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


Our study provides evidence that patients with COVID-19 experience more severe aLVO than patients without COVID-19, as assessed by early brain imaging. Despite a small number of patients, we found that COVID-19 patients with aLVO had lower clot burden scores, associated with lower rate of recanalization after thrombolysis,[7] higher rates of multivessel occlusions, associated with lower rate of recanalization after thrombectomy,[8] lower DWI-ASPECTS and higher infarct core volume, which are well-established predictors of poor outcome in ischemic stroke.[9] As a result, in-hospital mortality was much higher in patients with COVID-19. We think that systemic inflammation, coagulation disorders, and endothelial dysfunction[10,11] associated with COVID-19 could be involved in the trend observed towards higher infarct volumes and lower DWI-ASPECTS in COVID-19 patients without multivessel occlusion. This hypothesis is supported by recent reports regarding the presence of microvascular immunothrombosis in patients with COVID-19.[12,13] These findings are in line with the current literature which has started to emphasize the devastating extrapulmonary thrombotic complications associated with the COVID-19.[14,15]

In addition to being predicting factors of poor outcome, these factors may negatively influence the decision to propose recanalization treatments such as thrombolysis or thrombectomy,[16] despite early stroke diagnosis (within 3 hours from onset in our series), and therefore severely impact the prognosis of acute ischemic strokes in patients with COVID-19.

A recent large cohort study raised concerns about the potential decrease in the amount of care provided to stroke patients across the United States,[17] stressing at the same time the increased use of advanced-imaging in the decision-making for stroke treatment.[18] Concerns should be raised about the coming neurovascular consequences of the pandemic.