With the paucity of evidence from large cohorts, it is crucial to maintain vigilance in the management of the neurological manifestations of COVID-19, especially for life-threatening pathologies such as AIS.2,4,10 Our data demonstrate multiple critical outcomes that are essential to share. First, the mean age of the patients was 59.5 years, which is lower than historical non-COVID stroke series.11,12 Half of the patients had a stroke as the initial manifestation of COVID-19, and there was a lag period of nine days between COVID-19 symptoms and the cerebrovascular event. Occlusions involved both arterial and venous vasculature (10.5%), and 84.2% of stroke patients had a large vessel occlusion treated with MT. The procedures were complicated due to the clot burden and consistency of the clots. Despite treating all patients within an average of 4.5 h from symptom onset and achieving favorable revascularization outcomes in all stroke patients, mortality reached 31%. Three patients developed hemorrhagic conversion (18.8%), requiring surgical decompression (Figure 1). Inflammatory markers (CRP, IL-6) and d-dimer were elevated, indicating a hypercoagulable state. IL-6 is a potent proinflammatory cytokine and is a marker of the “cytokine storm” seen in patients with COVID-19. The pooled analysis of LVO demonstrated similar outcomes: younger age group (59.5 years), involvement of multiple vessels, complicated MT procedures requiring multiple attempts, high complication rate (15.4%), and a high mortality rate (45.9%). Previous studies have described a similar experience with COVID-19 patients: having a stroke at a younger age, having worse radiographic and clinical outcomes after EVT, multiple vessel occlusion, clot fragility, and high rate of distal embolization with extensive clot burden.3,5–7
Figure 1. Fifty-one-year-old male with no past medical concerns developed an acute neurological insult. On admission his NIHSS score was 15, head CT did not show any hemorrhage and tPA was given. The patient underwent a MT procedure within 3 h and 52 min. The patient had a right ICA occlusion from the cervical segment into the supraclinoid segment with a tandem M1 occlusion. The procedure was complicated by ICA re-occlusion and distal embolization occluding the A1. The insult progressed into complete infarct, and the patient passed away three days later. (a) Antero-posterior (AP) digital subtraction angiography (DCA) of a right ICA injection showing complete occlusion at cervical ICA segment; (b) AP DCA view showing an occlusion of the supraclinoid segment of the ICA; (c) AP DCA view showing an M1 occlusion; (d) AP DCA view showing re-occlusion of the cervical ICA segment; (e) AP DCA occlusion of the A1 segment either due to a distal embolization or a dissection; (f) final view showing revascularization of the ICA, M1, and A1 with a TICI 2B result by deploying intracranial and extracranial rescue stents; (g) non-contrast axial view of the brain, day 1 post mechanical thrombectomy showing the progression of the insult into a complete infarct; (h) all the devices in the room are draped; and (i) showing the powered air-purifying respirator used by operators.