Amid the coronavirus disease 2019 (COVID-19) pandemic, neurologists have been confronted with unprecedented situations, among which acute stroke management in COVID-19 patients. To the best of our knowledge, this is the first report of protected code stroke in Belgium.
A 74-year-old patient, while hospitalized for a COVID-19 pneumonia, experienced sudden-onset left-sided hemiplegia and aphasia. Two hours after symptom onset, an in-hospital code stroke was activated. A neurologist in personal protection equipment (PPE) consisting of mask, goggles, gown and gloves [1], evaluated the patient and documented a National Institutes of Health Stroke Scale (NIHSS) of 16, rapidly deteriorating to 25. Neuroimaging in the COVID-19 section of the radiology department showed no abnormality on the non-contrast computed tomography (NCCT) of the brain but CT angiography revealed a right carotid T occlusion. Intravenous thrombolysis with alteplase was administered within 3 h of symptom onset. The patient was then promptly transferred to the interventional radiology suite dedicated to COVID-19 patients to undergo endovascular thrombectomy (EVT). EVT by thrombus aspiration was performed under general anesthesia, using a Cello 9F balloon guide catheter for proximal flow control and a Sofia 6F catheter for distal aspiration. Complete recanalization of the carotid artery (modified treatment in cerebral ischemia (mTICI) grade 3) by first-pass thrombus aspiration was achieved 4 h and 30 min after symptom onset (Fig. 1). The patient was closely monitored in a COVID-19 Intensive Care unit. The neurological symptoms resolved as reflected by a NIHSS of 1 at 72 h after symptom onset.
Fig. 1.
a Persistent right carotid T occlusion despite initiation of intravenous alteplase, with no visualization of the middle and anterior cerebral arteries. b Complete recanalization of the right carotid artery (mTICI grade 3) after first-pass thrombus aspiration
In a health care system overwhelmed by COVID-19 patients, acute stroke management represents a major challenge. Awareness of stroke symptoms may be reduced, patients are experiencing fear of hospitals and stay at home, although they require urgent medical attention, while in-hospital logistical pathways have changed. For instance, PPE regulations have been implemented to reduce nosocomial infection rate, which has been reported to be as high as 41.3% [2]. However necessary, they may prove to be time-consuming in a code stroke setting. Despite these difficulties, successful outcome may be achieved, such as in our case. Since cerebrovascular disease has been observed in 5.9% of COVID-19 patients [3], this situation will not be infrequent. The implementation of protected code stroke is, therefore, essential [1, 4, 5]. Treating patients early after symptom onset remains the cornerstone of stroke management and stroke physicians should continue to pursue this goal during the COVID-19 pandemic.
Acknowledgements
The authors wish to thank Prof. Robin Lemmens (Department of Neurology, University Hospitals Leuven, Leuven, Belgium) for critical revision of the manuscript.
Author contributions
Sofia Maldonado Slootjes drafted the manuscript. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
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Compliance with ethical standards
Conflicts of interest
The authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with human participants (or animals) by any of the authors.
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Patient consent was obtained.
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