesthesia was deemed to be
nism, which could provide some scientific rationale, should the best choice, especially to prevent emergency intubation
be investigated further. Neuroinvasiveness and transsynaptic and exposure of personnel to an aerosolizing procedure. In
retrograde axonal transfer are common properties of corona- retrospect, 4 patients in our case series had distal clot frag-
viruses5—phenomena that have been exemplified in studies ment migration. Thrombus migration, embolism, or develop-
where mice infected with severe acute respiratory syndrome ment of new cerebrovascular thrombi due to a prothrombotic
coronavirus demonstrated virus in their thalami, cerebrum, state may make endovascular treatment technically challeng-
and brainstem.6 The SARS-CoV-2 spike protein has a high ing, necessitating general anesthesia. However, patients with
binding affinity to the angiotensin-converting enzyme 2 COVID-19 may need significant amounts of vasopressor sup-
(ACE-2) receptor.7 The rostral ventrolateral medulla has been port when under general anesthesia. Unless a difficult airway
demonstrated to express these receptors, where their over- is encountered (as in patient 4), general anesthesia did not sig-
expression augments the baroreceptor reflex and decreases nificantly delay intervention in our group of patients.
blood pressure.8 Viral docking on these ACE-2 receptors is Patients with COVID-19 and ischemic stroke may have
one mechanism by which SARS-CoV-2 may cause a lack of poor mental status at presentation or as a result of complica-
hypertensive response in ischemic stroke patients. Other tions of their clot fragmentation, migration, or hemorrhagic
mechanisms by which SARS-CoV-2 may cause a lack of conversion after thrombectomy. This may be confounded by
hypertensive response include ischemia from capillary endo- deep sedation, and intubation is often needed for adequate
thelial damage and direct cytopathic damage to neurons.9,10 ventilation. Therefore, daily sedation wean and awakening tri-
Our case series describes clot fragmentation and distal als are of paramount importance. They would facilitate early
migration of the clot to various vascular territories. It is detection of a new stroke or postprocedural complications.
not known if clot composition is different in patients with In summary, ischemic stroke patients with COVID-19
COVID-19. Our patients’ clots were dark red to tan in color, have atypical features. They usually have some degree of
suggesting an erythrocyte-rich, friable composition. Clots pulmonary compromise, with many requiring high inspired
with more red blood cells than white blood cells and fibrin oxygen and positive pressure for adequate blood oxygen
are associated with higher chances of breakage and migra- saturation (>94%). The procedure may be prolonged and
tion.11 Tissue-type plasminogen activator (tPA) may further technically challenging due to abnormal coagulability.
increase their fragility and migration, making them too dis- Starting the case with general anesthesia may be a better
tal to be approached by endovascular treatment.12 Clots with choice compared to monitored anesthesia care to prevent
lower leukocyte counts and fibrin are associated with non- the emergency conversion from the latter to the former.
cardioembolic origin.13 While 1 patient had risk factors for a Maintaining normal to high blood pressure (systolic blood
thrombus of cardioembolic origin, it is conceivable that our pressure 140–180 mm Hg) in patients with COVID-19 under
patients’ clots formed in situ in a prothrombotic and hyper- general anesthesia frequently requires vasopressors due to
inflammatory milieu, as evidenced by the high D-dimer atypical hemodynamic parameters. E
levels, hypercoagulable rotational thromboelastometry
profiles, and high levels of interleukin-6 and C-reactive
protein. Systemic inflammatory responses heighten the DISCLOSURES
risk of intracranial hemorrhage with tPA administered for Name: Richa Sharma, MBBS.
ischemic stroke.14 Therefore, further investigations into the Contribution: This author made substantial contributions to
hemorrhagic conversion of stroke in patients with COVID- the conception of the work, the acquisition, analysis, and inter-
19 who received tPA are warranted. In our study, all patients pretation of data for the work; and drafting the work, revising it
received tPA. Patient 5 had complete resolution of the clot critically for important intellectual content; and final approval
with tPA only, but patients 1 and 2 developed hemorrhagic of the version to be published.
conversions after the endovascular treatment. Name: Peter D. Yim, MD.
Some patients with ischemic stroke who undergo Contribution: This author made substantial contributions to
mechanical thrombectomy may have compelling reasons for the design of the work; the interpretation of data for the work,

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cases-anesthesia-analgesia.org A & A PRACTICE
Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
revising it critically for important intellectual content, final 6. McCray PB Jr, Pewe L, Wohlford-Lenane C, et al. Lethal infec-
approval of the version to be published. tion of K18-hACE2 mice infected with severe acute respiratory
Name: Paul S. García, MD, PhD. syndrome coronavirus. J Virol. 2007;81:813–821.
7. Wrapp D, Wang N, Corbett KS, et al. Cryo-EM structure of
Contribution: This author made substantial contributions to
the 2019-nCoV spike in the prefusion conformation. Science.
the design of the work; the interpretation of data for the work, 2020;367:1260–1263.
revising it critically for important intellectual content, final 8. Sriramula S, Cardinale JP, Lazartigues E, Francis J. ACE2 over-
approval of the version to be published. expression in the paraventricular nucleus attenuates angioten-
This manuscript was handled by: BobbieJean Sweitzer, MD, sin II-induced hypertension. Cardiovasc Res. 2011;92:401–408.
FACP. 9. Baig AM, Khaleeq A, Ali U, et al. Evidence of the COVID-19
virus targeting the CNS: tissue distribution, host-virus inter-
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