Ericka Samantha Teleg, MD

Majidi S, Fifi JT, Ladner TR, Lara-Reyna J, Yaeger KA, Yim B, Dangayach N, Oxley TJ, Shigematsu T, Kummer BR, et al. Emergent Large Vessel Occlusion Stroke During New York City’s COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings. Stroke. 2020;51:2656–2663.

This article aimed to report observations of emergent large vessel occlusion (ELVO) ischemic strokes during the time of COVID-19 in one of the most affected cities in the United States, New York City. The association of strokes, prevalence and mechanisms are important to be investigated at this time as it is known that the virus invades cells and adheres to angiotensin converting enzyme 2 receptors that are distributed throughout the body, including the endothelium.

The timeline of this retrospective observational study is important as they highlight the 3-week period (March 21 to April 12, 2020) when hospitalizations and deaths due to COVID-19 were at their peak. Interestingly, in their exploratory analysis, the authors compared the study population with ELVO patients from March 20, 2020 backward to even include the entire year of 2019 (pre-pandemic). This is one of the most important strengths of this observational study, as it explores the potential cause-effect associations between COVID-19 and ELVO.

This article highlights that there were 45 patients with ELVO during the 3-week peak, and 53% had COVID-19. The patients were younger than the patients without COVID-19, (mean age 59 +/- 13 versus 74 +/- 17 [OR=0.94; 95%CI 0.81-0.98; P=0.004]). Seventy-five percent of patients with COVID-19 were male versus 43% of COVID-19 negative patients (OR=3.99; 95%CI 1.12-14.7; P=0.032). Endothelial injury due to the virus can activate a severe inflammatory reaction that can result in a hypercoagulable state, critical illness and shock, heart failure, and ultimately disseminated intravascular coagulation. This can cause hypoperfusion and hence compromise cerebral oxygenation. Concomitantly, cardiomyopathy and thrombus formation can develop, causing embolic occlusions.

The authors described that the COVID-19 ELVO patients had lower cardiovascular risk factors seen in 46% patients versus 24% of non-COVID-19 ELVO. Particularly, they reported a patient who had evidence of a left ventricular thrombus with a left ejection fraction of 42%. This patient had no prior history of cardiac illness. Also, in the same patient, there was no evidence of any underlying possible predilection to a cardiac disease, except the presence of COVID-19. This is important as this is different from the usual presentation of large vessel occlusive disease, having ruled out in a thorough review of the cerebral DSA or CTA of head and neck done in the young particular group of patients who do not present with vascular risk factors or any evidence of vasculopathies and arteriopathies.

In summary, the author’s data on ELVO prevalence during the pandemic, as compared to pre-pandemic time, showed a two-fold increase in the number of ELVO patients in their health system. Is COVID-19 the real culprit? Can we apply their observations to other sites as well across the world? This is a question we hope to use in reading this article. Treatment in consideration warrants IV-TPA and/or thrombectomy within window time. This study did not find any statistically significant difference in the rate of administration of the treatments, pre-pandemic versus during the pandemic.