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Management of COVID-19 Stroke Patients: Experience from Montefiore Medical Center, New York

M. Aaron Chyfetz, MD, MSc
Assistant Professor of Anesthesiology,
Division of Neuroanesthesiology
Montefiore Medical Center, Albert Einstein College of Medicine

M. Aaron Chyfetz, MD, MSc

Montefiore Medical Center is the only thrombectomy capable stroke center between upper Manhattan and Albany, New York. Our main campus in the Bronx encompassed the heart of the COVID-19 outbreak. The burden of chronic disease, obesity and poverty resulted in the highest per case mortality rate in New York City and possibly the nation. Our experiences are vast during this outbreak with many lessons to be learned.

During the COVID-19 pandemic, Montefiore experienced an increased volume in mechanical thrombectomy and carotid endarterectomies. COVID-19 stroke patients typically presented with a larger than expected clot burden. Despite lack of underlying respiratory symptoms, patients undergoing mechanical thrombectomy had a lower rate of successful thrombectomy characterized by lower TICI scores and increased rate of decompressive craniectomy. The majority of COVID-19 stroke patients in respiratory failure, secondary to ARDS, did not survive to discharge regardless of intervention. It is reassuring to note that all patients had a documented preexisting condition including history of cancer, obesity, HTN, diabetes and/or heart disease.      

A coordinated and multidisciplinary approach is necessary to protect all frontline workers involved in management of these patients. Every stroke activation should be screened for signs and symptoms of COVID-19 including shortness of breath, fever, hypoxia, and a high oxygen requirement. A CT scan of the chest demonstrating “ground glass opacities” is strongly pathognomonic for COVID-19 pneumonia. A patient with a high oxygen requirement should be immediately intubated to facilitate transfer to the CT scanner and neuro intervention.

The angiography suite is frequently a positive-pressure room. As intubation and extubation are high aerosolizing procedures, caution must be taken and only anesthesia staff should be present during this time. Almost all patients with confirmed or presumed COVID-19 were intubated for thrombectomy and we protected ourselves with N-95 mask (or full respirator), face shield and Tyvek suits. A plexiglass box or clear plastic drape can be placed over the head to minimize exposure to the pathogen. It is important to communicate to your anesthesia techs and cleaning staff the COVID-19 status of the patient so proper cleaning precautions are followed.   

New York’s Governor Cuomo required all hospitals to increase patient capacity by at least 50% during the pandemic. This prompted numerous challenges in coordinating patient disposition post thrombectomy. A rapid COVID-19 test is critical, and status must be determined before leaving the procedure room. Every ICU was designated COVID-19 and the PACU was our “clean” unit. This prompted all extubated COVID-19 strokes to be transported directly to a designated neuro COVID-19 unit. A dedicated COVID-19 CT scanner should also be chosen to minimize cross contamination.    

The COVID-19 pandemic has fueled multiple debates and conundrums best suited to be answered by SNACC. Is there any connection between formation of a large vessel occlusion and the development of cytokine storm precipitating multi-organ system failure?  We did not see any correlation in our limited patient subset free of respiratory symptoms on presentation. In addition, we failed to quantify the degree of cerebrovascular events in our ICU cohorts and the small percentage successfully extubated were noted to have slow emergence, poor mental status, and delirium. Further research is necessary to determine the role of EEG monitoring in these critical patients. First and foremost, stay rested and take all precautions to protect yourself!