Letter by Sharma and Rasmussen Regarding Article, "Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams: A Guidance Statement From the Society of Vascular and Interventional Neurology".

To the Editor:

We read with interest the guidance statement on mechanical thrombectomy during coronavirus disease 2019 (COVID-19) pandemic.[1] However, it does not refer to the consensus statement on anesthetic management of stroke thrombectomy during COVID-19 pandemic from the Society for Neuroscience in Anesthesiology & Critical Care endorsed by Society of Vascular & Interventional Neurology, Society of NeuroInterventional Surgery, Neurocritical Care Society, European Society of Minimally Invasive Neurological Therapy, American Association of Neurological Surgeons, and Congress of Neurological Surgeons cerebrovascular section.[2] We are writing to bring up an important difference between the guidance statements. Nguyen et al[1] suggest that conscious sedation (CS) be considered the first-line technique for stroke thrombectomy. However, the Society for Neuroscience in Anesthesiology & Critical Care consensus recommends a lower threshold for the use of general anesthesia (GA) during COVID-19 pandemic.[2] There are several reasons for the later recommendation: (1) based on data from randomized control trials, GA is associated with better neurological outcomes compared with CS,[3-5] (2) emergent conversion from CS to GA during thrombectomy is undesirable given the risk to the patient and personnel in the angiography suite, and (3) coughing and sneezing in spontaneously breathing, patients with COVID-19 positive may increase aerosolization, the distance that viral particles spread and the time they remain airborne, posing potential risk to healthcare workers in proximity.[2] If the anesthesiologist has any concerns for possible conversion from CS to GA during thrombectomy, it is advisable to start with GA.[2] The Society for Neuroscience in Anesthesiology & Critical Care consensus statement has provided detailed recommendations on which subset of patients may be better suited for GA.[2] Importantly, anesthesiologists should be involved in early evaluation of patients (preferably in the emergency department) to make a timely decision about appropriate anesthetic technique. This is critical to facilitate possible induction of anesthesia in a negative pressure location before the patient is brought to angiography suite.

We disagree with Nguyen et al[1] in their recommendations “Review in advance whether anesthesia presence is required in the room …” and “Keep staff to a minimum in the procedure (ie, 1 nurse, 1 technologist, 1 physician) …”. We recommend that during the COVID-19 pandemic, an anesthesiologist should be involved in every stroke thrombectomy. It is important that CS be performed by an anesthesiologist given the medical complexity of COVID-19 including the possibility of associated cardiomyopathy, hemodynamic fluctuations, and the possible need to emergently convert to GA. Lack of early involvement of anesthesiologists and extra time required for preparation to safely intubate a possible patient with COVID-19 may increase the risk to the patient as well as angiography suite staff.

The impact of anesthetic technique on outcomes of stroke thrombectomy is huge, and it is critical that evidence-based anesthetic management be provided by qualified anesthesiologists, especially during COVID-19 pandemic.

Disclosures

Dr Sharma receives grant from Agency for Healthcare Research and Quality and honorarium from Wolters Kluver. The other authors report no conflicts.