Letter: Incidence, Characteristics, and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study

Abstract

To the Editor:We read with great interest the article by Khandelwal et al 1 titled "Incidence, Characteristics, and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study." The authors have meticulously conducted a crosssectional retrospective, multicenter study, to determine the incidence of acute ischemic stroke with large vessel occlusion (LVO) in patients with the coronavirus-19 disease , in 12 centres specialized in the management of neurovascular diseases. It was found that of 6698 patients with COVID-19 admitted to 9 neurovascular care centers, the incidence of stroke was 1.3% (88/6698), and of these, 60% were LVOs. 1 Similarly, the acute LVOs of the 12 centres were analyzed and a total of 66 patients were identified, whose mean age was 51 yr, and of whom 42 underwent treatment with mechanical thrombectomy. This suggests that stroke is a neurological complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, whose pathophysiology may be explained by the state of generalized hypercoagulability and endothelial dysfunction caused by this virus. 1,2 A plethora of scientific literature has been published in the last few months exploring stroke and several links, including mast cells, histiocytes, thrombotic complications, and, but not limited to, neuroinflammation in neurological complications of COVID-19.As with most of the clinical data on COVID-19, the scientific community recognized neurological complications as a recognized marker of severe COVID-19 with a call for action to prevent significant morbidity and mortality. 3,4 We thank Khandelwal et al 1 for providing such valuable evidence; however, we would like to make a few comments. COVID-19 resulting in LVO and stroke in the young population has been predominantly reported as case reports and small series. 5,6 In the present study by Khandelwal et al, 1 16% had LVO under 50 yr of age. This further suggests the validity of existing pathogenic mechanisms of COVID-19 resulting in LVO as stroke in the young population. The authors have included patients with acute ischemic stroke (AIS) with COVID-19 in this study. The findings need to be interpreted with caution as the authors have not mentioned how many of these patients had COVID-19 following the development of AIS and how many had an AIS following the development of COVID-19. Since AIS has been described as a comorbidity with increased risk of adverse events for COVID-19 and vice versa, 3,7,8 it is essential to identify COVID-19 patients complicated by the development of AIS and AIS patients complicated by COVID-19. It has been shown that, during the acute phase of infection, approximately 36% of