Simultaneous bilateral mechanical thrombectomies on a COVID-19 patient

CASE PRESENTATION

• A 60-year-old female patient with no cardiovascular risk factors previously healthy presented to the ER for decreased mental status
• In the ER, she turned unresponsive and was intubated, tested positive for COVID-19
• CTA shows left T occlusion and right M1 occlusion
• She was transferred to Neurosurgery Department at Thomas Jefferson University Hospital 6 hours after onset of symptoms, at that moment, she was plegic on the right and had minimal reaction to painful stimulus on the left
• She was taken to the angio suite right away

BILATERAL MECHANICAL THROMBECTOMIES SET UP 

• Radial artery was small caliber so bilateral femoral access was performed because Dr. Jabbour wanted to do the mechanical thrombectomy simultaneously in both hemispheres
• 2 operators performed the thrombectomies. The system consisted bilaterally of:
  • 8Fr groin sheath
  • Neuromax 90
  • 071 React
  • Riptide aspiration
• The  MT was performed with Aspiration one pass each side, TICI 3 both sides, and groin to revascularisation was 18 minutes 

RESULTS

• Post Procedure MRI didn’t show any major diffusion restrictions
• The patient was extubated 8 hours later and is neuro intact NIHSS0 
• Stroke work up done was all negative
• Dr. Jabbour and his team believe this was a hypercoagulable state caused by COVID-19, they have published multiple papers on this phenomenon/association (see references listed below)

References:

• Sweid A, Hammoud B, Weinberg JH, Oneissi M, Raz E, Shapiro M, DePrince M, Tjoumakaris S, Gooch MR, Herial NA, Zarzour H, Romo V, Rosenwasser RH, Jabbour P. Letter: Thrombotic Neurovascular Disease in COVID-19 Patients. Neurosurgery. 2020 Sep 1;87(3):E400-E406. doi: 10.1093/neuros/nyaa254 . PMID: 32496534; PMCID: PMC7313768.
• Al Saiegh F, Ghosh R, Leibold A, Avery MB, Schmidt RF, Theofanis T, Mouchtouris N, Philipp L, Peiper SC, Wang ZX, Rincon F, Tjoumakaris SI, Jabbour P, Rosenwasser RH, Gooch MR. Status of SARS-CoV-2 in cerebrospinal fluid of patients with COVID-19 and stroke. J Neurol Neurosurg Psychiatry. 2020 Aug;91(8):846-848. doi: 10.1136/jnnp-2020-323522 . Epub 2020 Apr 30. PMID: 32354770.  
• Sweid A, Hammoud B, Bekelis K, Missios S, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Romo V, DePrince M, Rosenwasser RH, Jabbour P. Cerebral ischemic and hemorrhagic complications of coronavirus disease 2019. Int J Stroke. 2020 Oct;15(7):733-742. doi: 10.1177/1747493020937189 . Epub 2020 Jun 26. PMID: 32501751; PMCID: PMC7534206.  
• Sweid A, Jabbour P, Tjoumakaris S. Letter to the Editor: Incidence of Acute Ischemic Stroke and Rate of Mechanical Thrombectomy During the COVID-19 Pandemic in a Large Tertiary Care Telemedicine Network. World Neurosurg. 2020 Aug;140:491-492. doi: 10.1016/j.wneu.2020.06.053 . Epub 2020 Jun 13. PMID: 32544621; PMCID: PMC7293475.  
• Jabbour P, Sweid A, Tjoumakaris S, Piotin M, Brinjikji W, Bekelis K, Raz E, Sourour N, Nimjee SM, Lopes DK, Hassan AE, Pandey AS, Gonzalez LF, Hanel RA, Siddiqui AH, Hasan D, Lavine SD, Bendok BR. In Reply: May Cooler Heads Prevail During a Pandemic: Stroke in COVID-19 Patients or COVID-19 in Stroke Patients? Neurosurgery. 2020 Aug 28:nyaa384. doi: 10.1093/neuros/nyaa384 . Epub ahead of print. PMID: 32856706; PMCID: PMC7499717.  
• Hoelscher C, Sweid A, Ghosh R, Al Saiegh F, Keppetipola KM, Farrell CJ, Jallo J, Jabbour P, Tjoumakaris S, Gooch MR, Rosenwasser RH, Shah SO. Cerebral deep venous thrombosis and COVID-19: case report. J Neurosurg. 2020 Sep 4:1-4. doi: 10.3171/2020.5.JNS201542 . Epub ahead of print. PMID: 32886922.  
• Kananeh MF, Thomas T, Sharma K, Herpich F, Urtecho J, Athar MK, Jabbour P, Shah SO. Arterial and venous strokes in the setting of COVID-19. J Clin Neurosci. 2020 Sep;79:60-66. doi: 10.1016/j.jocn.2020.07.005 . Epub 2020 Jul 7. PMID: 33070919; PMCID: PMC7340078.