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International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG
  1. Sami Al Kasab1,2,
  2. Eyad Almallouhi2,
  3. Ali Alawieh3,4,
  4. Michael R Levitt5,
  5. Pascal Jabbour6,
  6. Ahmad Sweid6,
  7. Robert M Starke7,8,
  8. Vasu Saini8,
  9. Stacey Q Wolfe9,
  10. Kyle M Fargen9,
  11. Adam S Arthur10,11,
  12. Nitin Goyal12,
  13. Abhi Pandhi12,
  14. Isabel Fragata13,
  15. Ilko Maier14,
  16. Charles Matouk15,
  17. Jonathan A Grossberg16,
  18. Brian M Howard17,18,
  19. Peter Kan19,
  20. Muhammad Hafeez20,
  21. Clemens M Schirmer21,
  22. R Webster Crowley22,
  23. Krishna C Joshi23,
  24. Stavropoula I Tjoumakaris6,
  25. Shakeel Chowdry24,
  26. William Ares25,
  27. Christopher Ogilvy26,
  28. Santiago Gomez-Paz26,
  29. Ansaar T. Rai27,
  30. Maxim Mokin28,
  31. Waldo Guerrero28,
  32. Min S Park29,
  33. Justin R Mascitelli30,
  34. Albert Yoo31,
  35. Richard Williamson32,
  36. Andrew Walker Grande33,
  37. Roberto Javier Crosa34,
  38. Sharon Webb35,
  39. Marios N Psychogios36,
  40. Andrew F Ducruet37,
  41. Christine A Holmstedt2,
  42. Andrew J Ringer38,
  43. Alejandro M Spiotta1
  44. On behalf of STAR collaborators
  1. 1Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  2. 2Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3Neurosurgery, Emory University, Atlanta, Georgia, USA
  4. 4Microbiology and Immunology, Medical University of South Carolina, South Carolina, USA
  5. 5Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  6. 6Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  7. 7Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA
  8. 8University of Miami Miller School of Medicine, Miami, Florida, USA
  9. 9Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  10. 10Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  11. 11Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  12. 12Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  13. 13Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  14. 14Neurology, University Medicine Goettingen, Goettingen, NS, Germany
  15. 15Neurosurgery, Yale University, New Haven, Connecticut, USA
  16. 16Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  17. 17Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  18. 18Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
  19. 19Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  20. 20Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
  21. 21Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
  22. 22Rush University, Chicago, Illinois, USA
  23. 23Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
  24. 24North Shore University Health System, Evanston, Illinois, USA
  25. 25Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
  26. 26Neurosurgery, BIDMC, Boston, Massachusetts, USA
  27. 27Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
  28. 28Neurosurgery, University of South Florida, Tampa, Florida, USA
  29. 29Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  30. 30Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  31. 31Texas Stroke Institute, Fort Worth, Texas, USA
  32. 32Stroke & Cerebrovascular Center, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
  33. 33Neurosurgery, Radiology and Neurology, University of Minnesota, Mendota Heights, Minnesota, USA
  34. 34Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
  35. 35Neurosurgery, Bon Secours St Francis Hospital, Greenville, South Carolina, USA
  36. 36Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  37. 37Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  38. 38Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
  1. Correspondence to Dr Alejandro M Spiotta, Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA; spiotta{at}


Background In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.

Methods A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.

Results 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015).

Conclusion We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

  • stroke
  • thrombectomy
  • complication

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  • SAK and EA are joint first authors.

  • Twitter @DrMichaelLevitt, @PascalJabbourMD, @AhmadSweidMD, @Starke_neurosurgery, @AdamArthurMD, @abhipandhi, @BrianHoward_MD, @brainvesseldoc, @SantiagoGP92, @@alex_spiotta

  • Collaborators Dileep R Yavagal MD, Eric C Peterson MD, Daniel Raper MBBS, Patrick A Brown MD, M. Reid Gooch MD, Nabeel Herial MD, Ajith Thomas MD, Justin Moore MD, Felipe Albuquerque MD, Louis J. Kim MD, Melanie Walker MD, Michael Chen MD, Stephan Munich MD, Daniel Alan Hoit MD MPH, Violiza Inoa-Acosta MD, Christopher Nickele MD, Lucas Elijovich MD, Fernanda Rodriguez-Erazú PD Dr. med. Jan Liman, Michael Cawley, MD, Gustavo Pradilla MD, Brian Walcot, MD, Zeguang Re, MD PhD, Ryan Hebert MD, João Rei, MD, Jaime Pamplon, Rui Carvalho MD, Mariana Baptist, MD, Ana Nunes MD, Russell Cerejo MD, Ashis Tayal MD, Parita Bhuv, MD, Paul Hansen MD, Norman Ajiboye MD, Alex Brehm, MD

  • Contributors All authors have: provided a substantial contribution to the conception and design of the studies ‎and/or the acquisition and/or the analysis of the data and/or the interpretation of the data. ‎They have drafted the work or revised it for significant intellectual content and approved the ‎final version of the manuscript. They agree to be accountable for all aspects of the work, ‎including its accuracy and integrity.‎

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction, or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Additional data from this project can be acquired by contacting the ‎corresponding author.‎