Article published online: 2022-09-07
THIEME

Case Report

Large-Vessel Occlusion Stroke Treated by
Endovascular Thrombectomy in Patient withCoronavirus Disease 2019
Yuko Tsurumi1

Noriaki Matsubara2

Hayato Yokoyama1

1 Department of Neurosurgery, Tsurumi Hospital, Koga, Ibaraki, Japan
2 Department of Neurosurgery, Soseikai General Hospital, Kyoto,

Japan

Osamu Hososhima1

Arihito Tsurumi1

Address for correspondence Yuko Tsurumi, MD, Department of
Neurosurgery, Tsurumi Hospital, 813, Kami-katata, Koga, Ibaraki,
3060128, Japan (e-mail: yuko@tsurumi.pro).

AJNS 2022;17:489–494.

Abstract

Keywords► COVID-19► ischemic stroke► thrombectomy► infection prevention

We report a case of acute ischemic stroke caused by large-vessel occlusion in a patient
infected with coronavirus disease 2019 (COVID-19) who was treated by endovascularthrombectomy. The patient was a 41-year-old man hospitalized with moderately severe
COVID-19. Fourteen days after the onset of COVID-19, dysarthria and right hemiplegia
were observed, and acute occlusion of the left middle cerebral artery was diagnosed.
Mechanical thrombectomy was performed with a stent retriever while the patient wasunder local anesthesia and sedation. The staff involved in the intervention was asminimal as possible. The interventional surgeon wore a disposable surgical gown, an
N95 mask, a face shield, and two pairs of gloves, while the patient was ﬁtted with asurgical mask. The intervention involved the usual procedures, such as sheath
insertion, catheter manipulation, and stent deployment, and the thrombus wasremoved with the stent retriever. The time from puncture to recanalization was within
30 minutes. No infection was observed in our staff or inpatients after the intervention.
Thus, we were able to perform neuroendovascular treatment without spreading
COVID-19 by taking appropriate measures to prevent infection.

Introduction
Since the start of 2020, coronavirus disease 2019 (COVID-19)
has been spreading around the world, and various mutant
strains of the virus (severe acute respiratory syndrome
coronavirus 2 [SARS-CoV-2]) have already been reported.
As of July 2021, the number of infections caused by novel
mutant strains has been noted to increase in Japan. Although
the preparation and management of endovascular therapy
for acute ischemic stroke in patients positive for SARS-CoV-2
have been reported,1,2 the novel mutant strains have not

DOI https://doi.org/
10.1055/s-0042-1750807.
ISSN 2248-9614.

been mentioned widely. In this study, we report a case of
acute ischemic stroke caused by large-vessel occlusion in an
infected patient. In performing endovascular thrombectomy,
we successfully prevented the spread of infection in thehospital, and we describe the precautions we used in the
management of patients with stroke and COVID-19.

Case Presentation
The patient was a 41-year-old man who was a smoker and had
no medical history. A family member living with the patient© 2022. Asian Congress of Neurological Surgeons. All rights
reserved.
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Mechanical Thrombectomy in Stroke Patient with COVID-19
had developed COVID-19, and because our patient was a close
contact, he was tested by polymerase chain reaction (PCR) andfound to be infected. Initially, he had only a fever and remained
at home; on the 9th day, however, he was admitted to a general
hospital with bilateral pneumonia. Diabetes mellitus was also
diagnosed at the time of admission, and oral metformin andinsulin therapy were started. Because his oxygen saturation
was 95%, oxygen was not required. However, because of theimage ﬁndings of pneumonia, his smoking history, and the
diagnosis of diabetes mellitus, this case of COVID-19 wasconsidered moderately severe, and treatment with dexamethasone was initiated.
On the 14th day after the onset of COVID-19, the patient
exhibited dysarthria and right-sided hemiplegia and underwent cerebral computed tomography (CT) and cerebral
magnetic resonance imaging (MRI), which revealed acutecerebral infarction of the left middle cerebral artery (MCA).
The patient was then transferred to our hospital, which
focuses on neurosurgery, because the general hospital had
difﬁculty providing interventional radiology (IVR) treatment. Although we had no prior in-hospital arrangements
for IVR treatment of COVID-19, patients with stroke wereusually transferred to our hospital for neurosurgical diseases
because the previous hospital lacked a full-time neurosurgeon, and a system of collaboration between the hospitals
was already in place.
After the patient arrived at our hospital, a stretcher was
set up outside the hospital, the patient was laid on it, and the
SARS-CoV-2 antigen test was performed, which yielded apositive result. A surgical mask was placed on the patient. For
the prevention of COVID-19 infections, personnel directly
involved in the patient’s care were limited to two physicians,
one nurse, and one radiology technician, all of whom wore
new N95 masks, face shields, long-sleeved gowns, caps,
gloves, and shoe covers.
The patient arrived at our hospital approximately
440 minutes after the last well known. His hemoglobin A1clevel was 11.2%, and his D-dimer level was 3.3 μg/mL on

Tsurumi et al.

arrival. Atrial ﬁbrillation, which was not detected at theprevious hospital, was identiﬁed on electrocardiography at
our hospital. Diffusion-weighted cerebral MRI showed areasof hyperintensity in the left temporal lobe, and ﬂuid-attenuated inversion recovery sequences showed signal changes inthe same area. Ischemic changes were also partially observedin the frontal/parietal lobes. Cerebral magnetic resonanceangiography demonstrated occlusion of the M1 portion of
the left MCA, caused by cardiogenic cerebral embolism. The
National Institutes of Health Stroke Scale (NIHSS) score andthe Diffusion-Weighted Imaging–Alberta Stroke Program
Early Computed Tomography (DWI-ASPECT) scores were
27 and 5, respectively.
Because more than 8 hours had passed since the patient’s
symptoms began, intravenous tissue plasminogen activator(t-PA) therapy was not performed. Diffusion-weighted
images showed a limited hyperintense area in the M1
portion of the left MCA; we assumed that some ischemic
areas remained, and we decided to perform thrombectomy(►Fig. 1A–C).
Three ceiling-mounted air conditioners with high-efﬁciency particulate air ﬁlters and six air puriﬁers had been
installed in the angiography room. The air conditioners andair puriﬁers were at maximum output.
Only one physician performed the intervention; the otherone stayed in the operating room whenever possible, moving
between the angiography room and the operating room tobring out required devices and items or to administer drugs.
The door between the angiography room and the operating
room was closed except when staff needs to move from one
room to the other, and nurses and laboratory technicians
waited in the operating room except when transferring
patients (►Fig. 2).
Local anesthesia and sedation were induced with dexmedetomidine and propofol. The interventional surgeon wore adisposable surgical gown, an N95 mask, a face shield, and twopairs of groves, and the patient was ﬁtted with a surgicalmask.

Fig. 1 Diffusion-weighted magnetic resonance imaging (A) and ﬂuid-attenuated inversion recovery imaging (B) at onset revealed an area ofhyperintensity in the left middle cerebral artery in the temporal lobe. Magnetic resonance angiography (C) showed the occlusion of the M1
segment of the left middle cerebral artery.
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Mechanical Thrombectomy in Stroke Patient with COVID-19

Tsurumi et al.

Fig. 2 The stretcher was set up outside the hospital (A and B). The patient was laid on the stretcher upon arrival (C), and the severe acuterespiratory syndrome coronavirus 2 (SARS-CoV-2) antigen test was performed before image examinations (not shown). The interventional
surgeon wore an N95 mask, a face shield, a long-sleeved disposable surgical gown, a cap, eye goggles, two pairs of gloves, and shoe covers (D).

An 8-Fr sheath was placed in the right common femoral
artery, and an 8-Fr guiding catheter with a balloon (Optimo;
Tokai Medical Products, Aichi, Japan) was advanced to the leftinternal carotid artery coaxially with a 6-Fr catheter (Slimguide; Medikit, Tokyo, Japan) and a 4-Fr catheter (HK; Medikit). A microcatheter (Trevo Trak 21; Stryker Corporation,
Kalamazoo, MI, USA) was guided distal to the occlusion in
the MCA using a guide wire (Chikai black 14; Asahi Intec Co.,
Ltd., Aichi, Japan). The stent retriever (Solitaire 4  20 mm;
Covidien/Medtronic, Irvine, CA, USA) was deployed to ensure
adequate coverage of the clot. The thrombus was then retrieved in two passes, and thrombolysis in cerebral infarction(TICI) grade 2b recanalization of the left MCA was achieved.
The time from puncture to recanalization was 24 minutes(►Fig. 3A–C).
After the procedure, staff members monitored each otherwhen removing contaminated gowns and gloves, and they
thoroughly disinfected their skin with isopropyl alcohol
before touching clean areas. Areas such as examination
room, angiography room, and elevators that were contacted
by the patient with COVID-19 patient or staffs who cared forthe patient directly were wiped down with isopropyl alcoholand disinfected.
The inpatient room was a private negative-pressure room,with a vital signs monitor positioned at the patient’s bedside,
Asian Journal of Neurosurgery

and vital signs were monitored from the nurses’ station. The
intravenous drip line was extended outside the room so thatnecessary medications could be administered from outside.
Room visits by staff were kept to a minimum. Postoperatively, no infection was recognized in our staff or other hospitalized patients.
On the day after thrombectomy, the patient’s NIHSS score
was 15, and the patient nodded in response to questions.
Cerebral CT showed no intracranial hemorrhage, and thepatient returned that day to the initial general hospitalwhere he had been admitted earlier for treatment of
COVID-19. PCR testing was later performed and revealed
that the patient was positive for SARS-CoV-2 with the N501Y
mutant strain.

Discussion
We were able to perform endovascular thrombectomy forlarge-vessel occlusion in a patient with COVID-19 caused by
the N501Y mutant strain. Some reports have suggested thatthe incidence of stroke in patients with COVID-19 does notdiffer signiﬁcantly from that in the general population,3
whereas others have suggested that it could be signiﬁcantly
higher.4,5 The main causes of stroke in patients with COVID19 are thought to be general risk factors such as

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Fig. 3 Angiography of the left internal carotid artery (A) showed occlusion of the left middle cerebral artery (MCA). Angiography of the left
carotid artery (B) obtained after stent retriever deployment showed partial recanalization of the left MCA. Angiography of the left carotid artery(C) obtained after thrombectomy showed revascularization of the MCA and conﬁrmed that Thrombolysis in cerebral infarction (TICI) grade 2b
recanalization had been achieved.

Fig. 4 Acute stroke care during COVID-19 pandemic at Tsurumi Hospital, Koga, Ibaraki, Japan.

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Mechanical Thrombectomy in Stroke Patient with COVID-19
atherosclerotic lesions and cardiogenic, as previously pointed out.3,6 However, the incidence of stroke is higher in casesof moderate or severe respiratory disease, as in our patient.3
In addition, some researchers theorize that COVID-19 is
involved in plaque destabilization through inﬂammation andcytokine responses, which may increase the likelihood ofthromboembolism, worsen cardiac function, and result in
cardiogenic stroke through arrhythmia and heart failure. It
may also be related to the interaction of multiple risk factors
for each patient and the factors caused by COVID-19 infection.6
Our patient had moderately severe COVID-19 and required inpatient care. The patient, in whom diabetes mellitus
was detected earlier, was also found to have atrial ﬁbrillation, and cardiogenic cerebral embolism was diagnosed.
Horiuchi et al.7 reported that the incidence of thrombosis,
including arterial and venous thrombosis, among hospitalized patients with mild and moderate COVID-19 was 0.59%,
in contrast to 13.5% among patients with severe cases,
according to the results of a survey conducted in 399
hospitals in Japan. However, whether COVID-19 increases
the incidence of embolic stroke, or whether the incidence ofembolic cerebral infarction increases with increasing severity of COVID-19, has not yet been reported. In our patient, theembolism was thought to be cardiogenic because of thepresence of atrial ﬁbrillation, but it remains difﬁcult todetermine whether cerebral main artery occlusion was
related to COVID-19 or occurred incidentally.
During the COVID-19 epidemic, all patients who have cometo our hospital by ambulance are tested for SARS-CoV-2
antigen; a stretcher is prepared in the ambulance arrival spaceoutside the hospital, and management is arranged according to
the results of the antigen test (►Fig. 4). The reason is that our
hospital is a single-specialty institution that focuses on neurosurgery and does not provide inpatient care for patients with
COVID-19. Patients are tested for COVID-19 even if they haveno symptoms. In the case of our patient, COVID-19 had been
diagnosed previously, and the result of the SARS-CoV-2 antigen test performed in our hospital was positive. Normally,
there are no restrictions on the number of personnel who canenter the angiography room: two or three physicians, one or
two nurses, one or two radiologists, and two or three medical
secretaries come and go as needed. But for this patient, thenumber of patient care personnel was kept as low as possible
from the time of his arrival—two physicians, one nurse, andone radiologist—to prevent the spread of COVID-19 infection.
Only one physician performed the intervention, while theother one waited in the operating room as much as possible,
moving between the angiography room and the operating
room only when necessary.
For the surgery, local anesthesia and sedation were induced. Yavagal et al8 reported that COVID-19 infection rates
did not differ between facilities that preferentially intubate
and those that preferentially do not intubate during endovascular surgery, according to the results of 113 questionnaires from 25 countries. Our interventional procedure itself
was the usual protocol, including sheath insertion, catheter
advancement, and stent deployment and was performed
without any particular problems. In addition, the thrombus
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Tsurumi et al.

was removed in the usual manner (by stent retrieval) during
the treatment procedure, and the gross appearance of thethrombus was no different from that in other patients.
Contaminated gowns, gloves, and other personal protective
equipment used were in accordance with the Japanese Stroke
Association’s version of the COVID-19-compliant stroke protocol (Protected Code Stroke: JSS-PCS). Patient transfer after
the procedure and disinfection of laboratories and transfer
routes were also performed according to this protocol.
Because emergency stroke management, including recanalization therapy, may be required, personnel who may comeinto contact with patients with COVID-19 should be familiar
with how to properly put on and take off N95 masks, faceshields, long-sleeved gowns, caps, gloves, and shoe covers toprevent infection on a daily basis.
After the intervention, COVID-19 infection was not observed in our staff or other hospitalized patients. A later PCR
test in our patient yielded a positive result for SARS-CoV-2
with the N501Y mutation. N501Y mutation strains have beencalled as Alfa variant. As of June 2021, the number of
infections caused by N501Y mutant strains has had been
noted to increase in Japan. Alfa variant is reported more
infectious than the original strains.9 More recently, L452R
mutation strains have been widely spread in Japan. L452R
mutation strains have been called as Delta variant and which
are considered much more infectious than other variants.
Although the preparation and management of endovasculartherapy for acute ischemic stroke in patients positive for
SARS-CoV-2 have been reported,2,3 the N501Y or L452R
mutant strains have not been mentioned widely.
It has been reported that thrombus retrieval therapy forin-hospital stroke with large-vessel occlusion takes longer if
the patient must be transferred to another hospital.10 In ourpatient, however, COVID-19 could be treated at the ﬁrst
hospital. Because our hospital is a single-specialty neurosurgery hospital, as mentioned previously, it was difﬁcult totreat COVID-19; thus, after the neurosurgery, the patient
returned to the general hospital where he had been hospitalized for COVID-19. In this way, collaboration between thehospitals enabled appropriate management. This demonstrates how vital collaboration is among hospitals not only
during the COVID-19 epidemic but also at other times.11

Conclusion
We performed recanalization therapy with thrombus retrieval for cerebral large-vessel occlusion in a patient
infected with the novel mutant strain of SARS-CoV-2. We
were able to avoid spreading the virus by taking appropriate
measures to prevent infection.
Conﬂict of Interest
None declared.

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