Medknowcontrol screen should assess for the following constellationof signs and symptoms: fever, cough, chest pain, dyspnoea,headache, myalgias, and gastrointestinal symptoms,including vomiting and diarrhoea. However, there is agood number of patients who are symptomatic with strokeas the first presenting symptom has been documented.Various guidelines for surgical procedure relatedprecaution have been published that includeIntercollegiate surgical guidelines, Society of AmericanGastrointestinal and Endoscopic surgeons and TheEuropean Association of endoscopic and surgeryrecommendations regarding surgical response to theCOVID 19 crisis delineate the need for precautionduring the surgical procedure.[1] Society of AmericanGastrointestinal and Endoscopic Surgeons and TheEuropean Association of Endoscopic Surgery.[2] Theconcept of protected code stroke has been proposed toaddress preparedness and protect health‑care workersOriginal ArticleIntroductionSevere Acute Respiratory Syndrome – Coronavirus –2 (SARS‑CoV‑2) virus causing coronavirus disease2019 (COVID 19) infection is causing a rampageacross the globe, stressing even the most organised thehealth‑care system. Challenges faced by India is farmore given the baseline scarcity of beds and discrepancyin accessibility to health care. In this scenario,neurovascular emergencies in particular acute stroke,happen with increased incidence given the endothelialinvasion and thrombogenic potential of COVID 19infection. There are various care recommendations fromdifferent parts of the world, taking into consideration theseamless delivery of care along with the safety of thehealth‑care workers. We need to adapt and modify thepathways and recommendations based on the health‑caresystem and have a systematic approach.SARS‑CoV‑2 virus, causing COVID 19 is transmittedprimarily via respiratory droplets. The symptom associatedwith the illness includes, respiratory along with othersystems such as enteric or neurological. An infectionIntroduction: Since the outbreak of the coronavirus pandemic, much has changedin the protocol for management of healthcare setups and patients presenting withany illness including neurological and neurosurgical emergencies. Patients arethemselves deterred from visiting a hospital in an emergency, and healthcareworkers require stringent precautions and plans to prevent the spread of the virusto themselves and others, without compromising on the care that is to be provided.Aims and objectives: To outline the importance of identifying neurologicalemergencies requiring urgent intervention even in the time of a pandemic, andmethods to effectively manage patients without compromising on safety andinfection prevention measures.Materials: Guidelines reviewed from existing literature and retrospective analysisof management protocol and care delivered in a neurovascular unit during theCOVID-19 pandemic..Conclusion: Acute neurovascular care should not be compromised upon evenduring a pandemic, but neither should the safety of healthcare workers. Safetyguidelines and protocols require strict adherence.Keywords: Covid-19, neurovascular, stroke, safetyAcute Neurovascular Care in the COVID Era: Safety and ResilienceSrinivasan Paramasivam, Harihara Sudan, Dinesh Babu, N V Vinoth KumarDepartment ofNeurosurgery, ApolloHospitals, Chennai, TamilNadu, IndiaAbstractSubmitted: 31-Jul-2020Accepted: 01-Sep-2020Published: 01-Oct-2020Access this article onlineQuick Response Code:Website: www.jcvs.inDOI: 10.4103/jcvs.jcvs_5_20Address for correspondence: Dr. Srinivasan Paramasivam,E-mail: neurosurgeonsrini@gmail.comThis is an open access journal, and articles are distributed under the terms of the CreativeCommons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others toremix, tweak, and build upon the work non‑commercially, as long as appropriate credit isgiven and the new creations are licensed under the identical terms.For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.comHow to cite this article: Paramasivam S, Sudan H, Babu D, Kumar NV. Acuteneurovascular care in the COVID era: Safety and resilience. J CerebrovascSci 2020;8:24-8.[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam, et al.: Acute neurovascular care in the COVID eraJournal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020 25and other patients.[3] The society of Neuro interventionalsurgery released the recommendations specific to neurointerventional patients in the setting of COVID 19.[4]Later, Consensus statement on Recommendations foracute stroke management during COVID 19 pandemicwas released on behalf of the Indian stroke association.[5]Major concern is the fear of the public and only asmaller proportion of acute neurological emergenciescome to the hospital during the acute phase dueto fear of contracting COVID‑19 while accessinghealth services.[6] There is a general thought that allhealth‑care resources are mobilised to prioritise care forCOVID‑19 patients.Acute Neurovascular EmergenciesAcute stroke is an emergency that needs immediateattention in spite of the pandemic. Preparedness andprompt treatment to provide evidence‑based care areessential for good outcome in acute ischaemic strokeand other subtypes of strokes, including sub arachnoidhaemorrhage (SAH), intracerebral haemorrhage (ICH),and cerebral venous thrombosis. Patients withNeurovascular emergencies come to hospitals as directpatient walk‑ins, referral form other hospitals and fromprimary stroke centres after thrombolysis. Contrary tothe conventional screening process, COVID 19 pandemicnecessitates additional screening by paramedics and athospital emergency rooms that include travel historyand infection control screening. In most situations,the patient may not be able to communicate due tostroke and decreased level of alertness. Hence, validinformation will be missing and family members maynot be available to give information. COVID 19 testingavailability and time for reports grossly vary based onthe setting and testing load in a particular region. In ourhospital, with in‑house testing it takes approximately 8‑hfor the report to arrive. Given the scenario, Covid testingis impractical in acute stroke treatment. It is presumedthat every patient is COVID 19 positive, care needs to goon with additional protection.Protection during Initial AssessmentAll patients are assessed in isolation chambers in theemergency room. The current consensus on the use ofpersonal protective equipment (PPE) is standardisedand that include, Full sleeved Gown, Surgical mask,eye protection and gloves with extended sleeve tooverlap the gown. Head covering is not mandated if eyeFigure 1: A 35 year old patient with recent travel history presented with acute stroke to the emergency room at 6:30 PM with NIHSS of 14. Urgentevaluation revealed a right internal carotid artery occlusion and computed tomography chestshowed parenchymal changessuggestive ofCOVID infection(a,b). Initial angiogram showsright internal carotid artery complete occlusion (c) that wasrecanalised by direct aspiration (d) and middle cerebral arteryocclusion recanalised using stent retriever (e). Thrombolysis was done and subsequently taken to the Cath lab for mechanical thrombectomy. The healthcare workers adequately protected with personal protective equipment (f). Powered air purifying respirator is a value addition during the procedure (g).Post procedure the patient made a dramatic recovery to NIHSS 3 and computed tomography scan showed good preservation of brain parenchyma (h)dhcgbfae[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam, et al.: Acute neurovascular care in the COVID era26 Journal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020protection is well worn. When aerosolisation is expected,N95 mask is mandatory. In a stroke patient, commonaerosol‑generating procedures include oropharyngealor nasal suctioning, bag‑valve‑mask ventilation, andintubation. Intubation in a negative pressure rooms reducethe aerosol generation and it is highly recommended.Post‑intubation if the circuit is maintained without abreakage for providing care, aerosol precaution is notmandatory. In general, nebulisation, continuous positiveairway pressure, Bi‑level positive airway pressure andhigh flow nasal therapy is to be avoided as they aresignificant aerosol‑generating procedures.[7]During the initial assessment, the team membersare mandated to wear PPE as recommended; strokeneurology assessment may be done with PPE or throughTelemedicine along with review of imaging to decide onthe need for thrombolysis. Dedicated sperate pathwayfor transport, dedicated scanning equipment for COVIDstatus unknown, suspected, confirmed cases are neededbased on the institutional resource availability. In anon‑intubated patient, a surgical mask is worn and kepton during transport and during imaging procedures. Ifneeded, nasal prongs oxygen may be applied underneaththe mask. Radiology technicians and other staff areinstructed to wear appropriate PPE while imaging.Imaging to be done as per the institutional protocoleither with Bi‑level positive airway pressure (CT) andCT angiography in patients presenting within 6 h ofthe onset of stroke and CT perfusion scan or magneticresonance imaging stroke protocol to be done in thosecoming later. CT chest is done along with neuroimagingto look for COVID‑related changes [Figure 1a and b]The images can be reviewed by radiologist, neurologistand Neurovascular surgeon through remote accessand discussion is done to make a decision on furthermanagement. Intravenous thrombolysis considered forall eligible patients and done as per the standard protocolwith emphasis to look at platelet count as cytopenia maybe caused by COVID 19 infection.[5] Family counsellingideally done in the COVID era remotely through videoconference or over telephone to avoid contact for thesafety of the family and the medical staff.Protection during Neuro‑InterventionAcute ischemic stroke due to large vessel occlusion,treatment by endovascular thrombectomy is the standardof care and this procedure has aerosol generationpotential making it challenging and protectionof health‑care workers needs stringent protectivemeasures.[8] Dedicated cathlab for COVID statusunknown, suspected and positive cases are recommendedwhen more than one cathlab suites are available in aninstitution. It may be shared between cardiac, neuro andother peripheral procedures.The laboratory is fumigated after each procedure, the aircirculation in the air condition is modified to have >12fresh air exchanges per hour. All the staff membersare trained and rehearsed to be aware of the protocolfor equipment, inventory handling, patient movement,donning and doffing techniques [Figure 1f]. Alternatively,the operator can wear a positive Air‑purifyingrespirator to protect against virus with maximumcomfort [Figure 1g]. Adequate sign boards are placedfor reinforcements of the protocol. The procedural zonein the cathlab is designated RED zone with minimalpersonal that include operator, assistant, anaesthetistand a technician all with full PPE. The control roomis designated GREEN zone where the floor nurse andassistant technician are present to provide support. Thedoor is kept closed and communication is done throughtwo way radio communication. At the end of theprocedure, the operator followed by other members doffthe PPE at the YELLOW zone just outside the cathlaband properly disposed. Neurointervention procedure isdone either using direct aspiration technique or stentretriever [Figure 1c‑e and h]. The essential materialsneeded for the procedure are taken into the room andonce inside, it is considered used (RED Zone). Reservematerials are kept in the control room (GREEN Zone)and handed over by support staff when needed. Thispractice reduces the inventory and keeps a check on thecost of the procedure.The threshold for intubation of patient with acutestroke be low contrary to conventional strategy asmid‑procedural patient agitation, coughing, suctional andsubsequent conversion to intubation can be detrimentaland could expose the whole team to significant aerosols.In patients with agitation, extreme drowsiness anduncooperative patients, intubation is done in the negativepressure room before shifting to cahtlab and the circuitis kept intact through the procedure without breaking toprevent aerosol generation.Protection During Surgical Managementof StrokePatients with large ICH with or without intraventricularhemorrhage (IVH), Cerebellar hemorrhage, SAHwith IVH and hydrocephalus, malignant middlecerebral artery infarct are emergencies that need tobe tackled right away without waiting for reversetranscription‑polymerase chain reaction (PCR) COVIDtesting report. There needs to be a regional collaboration,with change in the system, referral pattern and caresetting. The protocol designed and implemented to[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam, et al.: Acute neurovascular care in the COVID eraJournal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020 27manage such emergencies in well‑equipped setup withall facilities.[9] Whenever possible, if the procedurecan wait till the COVID test reporting like definitivecoiling or clipping of an aneurysm that has to be done.However, the care cannot be delayed for the report toarrive.Designated COVID operation Theaters must be in placefor suspected, unknown and confirmed cases with similarstructural and organisational changes as described for thecath lab should be in place. Air circulation, air exchanges,High Efficiency Particulate Air (HEPA) filter placement,needs to be done as per the local guidelines. Negativepressure rooms are ideal but not practical in mostsituations. Sanitisation after each procedure is extremelyimportant to prevent cross contamination. The teammembers in the room are kept to minimum, with full PPEthat includes eye protection. Team members are trainedfor proper donning and doffing techniques. Surgeons andpersonnel not needed for intubation should remain outsidethe operating room until and after 15 min of inductionand intubation to allow aerosols to settle down. Burr holeplacements and cutting of bone with high‑speed drill isan aerosol‑generating process. It has to be done undercopious irrigation to minimise the chances.Following procedures, the patients are preferably treatedin isolation rooms till the PCR testing report comes backwithin the intensive care uni setting for all surgical patientsand for sick patients post‑thrombectomy or in a dedicatedstroke ward for stable patients post‑thrombectomy. Thecare setting should be able to provide basic monitoring,bedside care along with neuromonitoring to look forchanges in neuro examination.Protection during Further CareSpecial and dedicated care of the stroke patients has tobe done to ensure the quality of stroke care, the patientmay need to be admitted to other wards with dedicatedand trained staff with appropriate PPE to concentrateon dysphagia management, physical therapy, in‑hospitalrehabilitation. Physiotherapist, occupational therapist,speech therapist and clinical psychologist play a pivotalrole in rehabilitation. In general, rehabilitation servicesduring the pandemic are challenging as it involves moreand prolonged personal contact between the patient andthe provider. Patients are assessed on an individual basison the need for the type of rehab services they need andtailored to minimise the exposure for both patient andthe provider.Other Neurological EmergenciesThere is general belief that the entire health‑care systemis geared up to tackle COVID 19 and the patientsfear coming to the hospital for other emergencies andgeneral care. They end up having more severe problemsbefore seeking medical help. This belief needs to beaddressed at large. Early signs of brain tumour likeheadache, ataxia and other neuro symptoms are ignoredfor the fear of COVID 19. Public health campaigns onprecautionary measures that are in place to minimiseinfection transmission and negative impact of delayedpresentation has to be emphasised to the public.Telehealth services with remote consulting and screeningfollowed by maintaining social distancing in out‑patientclinics are mandatory to prevent and to give reassuranceto patients coming for other ailments. COVID 19 inpaediatric population is relatively low and neurologicalmanifestations are less likely to be delineated. Overallonly about 2% of COVID positive patients are <18‑yearof age. They should be encouraged to come to thehospital at the earliest to provide early care.Health‑Care Worker ProtectionHealth‑care workers are at a constant fear of contractingCOVID infection during work hours leading to stress.[3,6]Further, concerns like lack of PPE, prolonged workhours and the system in place to care for them in casethey get sick, along with fear of passing the infectionto the family member, is in the minds of every healthcare worker. The scarcity of resources during the peakof pandemic can be challenging, leading to constantstress and mental health problems. Measures to reassureand improve the morale of health care workers areparamount to boost their enthusiasm for effective andefficient work. They need breaks and given informationregarding relaxation and coping strategies. The advantageof adequately protecting the health‑care workers includepreventing their absence from work, continued care forsick patients by the trained specialist; further it adds tosecondarily protecting their family, other patients andthe community spread.Team Training, Cohesiveness andSupportTo achieve a good standard of care, it is mandatoryto formulate protocol and train the staff. Changesimplemented to the protocol in carrying out stroke codeaction are to be rehearsed. Donning and Doffing of PPE,protocol to adhere in the procedure room and outside,cleaning the procedure room after the procedure are to betaught and implemented in each institution. Any breachin the protocol are to be addressed and improved withfuture cases. The WHO ‘Mental health and psychosocialconsiderations during the COVID‑19 outbreak’ documentdefines the role of a ‘peer support system. Experiencedclinicians to assist and support their less experienced[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam, et al.: Acute neurovascular care in the COVID era28 Journal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020colleagues, to manage stress and efficiently enact theprotocols that are in place in an organisation.[10] Onlinepeer support systems for discussion may help copewith shortcomings along with social media and groupmessaging systems. Rearrangement of health careworkers home living arrangements and isolation if testedpositive with hotel accommodation for self‑isolationminimises the risk to family and gives a sense ofreassurance among frontline workers.ConclusionsIn the COVID era, with most services rationed tocare for COVID 19 cases, acute neurovascular care isunder stress. We focussed on significant factors in thesystem that can be addressed to help the system, itsworkers and patients for continued and effective care.All patients during the pandemic need to be screenedfor COVID‑19 and telemedicine could be used to triagethese patients and deliver intravenous thrombolysis.Mechanical thrombectomy needs protocolised movementof the patient and controlled care setting to minimiseaerosol transmission and exposure of health‑care staff.To encourage patients to come early with neurologicalsymptoms, public health campaigns to educate andincrease awareness of the community about thesafety measure are important. Special considerationsto be applied and care pathways to be developed forother emergencies like traumatic brain injury as likeNeurovascular disorders. In view of the pandemicexpected to stay longer, limiting exposure and safety ofhealth‑care workers is paramount with heightened safetymeasures. Wading the negative impact on the moraleof professional colleagues is important for efficient andcontinued health‑care delivery.References1. Royal College of Surgeons of England. Updated IntercollegiateGeneral Surgery Guidance on COVID‑19. 35‑43 Lincoln’s InnFields. London: Royal College of Surgeons of England; 2020.2. SAGES and EAES Recommendations Regarding SurgicalResponse to COVID‑19 Crisis. Society of AmericanGastrointestinal and Endoscopic Surgeons; 2020.3. Khosravani H, Rajendram P, Notario L, Chapman MG,Menon BK. Protected code stroke: Hyperacute strokemanagement during the coronavirus disease 2019 (COVID‑19)Pandemic. Stroke 2020;51:1891‑5.4. Fraser JF, Arthur AS, Chen M, Levitt M, Mocco J,Albuquerque FC, et al. Society of neurointerventional surgeryrecommendations for the care of emergent neurointerventionalpatients in the setting of COVID‑19. J Neurointerv Surg2020;12:539‑41.5. Bhatia R, Sylaja PN, Srivastava MV, Khurana D, Pandian JD,Suri V, et al. Consensus Statement‑Suggested recommendationsfor acute stroke management during the COVID‑19 pandemic:Expert group on behalf of the Indian stroke association. AnnIndian Acad Neurol 2020;23:S15‑23.6. AHA/ASA Stroke Council Leadership. Temporary emergencyguidance to us stroke centers during the coronavirus disease2019 (COVID‑19) pandemic: On behalf of the AmericanHeart Association/American stroke association stroke councilleadership. Stroke 2020;51:1910‑2.7. Murthy S, Gomersall CD, Fowler RA. Care for critically illpatients with COVID-19. Jama 2020;323:1499-500.8. Sharma D, Rasmussen M, Han R, Whalin MK, Davis M,Kofke WA, et al. Anesthetic Management of endovascular treatmentof acute ischemic stroke during COVID‑19 pandemic: Consensusstatement from society for neuroscience in anesthesiology &critical care (SNACC): Endorsed by society of vascular &interventional neurology (SVIN), society of neurointerventionalsurgery (SNIS), neurocritical care society (NCS), Europeansociety of minimally invasive neurological therapy (ESMINT)and American Association of neurological surgeons (AANS) andCongress of neurological surgeons (CNS) cerebrovascular section.J Neurosurg Anesthesiol 2020;32:193‑201.9. Zoia C, Bongetta D, Veiceschi P, Cenzato M, Di Meco F,Locatelli D, et al. Neurosurgery during the COVID‑19 pandemic:Update from Lombardy, northern Italy. Acta Neurochir(Wien) 2020;162:1221‑2.10. World Health Organisation. Mental Health and PsychosocialConsiderations during the COVID‑19 Outbreak; 2020.