Burton J. Tabaac, MD

Escalard S, Chalumeau, Escalard C, Redjem H, Delvoye F, Hébert S, Smajda S, Ciccio G, Desilles J-P, Mazighi M, et al. Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients. Stroke. 2020.

In May of this year, amidst the sweeping COVID-19 global pandemic, the New England Journal of Medicine published a paper detailing how large vessel occlusive disease might be a presenting feature in patients with strokes secondary to the infection.1 The authors of this particular paper, cited above, build upon the NEJM observation with imaging evidence to posit that strokes secondary to COVID-19 are also more severe in nature.

Patients were selected and included to be a part of the comparative cohort if COVID-19 was diagnosed (via real-time PCR) and had documented acute large vessel occlusion between the observation and recruitment timeframe between March 15 and April 30, 2020. Two of the authors of the study were blinded to the COVID-19 status of the patient and were asked to quantify the infarct core volume for all patients with large vessel occlusion during the time period. During the study, fifteen patients with large vessel occlusion and confirmed COVID-19 infection were treated.

Results were as follows: Patients in the COVID-19 group were younger and had a history of diabetes mellitus more frequently. One of the more striking findings, as underscored by the title of the paper, is that patients with COVID-19 had more severe strokes, higher rates of multivessel occlusion (defined by simultaneous occlusion of the middle cerebral artery and either the anterior or the posterior cerebral artery), and higher infarct core volume than patients without COVID-19. As expected, in-hospital mortality was higher in the COVID-19 positive patient group.

It is postulated by the authors that systemic inflammation, coagulation disorders, and endothelial dysfunction associated with COVID-19 could be involved in the trend observed towards higher infarct volumes.2-3 Cited within the paper discussion is an important emphasis acknowledging and recognizing the extrapulmonary thrombotic complications associated with COVID-19.  As the pandemic continues to rage on, vascular neurologists and interventionalists alike debate whether these factors will lead to an increase in case volume and how to best adapt to care for sicker patients with more devastating injuries.


1. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh IP, De Leacy RA, Shigematsu T, Ladner TR, Yaeger KA, et al. Large-vessel stroke as a presenting feature of covid-19 in the young. N Engl J Med. 2020;382:e60.

2. Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, Chen H, Ding X, Zhao H, Zhang H, et al. Coagulopathy and antiphospholipid antibodies in patients with covid-19. N Engl J Med. 2020;382:e38.

3. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, Mehra MR, Schuepbach RA, Ruschitzka F, Moch H. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020;395:1417–1418.