Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients

Simon Escalard, MD; Vanessa Chalumeau, MD; Clément Escalard, MD; Hocine Redjem, MD; François Delvoye, MD; Solène Hébert, MD; Stanislas Smajda, MD; Gabriele Ciccio, MD; Jean-Philippe Desilles, MD, PhD; Mikael Mazighi, MD, PhD; Raphael Blanc, MD; Benjamin Maïer, MD; Michel Piotin, MD, PhD


Stroke. 2020;51(11):3366-3370. 

In This Article


During the study period, 15 patients with large vessel occlusion and confirmed COVID-19 were treated in our institution. Twelve had anterior circulation occlusion with early diagnosis imaging (within 3 hours from onset), 2 had late diagnosis, and one had basilar occlusion and were, therefore, excluded from the study. All data regarding patients' characteristics and imaging findings are reported in the Table. Patients in the COVID-19 group were younger with a mean age of 60.1±12.6 years old (P=0.032) and had a history of diabetes mellitus more frequently (P=0.039). The median National Institutes of Health Stroke Scale at admission was 19 (P=0.18). The median time from stroke onset to imaging was 116 minutes (interquartile range, 86–135). Ten patients (83.3%) had a brain magnetic resonance imaging and 2 patients had a computed tomography with computed tomography angiography for early diagnosis of stroke. Patients with COVID-19 had more severe strokes than patients with COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P=0.016), higher rate of multivessel occlusion (50% versus 8.8%, P=0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging–Alberta Stroke Program Early CT Scores; median: 5 versus 8, P=0.006), and higher infarct core volume (median: 58 versus 6 mL, P=0.004). Subgroup analysis of patients without multivessel occlusion showed a trend towards lower DWI-ASPECTS and higher infarct core volume in patients with COVID-19, but the difference did not reach significance (P=0.058 and P=0.06, respectively). Successful recanalization (defined by a modified Thrombolysis in Cerebral Infarction score ≥2B) rate after mechanical thrombectomy was similar in both groups (P=0.767). In-hospital mortality was higher in the COVID-19 patients' group (41.7% versus 11.8%, P=0.025). Two illustrative cases are presented in the Figure.


Early brain imaging findings in coronavirus disease 2019 (COVID-19) patients with large vessel occlusion strokes. A 56-year-old man with left hemiplegia (A and B), the computed tomography (CT) was performed 0.5 h after onset. The noncontrast-CT (A) showed no early ischemic changes (black arrow shows the anterior cerebral artery). The CT-angiography (B) shows a proximal middle cerebral artery (MCA) occlusion (arrow) associated with a proximal anterio cerebral artery occlusion (arrow head), the clot burden was 5. A 45-year-old female with left hemiplegia (C and D), the magnetic resonance imaging (MRI) was performed 2.25 h after onset. The 3-dimensional time-of-flight (C) shows a carotid terminus occlusion with proximal MCA occlusion (arrow) associated with an anterior cerebral artery occlusion (arrow head), the clot burden was 5. The DWI sequence (D) shows ischemic lesions in both MCA and anterior cerebral artery territories (arrow and arrow head, respectively), DWI-ASPECTS (Diffusion-Weighted Imaging–Alberta Stroke Program Early CT Scores) was 0, infarct core volume was 186.5 mL.