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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 24-28

Acute neurovascular care in the COVID era: Safety and resilience

Department of Neurosurgery, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission31-Jul-2020
Date of Acceptance01-Sep-2020
Date of Web Publication1-Oct-2020

Correspondence Address:
Dr. Srinivasan Paramasivam
Department of Neurosurgery, Apollo Hospitals, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvs.jcvs_5_20

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Introduction: Since the outbreak of the coronavirus pandemic, much has changed in the protocol for management of healthcare setups and patients presenting with any illness including neurological and neurosurgical emergencies. Patients are themselves deterred from visiting a hospital in an emergency, and healthcare workers require stringent precautions and plans to prevent the spread of the virus to themselves and others, without compromising on the care that is to be provided.
Aims and objectives: To outline the importance of identifying neurological emergencies requiring urgent intervention even in the time of a pandemic, and methods to effectively manage patients without compromising on safety and infection prevention measures.
Materials: Guidelines reviewed from existing literature and retrospective analysis of management protocol and care delivered in a neurovascular unit during the COVID-19 pandemic..
Conclusion: Acute neurovascular care should not be compromised upon even during a pandemic, but neither should the safety of healthcare workers. Safety guidelines and protocols require strict adherence.

Keywords: Covid-19, neurovascular, stroke, safety

How to cite this article:
Paramasivam S, Sudan H, Babu D, Kumar N V. Acute neurovascular care in the COVID era: Safety and resilience. J Cerebrovasc Sci 2020;8:24-8

How to cite this URL:
Paramasivam S, Sudan H, Babu D, Kumar N V. Acute neurovascular care in the COVID era: Safety and resilience. J Cerebrovasc Sci [serial online] 2020 [cited 2023 Feb 4];8:24-8. Available from: http://www.jcvs.in/text.asp?2020/8/1/24/296935

  Introduction Top

Severe Acute Respiratory Syndrome – Coronavirus – 2 (SARS-CoV-2) virus causing coronavirus disease 2019 (COVID 19) infection is causing a rampage across the globe, stressing even the most organised the health-care system. Challenges faced by India is far more given the baseline scarcity of beds and discrepancy in accessibility to health care. In this scenario, neurovascular emergencies in particular acute stroke, happen with increased incidence given the endothelial invasion and thrombogenic potential of COVID 19 infection. There are various care recommendations from different parts of the world, taking into consideration the seamless delivery of care along with the safety of the health-care workers. We need to adapt and modify the pathways and recommendations based on the health-care system and have a systematic approach.

SARS-CoV-2 virus, causing COVID 19 is transmitted primarily via respiratory droplets. The symptom associated with the illness includes, respiratory along with other systems such as enteric or neurological. An infection control screen should assess for the following constellation of signs and symptoms: fever, cough, chest pain, dyspnoea, headache, myalgias, and gastrointestinal symptoms, including vomiting and diarrhoea. However, there is a good number of patients who are symptomatic with stroke as the first presenting symptom has been documented.

Various guidelines for surgical procedure related precaution have been published that include Intercollegiate surgical guidelines, Society of American Gastrointestinal and Endoscopic surgeons and The European Association of endoscopic and surgery recommendations regarding surgical response to the COVID 19 crisis delineate the need for precaution during the surgical procedure.[1] Society of American Gastrointestinal and Endoscopic Surgeons and The European Association of Endoscopic Surgery.[2] The concept of protected code stroke has been proposed to address preparedness and protect health-care workers and other patients.[3] The society of Neuro interventional surgery released the recommendations specific to neuro interventional patients in the setting of COVID 19.[4] Later, Consensus statement on Recommendations for acute stroke management during COVID 19 pandemic was released on behalf of the Indian stroke association.[5]

Major concern is the fear of the public and only a smaller proportion of acute neurological emergencies come to the hospital during the acute phase due to fear of contracting COVID-19 while accessing health services.[6] There is a general thought that all health-care resources are mobilised to prioritise care for COVID-19 patients.

  Acute Neurovascular Emergencies Top

Acute stroke is an emergency that needs immediate attention in spite of the pandemic. Preparedness and prompt treatment to provide evidence-based care are essential for good outcome in acute ischaemic stroke and other subtypes of strokes, including sub arachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH), and cerebral venous thrombosis. Patients with Neurovascular emergencies come to hospitals as direct patient walk-ins, referral form other hospitals and from primary stroke centres after thrombolysis. Contrary to the conventional screening process, COVID 19 pandemic necessitates additional screening by paramedics and at hospital emergency rooms that include travel history and infection control screening. In most situations, the patient may not be able to communicate due to stroke and decreased level of alertness. Hence, valid information will be missing and family members may not be available to give information. COVID 19 testing availability and time for reports grossly vary based on the setting and testing load in a particular region. In our hospital, with in-house testing it takes approximately 8-h for the report to arrive. Given the scenario, Covid testing is impractical in acute stroke treatment. It is presumed that every patient is COVID 19 positive, care needs to go on with additional protection.

  Protection during Initial Assessment Top

All patients are assessed in isolation chambers in the emergency room. The current consensus on the use of personal protective equipment (PPE) is standardised and that include, Full sleeved Gown, Surgical mask, eye protection and gloves with extended sleeve to overlap the gown. Head covering is not mandated if eye protection is well worn. When aerosolisation is expected, N95 mask is mandatory. In a stroke patient, common aerosol-generating procedures include oropharyngeal or nasal suctioning, bag-valve-mask ventilation, and intubation. Intubation in a negative pressure rooms reduce the aerosol generation and it is highly recommended. Post-intubation if the circuit is maintained without a breakage for providing care, aerosol precaution is not mandatory. In general, nebulisation, continuous positive airway pressure, Bi-level positive airway pressure and high flow nasal therapy is to be avoided as they are significant aerosol-generating procedures.[7]

During the initial assessment, the team members are mandated to wear PPE as recommended; stroke neurology assessment may be done with PPE or through Telemedicine along with review of imaging to decide on the need for thrombolysis. Dedicated sperate pathway for transport, dedicated scanning equipment for COVID status unknown, suspected, confirmed cases are needed based on the institutional resource availability. In a non-intubated patient, a surgical mask is worn and kept on during transport and during imaging procedures. If needed, nasal prongs oxygen may be applied underneath the mask. Radiology technicians and other staff are instructed to wear appropriate PPE while imaging.

Imaging to be done as per the institutional protocol either with Bi-level positive airway pressure (CT) and CT angiography in patients presenting within 6 h of the onset of stroke and CT perfusion scan or magnetic resonance imaging stroke protocol to be done in those coming later. CT chest is done along with neuroimaging to look for COVID-related changes [Figure 1]a and b] The images can be reviewed by radiologist, neurologist and Neurovascular surgeon through remote access and discussion is done to make a decision on further management. Intravenous thrombolysis considered for all eligible patients and done as per the standard protocol with emphasis to look at platelet count as cytopenia may be caused by COVID 19 infection.[5] Family counselling ideally done in the COVID era remotely through video conference or over telephone to avoid contact for the safety of the family and the medical staff.
Figure 1: A 35 year old patient with recent travel history presented with acute stroke to the emergency room at 6:30 PM with NIHSS of 14. Urgent evaluation revealed a right internal carotid artery occlusion and computed tomography chest showed parenchymal changes suggestive of COVID infection (a,b). Initial angiogram shows right internal carotid artery complete occlusion (c) that was recanalised by direct aspiration (d) and middle cerebral artery occlusion recanalised using stent retriever (e). Thrombolysis was done and subsequently taken to the Cath lab for mechanical thrombectomy. The health care workers adequately protected with personal protective equipment (f). Powered air purifying respirator is a value addition during the procedure (g). Post procedure the patient made a dramatic recovery to NIHSS 3 and computed tomography scan showed good preservation of brain parenchyma (h)

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  Protection during Neuro-Intervention Top

Acute ischemic stroke due to large vessel occlusion, treatment by endovascular thrombectomy is the standard of care and this procedure has aerosol generation potential making it challenging and protection of health-care workers needs stringent protective measures.[8] Dedicated cathlab for COVID status unknown, suspected and positive cases are recommended when more than one cathlab suites are available in an institution. It may be shared between cardiac, neuro and other peripheral procedures.

The laboratory is fumigated after each procedure, the air circulation in the air condition is modified to have >12 fresh air exchanges per hour. All the staff members are trained and rehearsed to be aware of the protocol for equipment, inventory handling, patient movement, donning and doffing techniques [Figure 1]f. Alternatively, the operator can wear a positive Air-purifying respirator to protect against virus with maximum comfort [Figure 1]g. Adequate sign boards are placed for reinforcements of the protocol. The procedural zone in the cathlab is designated RED zone with minimal personal that include operator, assistant, anaesthetist and a technician all with full PPE. The control room is designated GREEN zone where the floor nurse and assistant technician are present to provide support. The door is kept closed and communication is done through two way radio communication. At the end of the procedure, the operator followed by other members doff the PPE at the YELLOW zone just outside the cathlab and properly disposed. Neurointervention procedure is done either using direct aspiration technique or stent retriever [Figure 1]c-e and h]. The essential materials needed for the procedure are taken into the room and once inside, it is considered used (RED Zone). Reserve materials are kept in the control room (GREEN Zone) and handed over by support staff when needed. This practice reduces the inventory and keeps a check on the cost of the procedure.

The threshold for intubation of patient with acute stroke be low contrary to conventional strategy as mid-procedural patient agitation, coughing, suctional and subsequent conversion to intubation can be detrimental and could expose the whole team to significant aerosols. In patients with agitation, extreme drowsiness and uncooperative patients, intubation is done in the negative pressure room before shifting to cahtlab and the circuit is kept intact through the procedure without breaking to prevent aerosol generation.

  Protection during Surgical Management of Stroke Top

Patients with large ICH with or without intraventricular hemorrhage (IVH), Cerebellar hemorrhage, SAH with IVH and hydrocephalus, malignant middle cerebral artery infarct are emergencies that need to be tackled right away without waiting for reverse transcription-polymerase chain reaction (PCR) COVID testing report. There needs to be a regional collaboration, with change in the system, referral pattern and care setting. The protocol designed and implemented to manage such emergencies in well-equipped setup with all facilities.[9] Whenever possible, if the procedure can wait till the COVID test reporting like definitive coiling or clipping of an aneurysm that has to be done. However, the care cannot be delayed for the report to arrive.

Designated COVID operation Theaters must be in place for suspected, unknown and confirmed cases with similar structural and organisational changes as described for the cath lab should be in place. Air circulation, air exchanges, High Efficiency Particulate Air (HEPA) filter placement, needs to be done as per the local guidelines. Negative pressure rooms are ideal but not practical in most situations. Sanitisation after each procedure is extremely important to prevent cross contamination. The team members in the room are kept to minimum, with full PPE that includes eye protection. Team members are trained for proper donning and doffing techniques. Surgeons and personnel not needed for intubation should remain outside the operating room until and after 15 min of induction and intubation to allow aerosols to settle down. Burr hole placements and cutting of bone with high-speed drill is an aerosol-generating process. It has to be done under copious irrigation to minimise the chances.

Following procedures, the patients are preferably treated in isolation rooms till the PCR testing report comes back within the intensive care uni setting for all surgical patients and for sick patients post-thrombectomy or in a dedicated stroke ward for stable patients post-thrombectomy. The care setting should be able to provide basic monitoring, bedside care along with neuromonitoring to look for changes in neuro examination.

  Protection during Further Care Top

Special and dedicated care of the stroke patients has to be done to ensure the quality of stroke care, the patient may need to be admitted to other wards with dedicated and trained staff with appropriate PPE to concentrate on dysphagia management, physical therapy, in-hospital rehabilitation. Physiotherapist, occupational therapist, speech therapist and clinical psychologist play a pivotal role in rehabilitation. In general, rehabilitation services during the pandemic are challenging as it involves more and prolonged personal contact between the patient and the provider. Patients are assessed on an individual basis on the need for the type of rehab services they need and tailored to minimise the exposure for both patient and the provider.

  Other Neurological Emergencies Top

There is general belief that the entire health-care system is geared up to tackle COVID 19 and the patients fear coming to the hospital for other emergencies and general care. They end up having more severe problems before seeking medical help. This belief needs to be addressed at large. Early signs of brain tumour like headache, ataxia and other neuro symptoms are ignored for the fear of COVID 19. Public health campaigns on precautionary measures that are in place to minimise infection transmission and negative impact of delayed presentation has to be emphasised to the public. Telehealth services with remote consulting and screening followed by maintaining social distancing in out-patient clinics are mandatory to prevent and to give reassurance to patients coming for other ailments. COVID 19 in paediatric population is relatively low and neurological manifestations are less likely to be delineated. Overall only about 2% of COVID positive patients are <18-year of age. They should be encouraged to come to the hospital at the earliest to provide early care.

  Health-Care Worker Protection Top

Health-care workers are at a constant fear of contracting COVID infection during work hours leading to stress.[3],[6] Further, concerns like lack of PPE, prolonged work hours and the system in place to care for them in case they get sick, along with fear of passing the infection to the family member, is in the minds of every health care worker. The scarcity of resources during the peak of pandemic can be challenging, leading to constant stress and mental health problems. Measures to reassure and improve the morale of health care workers are paramount to boost their enthusiasm for effective and efficient work. They need breaks and given information regarding relaxation and coping strategies. The advantage of adequately protecting the health-care workers include preventing their absence from work, continued care for sick patients by the trained specialist; further it adds to secondarily protecting their family, other patients and the community spread.

  Team Training, Cohesiveness and Support Top

To achieve a good standard of care, it is mandatory to formulate protocol and train the staff. Changes implemented to the protocol in carrying out stroke code action are to be rehearsed. Donning and Doffing of PPE, protocol to adhere in the procedure room and outside, cleaning the procedure room after the procedure are to be taught and implemented in each institution. Any breach in the protocol are to be addressed and improved with future cases. The WHO 'Mental health and psychosocial considerations during the COVID-19 outbreak' document defines the role of a 'peer support system. Experienced clinicians to assist and support their less experienced colleagues, to manage stress and efficiently enact the protocols that are in place in an organisation.[10] Online peer support systems for discussion may help cope with shortcomings along with social media and group messaging systems. Rearrangement of health care workers home living arrangements and isolation if tested positive with hotel accommodation for self-isolation minimises the risk to family and gives a sense of reassurance among frontline workers.

  Conclusions Top

In the COVID era, with most services rationed to care for COVID 19 cases, acute neurovascular care is under stress. We focussed on significant factors in the system that can be addressed to help the system, its workers and patients for continued and effective care. All patients during the pandemic need to be screened for COVID-19 and telemedicine could be used to triage these patients and deliver intravenous thrombolysis. Mechanical thrombectomy needs protocolised movement of the patient and controlled care setting to minimise aerosol transmission and exposure of health-care staff. To encourage patients to come early with neurological symptoms, public health campaigns to educate and increase awareness of the community about the safety measure are important. Special considerations to be applied and care pathways to be developed for other emergencies like traumatic brain injury as like Neurovascular disorders. In view of the pandemic expected to stay longer, limiting exposure and safety of health-care workers is paramount with heightened safety measures. Wading the negative impact on the morale of professional colleagues is important for efficient and continued health-care delivery.

  References Top

Royal College of Surgeons of England. Updated Intercollegiate General Surgery Guidance on COVID-19. 35-43 Lincoln's Inn Fields. London: Royal College of Surgeons of England; 2020.  Back to cited text no. 1
SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis. Society of American Gastrointestinal and Endoscopic Surgeons; 2020.  Back to cited text no. 2
Khosravani H, Rajendram P, Notario L, Chapman MG, Menon BK. Protected code stroke: Hyperacute stroke management during the coronavirus disease 2019 (COVID-19) Pandemic. Stroke 2020;51:1891-5.  Back to cited text no. 3
Fraser JF, Arthur AS, Chen M, Levitt M, Mocco J, Albuquerque FC, et al. Society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of COVID-19. J Neurointerv Surg 2020;12:539-41.  Back to cited text no. 4
Bhatia R, Sylaja PN, Srivastava MV, Khurana D, Pandian JD, Suri V, et al. Consensus Statement-Suggested recommendations for acute stroke management during the COVID-19 pandemic: Expert group on behalf of the Indian stroke association. Ann Indian Acad Neurol 2020;23:S15-23.  Back to cited text no. 5
AHA/ASA Stroke Council Leadership. Temporary emergency guidance to us stroke centers during the coronavirus disease 2019 (COVID-19) pandemic: On behalf of the American Heart Association/American stroke association stroke council leadership. Stroke 2020;51:1910-2.  Back to cited text no. 6
Murthy S, Gomersall CD, Fowler RA. Care for critically ill patients with COVID-19. Jama 2020;323:1499-500.  Back to cited text no. 7
Sharma D, Rasmussen M, Han R, Whalin MK, Davis M, Kofke WA, et al. Anesthetic Management of endovascular treatment of acute ischemic stroke during COVID-19 pandemic: Consensus statement from society for neuroscience in anesthesiology & critical care (SNACC): Endorsed by society of vascular & interventional neurology (SVIN), society of neurointerventional surgery (SNIS), neurocritical care society (NCS), European society of minimally invasive neurological therapy (ESMINT) and American Association of neurological surgeons (AANS) and Congress of neurological surgeons (CNS) cerebrovascular section. J Neurosurg Anesthesiol 2020;32:193-201.  Back to cited text no. 8
Zoia C, Bongetta D, Veiceschi P, Cenzato M, Di Meco F, Locatelli D, et al. Neurosurgery during the COVID-19 pandemic: Update from Lombardy, northern Italy. Acta Neurochir (Wien) 2020;162:1221-2.  Back to cited text no. 9
World Health Organisation. Mental Health and Psychosocial Considerations during the COVID-19 Outbreak; 2020.  Back to cited text no. 10


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