Figure 1 (left). AP-oblique view, left internal carotid artery injection, mid-arterial phase. The middle cerebral artery is occluded just distal to its take-off (red arrow). The anterior (A) and posterior (B) cerebral arteries with shift into the watershed area of the middle cerebral artery territory (blue stars). Figure 2 (right). AP view, left internal carotid artery injection, mid-arterial phase. Post-endovascular reperfusion therapy, the middle cerebral artery is fully recanalized (red arrow). The anterior (A) and posterior (B) cerebral arteries’ shift into the watershed area of the middle cerebral artery territory is no longer present.
This elderly man in his 80s was found to have an acute onset of right hemiparesis and global aphasia. Considered eligible for endovascular stroke treatment, he was transferred to the angiography room.
 
The initial angiogram showed occlusion of the left middle cerebral artery just distal to its origin (Figure 1). Clot extraction cleared the middle cerebral artery completely (Figure 2, 3). During the procedure, the patient’s stat COVID-19 antibody test came back positive with levels indicating strong immunity and negative COVID-19 nucleic acid amplification. Clinically unchanged, but in stable condition, the patient was discharged to a rehabilitation facility three days later.
Figure 3. Lateral view, left internal carotid artery injection, mid-arterial phase. Angiogram showing fully recanalized middle cerebral artery (red arrow) and reperfusion of its territory. The anterior (A) and posterior (B) cerebral arteries.
TREATMENT CONSIDERATIONS:
The procedure was performed in a single-plane angiographic suite. This technology, although not without challenges, allows patients to be treated in less richly resourced hospitals that do not have dedicated neuro-interventional suites, and even offers patients to be triaged into these hospitals in times of increased need (surge capacity). Additionally, it offers the application of a TRIP & TREAT approach, a possibly more beneficial shift from the DRIP & SHIP approach. 
 
Note, that using a non-tradition oblique view as shown in Figure 1 and 4, the anatomy can be seen well. In contrast, the post-reperfusion angiograms, in the classic AP and lateral views, can in cases with posterior cerebral artery origins or middle cerebral artery branch occlusions be difficult to interpret. 
 
Amusing, the patient’s glasses with its frame front and temples can be seen, as if inadvertently left on (Figures 1, 2, 4). There is a growing appreciation of the benefit of using minimal sedation in acute ischemic stroke patients to improve neurological outcome. In our practice, we avoid taking from the patient anything that does not represent a danger. Removing glasses, hearing aids, earrings, etc., often adds additional anxiety, fear, and sensory impairment to an already confused and agitated patient.  
Figure 4. Wide view of angiogram shown in Fig 1. AP-oblique view, left internal carotid artery injection, mid-arterial phase. The middle cerebral artery is occluded just distal to its take-off (red arrow). Patient wearing glasses (frame front and temples, yellow arrows).
Is there an age cut-off for endovascular stroke treatment? Perhaps. More certain, in the elderly, the hope for an extended period of life or significant QALY is often not realistic. The importance of knowing the patient’s wishes for end of life care cannot be overly stressed. More thought and consensus needs to be developed with shared societal expectations to guide emergency treatment1.   
 
The patient was COVID-19 antibody positive, with strong immunity and no clinical signs of an infection. The clinical course was without complications and the hospital stay was also not unusually prolonged. Hyperacute invasive care in the COVID environment is a challenge that is currently being met but continues to be difficult2.  
 
There is growing evidence for a relationship between stroke and COVID-19, but the exact nature of cerebral large vessel occlusion and COVID-19 infections is yet to be determined3.
AUTHORS
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NEUROLOGICAL SURGERY
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