Postoperative Neurologic Deficits in a Veteran With Recent COVID-19

Though less likely, our patient’s presentation could have been explained by a new cerebrovascular event—transient ischemic attack vs new MI. Speech and right-sided motor/sensory deficits can localize to the left middle cerebral artery or small penetrating arteries of the left brainstem or deep white matter. MRI was not performed to exclude this possibility due to hospital-wide COVID-19 precautions minimizing nonessential MRIs unlikely to change clinical management. We speculate, however, that due to recent SARS-CoV-2 infection, our patient may have been at higher risk for cerebrovascular events due to subclinical endothelial damage and/or microclot in predisposed neurovasculature. Though our patient had interval COVID-19 negative tests, the timeframe of coronavirus procoagulant effects is unknown.¹⁶

There are well-established guidelines for perioperative stroke management published by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC).¹⁷ This case exemplifies many recommendations including tight hemodynamic and glucose control, optimized oxygen delivery, avoidance of intraoperative β blockade, and prompt neurologic consultation. Additionally, special precaution was taken to ensure continuation of antiplatelet therapy on the day of surgery; in light of COVID-19 prothrombosis risk we considered this essential. Low-dose enoxaparin was also instituted on postoperative day 1. Prophylactic anticoagulation with low molecular weight heparin (LMWH) is recommended for hospitalized COVID-19–positive patients, though perioperatively, this must be weighed against hemorrhagic stroke transformation and surgical bleeding.^8,16 Interestingly, the benefit of LMWH may partly relate to its anti-inflammatory effects, of which higher levels are observed in COVID-19.^16,18

Though substantial health care provider energy and hospital resource utilization is presently focused on controlling the COVID-19 pandemic, the importance of appropriate stroke code processes must not be neglected. Recently, SNACC released anesthetic guidelines for endovascular ischemic stroke management that reflect COVID-19 precautions; highlights include personal protective equipment (PPE) utilization, risk-benefit analysis of general anesthesia (with early decision to intubate) vs sedation techniques for thrombectomy, and airway management strategies to minimize aerosolization exposure.¹⁹ Finally, negative pressure rooms relative to PACU and operating room locations need to be known and marked, as well as the necessary airway equipment and PPE to transfer patients safely to and from angiography suites.

Conclusions

We discuss a surgical patient with prior SARS-CoV-2 infection at elevated stroke risk that experienced recurrence of neurologic deficits postoperatively. This case informs anesthesia providers of the broad differential diagnosis for focal neurological deficits to include PSR and the possible contribution of COVID-19 to elevated acute stroke risk. Perioperative physicians, including VHA practitioners, with knowledge of current COVID-19 practices are primed to coordinate multidisciplinary efforts during stroke codes and ensuring appropriate anticoagulation.

Acknowledgments

The authors would like to thank perioperative care teams across the world caring for COVID-19 patients safely.