Acute MCA Stroke In Covid-19-Positive Patient

Figure 1 (left). AP-oblique view, left internal carotid artery injection, mid-arterial phase. The middle cerebral artery is occluded just distal to its take-off (red arrow). The anterior (A) and posterior (B) cerebral arteries with shift into the watershed area of the middle cerebral artery territory (blue stars). Figure 2 (right). AP view, left internal carotid artery injection, mid-arterial phase. Post-endovascular reperfusion therapy, the middle cerebral artery is fully recanalized (red arrow). The anterior (A) and posterior (B) cerebral arteries’ shift into the watershed area of the middle cerebral artery territory is no longer present.

Figure 3. Lateral view, left internal carotid artery injection, mid-arterial phase. Angiogram showing fully recanalized middle cerebral artery (red arrow) and reperfusion of its territory. The anterior (A) and posterior (B) cerebral arteries.

Figure 4. Wide view of angiogram shown in Fig 1. AP-oblique view, left internal carotid artery injection, mid-arterial phase. The middle cerebral artery is occluded just distal to its take-off (red arrow). Patient wearing glasses (frame front and temples, yellow arrows).

Treatment Considerations:
The procedure was performed in a single-plane angiographic suite. This technology, although not without challenges, allows patients to be treated in less richly resourced hospitals that do not have dedicated neuro-interventional suites, and even offers patients to be triaged into these hospitals in times of increased need (surge capacity). Additionally, it offers the application of a TRIP & TREAT approach, a possibly more beneficial shift from the DRIP & SHIP approach.

Note, that using a non-tradition oblique view as shown in Figures 1 and 4, the anatomy can be seen well. In contrast, the post-reperfusion angiograms, in the classic AP and lateral views, can in cases with posterior cerebral artery origins or middle cerebral artery branch occlusions be difficult to interpret.

Amusing, the patient’s glasses with its frame front and temples can be seen, as if inadvertently left on (Figures 1, 2, 4). There is a growing appreciation of the benefit of using minimal sedation in acute ischemic stroke patients to improve neurological outcome. In our practice, we avoid taking from the patient anything that does not represent a danger. Removing glasses, hearing aids, earrings, etc., often adds additional anxiety, fear, and sensory impairment to an already confused and agitated patient.

References:

1. Hilditch CA, Nicholson P, Murad MH, et al. Endovascular management of acute stroke in the elderly: A systematic review and meta-analysis. AJNR 2018; 39: 887-91.
2. Wen J, Qi X, Lyon KA, et al. Lessons from China when performing neurosurgical procedures during the Coronavirus disease 2019 (COVID-19) pandemic. World Neurosurg 2020; 138: 955-60.
3. Merkler AE, Parikh NS, Mir S, et al. Risk of ischemic stroke in patients with Coronavirus disease 2019 (COVID-19) vs patients with influenza. JAMA Neurol. Published online, July 02, 2020.