J Korean Neurosurg Soc.  2022 Mar;65(2):224-235. 10.3340/jkns.2021.0053.

Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy

  • 1Department of Neurosurgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea


: Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time.
: The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time.
: The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively).
: The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and doorto- recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.


Thrombectomy; Stroke, acute; COVID-19


  • Fig. 1. Timeline and patient selection process before and after establishing the coronavirus disease 2019 (COVID-19) protocol. Before the COVID-19 pandemic, mechanical thrombectomy was conducted for 55 patients. After the hospital reopened, mechanical thrombectomy was conducted for 54 patients. Finally, total 45 patients were treated under the conventional protocol and 43 patients under the COVID-19 protocol were included in this analysis. ER : emergency room.

  • Fig. 2. Comparison of the conventional protocol and COVID-19 protocol. Protection protocol for the prevention of COVID-19 was established and additional steps were included for CT imaging, mechanical thrombectomy, and patient transport route. COVID-19 : coronavirus disease 2019, EM : emergency medical, PPE : personal protective equipment, URI : upper respiratory infection, CTA : computed tomography angiography, CTP : perfusion computed tomography, CT : computed tomography, tPA : tissue plasminogen activator, MRI : magnetic resolution image, PAPR : powered air purifying respirator, NCU : neuro-intensive care unit.

  • Fig. 3. Graphical comparison of the door-to-imaging time and door-to-puncture time in the conventional, suspected coronavirus disease 2019 (COVID-19) positive, and suspected COVID-19 negative groups. The door-to-imaging time was longer in the suspected COVID-19 positive group compared to that in the suspected COVID-19 negative and conventional protocol groups. The door-to-puncture time showed no statistical difference between the three groups.



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