International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG

Al Kasab, Sami; Almallouhi, Eyad; Alawieh, Ali; Levitt, Michael R; Jabbour, Pascal; Sweid, Ahmad; Starke, Robert M; Saini, Vasu; Wolfe, Stacey Q; Fargen, Kyle M; Arthur, Adam S; Goyal, Nitin; Pandhi, Abhi; Fragata, Isabel; Maier, Ilko; Matouk, Charles; Grossberg, Jonathan A; Howard, Brian M; Kan, Peter; Hafeez, Muhammad; Schirmer, Clemens M; Crowley, R Webster; Joshi, Krishna C; Tjoumakaris, Stavropoula I; Chowdry, Shakeel; Ares, William; Ogilvy, Christopher; Gomez-Paz, Santiago; Rai, Ansaar T.; Mokin, Maxim; Guerrero, Waldo; Park, Min S; Mascitelli, Justin R; Yoo, Albert; Williamson, Richard; Grande, Andrew Walker; Crosa, Roberto Javier; Webb, Sharon; Psychogios, Marios N; Ducruet, Andrew F; Holmstedt, Christine A; Ringer, Andrew J; Spiotta, Alejandro M

BACKGROUND: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.