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May 13, 2020

SNIS Issues Recommendation for Mechanical Thrombectomy and Care of Emergent Neurointerventional Patients in the COVID-19 Setting

May 13, 2020—The Society of NeuroInterventional Surgery (SNIS) recommendations for the care of emergent neurointerventional patients in the setting of COVID-19 have been published by Justin F. Fraser, MD, et al online in Journal of NeuroInterventional Surgery (JNIS).

Given the number of health care providers who have contracted the disease, the document stated that failing to protect physicians, nursing staff, and ancillary providers will result in failing to meet the needs of future patients. The successful care of future COVID-19 patients will depend on effective safety and prevention strategies for health care workers.

According to the JNIS document, patients with a history of acute ischemic stroke and/or its risk factors are particularly at risk for the severe form of COVID-19. Additionally, there is early evidence that the virus can cause neurologic signs and that it has been reported in the brains of both patients and animal models. In this setting, neurointerventionalists should expect to be involved in the care of COVID-19-positive patients, as well as those whose status is unknown and those at risk of a severe form of the disease.

Although the data on COVID-19 are rapidly emerging, the SNIS is seeking to provide neurointerventionalists with rapid up-to-date recommendations on the management of stroke thrombectomy in this setting, with an emphasis on safety measures for health care providers.

In brief, the SNIS recommendations laid out in JNIS include:

Criteria for mechanical thrombectomy

  • The presence of COVID-19 as a public health issue should not alter the inclusion and exclusion criteria for mechanical thrombectomy.
  • Providers should use currently available guidelines and recommendations based on multiple randomized trials for identification and management of large vessel occlusion whenever possible.
  • Because of the significant proven benefit of thrombectomy for patients with emergent large vessel occlusion, denial of this treatment likely creates a greater drain on health care resources.

Treatment protocols based on patients’ COVID status

  • For documented COVID-negative status, SNIS recommends taking standard personal protective equipment (PPE) precautions. In regions of peak epidemic activity, protecting the health care team will need to be balanced with preserving PPE resources.
  • For documented COVID-positive status or presumed-positive status, patients should be treated with maximum safety precautions. Therefore, SNIS recommends standard institutional protocols with a low threshold for intubation of stroke thrombectomy COVID-19-positive patients before transport to the angiography suite, ideally in a negative pressure environment. Once an intubated patient is transported into the suite, all providers should wear enhanced PPE at all times, provided resources are available. Specifications of enhanced PPE are listed in the document. Patients should not be extubated in the angiography suite (unless in a negative airflow environment) but should be taken to an isolation ICU room for planned extubation with airborne and contact precautions.
  • For patients with undocumented COVID status, it is recommended they be treated as high risk for COVID-positive, provided institutional resources are available.

The SNIS recommendations in JNIS further address the following: additional postthrombectomy principles in the COVID-19 setting; early progressive care and related protocols; COVID testing; angiography equipment and turnover; and staffing organization and PPE use.

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