Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19

Abstract

Background and Purpose: Higher rates of strokes have been observed in patients with coronavirus disease 2019 (COVID-19), but data regarding the outcomes of COVID-19 patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) are lacking. We report our initial experience in the treatment of acute ischemic stroke with LVO in patients with COVID-19. Methods: All consecutive patients with COVID-19 with acute ischemic stroke due to LVO treated in our institution during the 6 first weeks of the COVID-19 outbreak were included. Baseline clinical and radiological findings, treatment, and short-term outcomes are reported. Results: We identified 10 patients with confirmed COVID-19 treated for an acute ischemic stroke due to LVO. Eight were men, with a median age of 59.5 years. Seven had none or mild symptoms of COVID-19 at stroke onset. Median time from COVID-19 symptoms to stroke onset was 6 days. All patients had brain imaging within 3 hours from symptoms onset. Five patients had multi-territory LVO. Five received intravenous alteplase. All patients had mechanical thrombectomy. Nine patients achieved successful recanalization (mTICI2B-3), none experienced early neurological improvement, 4 had early cerebral reocclusion, and a total of 6 patients (60%) died in the hospital. Conclusions: Best medical care including early intravenous thrombolysis, and successful and prompt recanalization achieved with mechanical thrombectomy, resulted in poor outcomes in patients with COVID-19. Although our results require further confirmation, a different pharmacological approach (antiplatelet or other) should be investigated to take in account inflammatory and coagulation disorders associated with COVID-19.

Characteristics and Comparison of 32 COVID-19 and Non-COVID-19 Ischemic Strokes and Historical Stroke Patients

“…To our knowledge, this is the first study that compares COVID-19 patients to non-COVID-19 patients within a prospectively collected stroke database. Similar to previous case reports and case-controlled studies, from USA ( 10 ), Iran ( 26 ), Dubai ( 27 ), France ( 28 ) and China ( 8 ), a third of our COVID-19 positive patients had severe disease, required ICU admissions, stayed longer in hospital and had fewer subjects with good outcome. These patients likely represent a subset of stroke patients in whom the viral infection likely contributed to a prothrombotic state resulting in vascular occlusions and large strokes.…”

Stroke and Novel Coronavirus Infection in Humans: A Systematic Review and Meta-Analysis

“…A total sample of 8,771 participants was included in the systematic review. These studies were conducted in many countries worldwide including in China ( 13 , 40 , 43 ), France ( 37 , 39 , 48 , 50 ), India ( 42 ), Iran ( 51 ), Italy ( 32 , 33 , 46 ), the Netherlands ( 34 ), Philippines ( 52 ), Spain ( 44 , 53 ), Turkey ( 58 ), UK ( 41 , 55 ), and the USA ( 21 , 35 , 36 , 45 , 47 , 49 , 54 , 56 , 57 ). Out of 27 studies, eight studies were of retrospective cohort study design, 11 were case series, and nine were case reports.…”

“…The numbers of stroke were almost equal for LVO (47 stroke cases in 10 studies) and non-LVO (42 cases in 10 studies). Location of LVOs involved were M1 vessels ( 21 , 37 , 41 , 42 , 44 , 45 , 47 , 53 , 54 ), M2 vessel ( 41 , 42 , 44 , 45 , 47 , 53 ), internal carotid ( 21 , 37 , 42 , 45 , 47 , 53 ), multiteritorial ( 37 , 47 ), posterior cerebral ( 41 , 45 ), basilar ( 37 ), ACA ( 21 , 53 ), and the vertebral artery ( 41 ).…”

Mechanisms of Stroke in COVID-19

“…Sinai Hospital in New York, after thrombectomy, most of the large arteries with occlusive thrombus appeared normal (M. Alberts, personal communication, May 28, 2020). Escalard et al [27] reported that among 10 patients with stroke and COVID-19, 5 had large artery occlusions in multiple vascular territories. This suggests that large artery occlusion in COVID-19 may be mainly cardioembolic/paradoxical.…”