In-stent stenosis (ISS) triggered by a metal-induced allergic reaction of Pipeline embolization device (PED) placement is extremely rare. The present report describes a patient who presented with delayed parent artery occlusion and refractory ISS after PED placement due to cobalt allergy. A patient in her 70s underwent PED placement for a right internal carotid artery (ICA) large aneurysm; 4 months later, the patient presented with left-sided hemiparesis, and MRI revealed right ICA occlusion even though antiplatelet therapy was optimal. She underwent mechanical thrombectomy, and successful recanalization was achieved. However, follow-up angiography 6 months after the thrombectomy revealed severe ISS, and the patch testing showed a positive reaction for cobalt. As a result of long-term administration of oral steroids and antihistamine, progression of ISS was suppressed. It was supposed that a delayed hypersensitivity reaction to cobalt might induce refractory ISS after PED placement.

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To examine the effectiveness of a newly developed emergency room (ER) protocol to treat patients with stroke and control the spread of SARS-CoV-2 by evaluating the door-to-picture time.Methods: We retrospectively enrolled 126 patients who were transported to our ER by ambulance with suspected stroke between April 15 and October 31, 2020 (study group). A risk judgment system named the COVID level was introduced to classify the risk of infection as follows: level 0, no infection; I, infection unlikely; II, possible; III, probable; and IV, definite. Patients with COVID levels 0, I, or II and a Glasgow Coma Scale (GCS) score >10 were placed in a normal ER (nER) without atmospheric pressure control; the medical staff wore standard personal protective equipment (PPE) in such cases. Patients with COVID level II, III, or IV, and a GCS score of ≤10 were assigned to the negative pressure ER (NPER); the medical staff wore enhanced PPE for these cases. The validity of the protocol was assessed. The door-to-picture time of the study group was compared with that of 114 control patients who were transported with suspected stroke during the same period in 2019 (control group). The difference in the time for CT and MRI between the two groups was also compared. In the study group, the time spent in the nER and NPER was evaluated.Results: In all, 118 patients (93.7%) were classified as level I, 6 (4.8%) as level II, and 2 (1.6%) as level III. Only five patients (4.0%) were treated with NPER. Polymerase chain reaction tests were performed on 118 out of 126 patients (93.7%) and were negative. No significant differences were observed in age, sex, neurological severity, modalities of diagnostic imaging, and diagnosis compared with the control group. The median door-to-picture time was 18 (11-27.8) min in the study group and 15 (10-25) min in the control group (p = 0.08). No delay was found on vs. 14 [9-21] min, p = 0.24). In contrast, there was an 8-min delay for MRI (30 [21.8-50] vs. 22 [14-30] min, p = 0.01). The median door-to-picture time was 29 min longer in patients treated with NPER than in those treated with nER, although the difference was not significant due to the small number of patients (47 [27-57] vs. 18 [11-26] min, p = 0.07). Conclusion:Our protocol could optimize the use of medical resources with only a 3-min delay in the door-to-picture time in an area without explosive outbreak. Unfortunately, the effectiveness of the protocol in preventing infection could not be verified because of the low incidence of COVID-19. When developing and modifying an institutional protocol, recognizing the outbreak status surrounding each institution is important.

The present study investigated changes in the management of acute stroke patients between before and during the coronavirus disease 2019 (COVID-19) pandemic in several countries using a questionnaire.Methods: A questionnaire survey was conducted at 23 stroke centers in 20 countries to examine how stroke management systems have changed from 2019 (before the COVID-19 pandemic) to 2020 (during the COVID-19 pandemic).Results: Questionnaire responses were obtained from 14 stroke centers (61%) in 14 countries. Among the surveyed stroke centers, 36% utilized full personal protective equipment (PPE) including N95 masks in all cases. After the proper application of infection precautions and screening for COVID-19, the initial imaging modality and indications for endovascular thrombectomy (ET) for ischemic stroke remained unchanged in more than 85% of the surveyed stroke centers. The transmission of COVID-19 from stroke patients to doctors or nurses was confirmed in 29% of the surveyed stroke centers, and hospital-acquired infection from patients to other patients occurred in 25%. The number of cases undergoing ET decreased by 10-70% in 50% of stroke centers during the COVID-19 pandemic. Despite successful recanalization, 50% of patients who underwent ET died, and death was mainly attributed to COVID-19-related systemic complications. Conclusion:No significant differences were observed in stroke management or treatment strategies between before and during the COVID-19 pandemic in most stroke centers, except for COVID-19 precautions. However, the higher proportion of hospital-acquired infections and increased morbidity rate among patients despite successful recanalization due to COVID-19-related systemic complications are important findings.