Characteristics of Large-Vessel Occlusion Associated with COVID-19 and Ischemic Stroke

Abstract

The mechanisms and phenotype of ischemic stroke associated with coronavirus disease 2019 (COVID-19) remain uncertain. A retrospective study was conducted in patients with COVID-19 presenting with ischemic stroke from March 1 to May 25, 2020, and cases with large-vessel occlusion were identified. To provide baseline institutional stroke data within and outside the COVID-19 pandemic, all consecutive ischemic stroke and TIA admissions (COVID and non-COVID) to the hospital during a 10-week period from March 1 to May 10, 2020, were collected and compared with data from the same time period in 2019. Among 20 patients with COVID-19 and acute ischemic stroke, 15 (75%) had large-vessel occlusion. These patients were young (mean age, 46.5 years), male (93%), without major burden of traditional cardiovascular risk factors, and had a severe stroke presentation. Largevessel occlusions were observed in multiple vessels (40%), uncommonly affected vessels, and atypical locations with a large thrombus burden. Systemic thrombosis separate from large-vessel occlusion was not uncommon (26%). At short-term follow-up, stroke etiology remained undetermined in 46% of patients and functional outcome was poor. The above findings raise the possibility of stroke related to mechanisms induced by the COVID-19 infection itself, including a hypercoagulable state and/or endothelial damage. In addition, they document the severe presentation and poor outcomes of large-vessel occlusion in COVID-19 ischemic stroke. ABBREVIATIONS: CCA ¼ common carotid artery; COVID-19 ¼ coronavirus disease 2019; LVO ¼ large-vessel occlusion; SARS CoV-2 ¼ Severe Acute Respiratory Syndrome coronavirus-2 C oronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by infection with the Severe Acute Respiratory Syndrome coronavirus-2 (SARS CoV-2). 1,2 There are now multiple reports of COVID-19 affecting the central nervous system, ranging from meningitis/encephalitis to stroke. [3][4][5] In a single-center study of 214 hospitalized patients with COVID-19 from Wuhan, China, where the infection first occurred, up to 36.4% of patients had neurologic manifestation, including acute cerebrovascular disease with severe and nonsevere infection in 5.7% and 0.8% of these patients, respectively. 3 In addition, there are also reports of ischemic stroke being caused by large-vessel occlusion (LVO) in patients with COVID-19 without significant pre-existing cardiovascular risk factors. 6 While the reasons for ischemic stroke in COVID-19 are unclear, hypotheses of an inflammatory cytokine storm-triggered hypercoagulable state, endothelial damage, and arrythmias have been postulated. 7,8 However, as it stands, the mechanisms, phenotype, and optimal management of ischemic stroke associated with COVID-19 still remain uncertain.There is an urgent need to identify associations and predictors of severity, morbidity, and mortality in patients with ischemic stroke and COVID-19, especially in the LVO subgroup, given that it is most disabling.

Stroke in patients with COVID-19: Clinical and neuroimaging characteristics

“…Patients with COVID-19 appeared to be particularly prone to (1) large vessel occlusion (including occlusion of the internal carotid artery, M1 and M2 segments of the middle cerebral artery [MCA], and the basilar artery); (2) multi-territory involvement; (3) involvement of otherwise uncommonly affected vessels [ 7 , 9 , 11 , 19 , 25 ], including for example the occlusion of the pericallosal artery [ 7 ], or the presence of multiple focal stenoses in the V4 segment of the vertebral artery [ 11 ]. The resulting neurological deficit was typically severe (reported median National Institutes of Health Stroke Scale, NIHSS, ranging from 19 to 21), and about one quarter of the cases had evidence of systemic thrombosis, including venous thrombosis, pulmonary, and spleen embolism [ 7 , 18 , 25 ]. Overall, more than 40% of the patients were diagnosed with cryptogenic stroke, often with an embolic radiologic appearance.…”

Blood Biomarkers for Detection of Brain Injury in COVID-19 Patients

“…There are also multiple descriptions of CNS pathological observations that include a predominance of reports of cerebrovascular injury, such as diffuse cerebral ischemia, ischemic and hemorrhagic stroke, microhemorrhages, white matter microangiopathy, and arterial thrombosis as well as meningitis, encephalitis, acute transverse myelitis (ATM), and encephalopathy 4,20,23,24,27,29,30,39,40,67,70,72,76,90,100,102,103,109,[123][124][125][126] (see also other works 24,69,121,[127][128][129][130][131][132]. Investigators have also observed associations between magnetic resonance (MRI) abnormalities and neurological deficits persisting in 55% of hospitalized patients 3 months after disease onset.…”

Coronavirus disease-19: The multi-level, multi-faceted vasculopathy

“…Also, possible reductions in nitric oxide bioavailability may contribute to these effects. Vasoconstriction and ischemia has been shown to occur in different vascular beds, including ischemia and cyanosis of extremities 9 , 112 (particularly limbs and fingers), acute cerebrovascular events 10 , 113 and myocardial infarction with non-obstructive coronary arteries 36 ( figure 2 ).…”

“…Age was the only independent predictor of poor prognosis. D-dimer levels were high in most patients John et al 113 Characteristics of Large-Vessel Occlusion Associated with COVID-19 and Ischemic Stroke Retrospective (longitudinal) 20 No control group An incidence of 2.97% of acute ischemic stroke was seen among patients with Covid-19. Large-vessel occlusion occurred in 15 out of 20.…”