Interventional Stroke Management in a Patient With COVID-19

Case

A known diabetic and hypertensive 49-year-old woman presented with progressive shortness of breath, fever, and fatigue. She had mild respiratory distress requiring oxygen supplementation, was treated in an isolation unit for patients with COVID-19, and received therapy with hydroxychloroquine and azithromycin. She had elevated C-reactive protein (18.7; reference less than 0.5 mg per dL), lactate dehydrogenase (386; reference range 125–22 units per L), procalcitonin (0.21; reference less than 0.10 ng per mL), ferritin (3578; reference range 5–204 ng per mL), and normal prothrombin time (14.2 seconds; reference range 12.1–14.8). On hospital day 2, she developed sudden weakness in the left limbs, sensory neglect, left hemianopsia, and right gaze deviation. The stroke team was mobilized to the quarantine COVID unit. Adhering to the isolation protocol implemented by the institution, a N95 face mask was placed on the patient before leaving the unit and all accompanying personnel used personal protective equipment (PPE) including head and body covers, face masks, goggles, and gloves. The initial NIH Stroke Scale (NIHSS) score was 14, and noncontrast head CT was normal. Alteplase (0.9 mg per kg) was initiated in the imaging suite (69 minutes after symptoms recognition). CT angiography showed a thrombus in the right middle cerebral artery and a filling defect in the left carotid bulb (figure, A and B). CT perfusion showed a mismatch between cerebral blood volume and mean transit time in the territory of the right middle cerebral artery (figure, C and D). The decision was made to proceed with mechanical thrombectomy in the interventional radiology suite where standard sterilization procedures were applied. The operating team consisted of 4 persons including 1 interventionalist, 2 supporting radiology technologists, and 1 registered nurse; all used PPE. Mechanical thrombectomy was successfully completed under conscious sedation through a transfemoral approach using the standard catheter aspiration with a retrievable stent in the right middle cerebral artery. A diagnostic left carotid angiogram confirmed the presence of a thrombus in the left carotid bulb that was asymptomatic (figure, G). Resolution of the neurologic symptoms (NIHSS 5) was immediately noticed after (TICI 3: Thrombolysis In Cerebral Infarction) revascularization of the right middle cerebral artery was achieved (figure, E and F). The patient returned to the quarantine unit where postintervention neurologic monitoring and physical assessment were performed. On postoperative day 2, the NIHSS dropped to 0, and a postintervention noncontrast head CT remained normal. Cardiac evaluation including telemetry monitoring and transthoracic echocardiography were normal. Owing to the asymptomatic thrombus in the left carotid system, a 6-month course of oral anticoagulation (apixaban) was commenced. She was discharged to home on hospital day 5 after complete resolution of the respiratory and neurologic symptoms.

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Figure CT Angiography and Perfusion, and Conventional Angiography in a Patient With COVID-19

CT angiography showing thrombus and occlusion of the right middle cerebral artery (A) and filling defect in the left carotid bulb (B) suggesting a floating thrombus. CT perfusion showing a mismatch between cerebral blood volume (C) and mean transit time (D) suggesting ischemic penumbra in the territory of the right middle cerebral artery. Conventional angiography of the right common carotid artery (E) showing complete occlusion in the right internal carotid artery followed by complete reperfusion (F) after mechanical thrombectomy. Left carotid angiogram (G) confirms a large floating thrombus in the left carotid bulb.