Results
The total sample size was 22 patients. The mean age was 59.5 ± 16.0 years, and 12 patients were female (54.4%). Twelve (54.4%) of the patients had no significant prior medical history. Ten patients (45.5%) had a cerebrovascular event as the initial manifestation of COVID-19. For patients who were symptomatic of COVID-19, the duration from symptom onset and neurological manifestation was 8.8 ± 4.4 days. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean NIHSS was 13.8 ± 8.0, and 16 (84.2%) patients underwent a MT procedure within 6 h of symptom onset. Of the 16 patients who underwent MT, 13/16 (81.2%) patients received general endotracheal anesthesia. A Solumbra technique, aspiration plus stentriever, was used in 13/16 (81.2%) to retrieve the clot completely. The mean number of passes was 2.1, and the average procedure duration from groin access to achieving final TICI score was 42.2 ± 36.3 min. Of note, 3/16 (18.8%) of all patients required intracranial stenting as a rescue measure to maintain the vessel patency. A favorable TICI score (≥2B/3) was achieved in all patients. The mortality incidence was 5/16 (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven patients (50%) had poor functional status (mRS 3–6) at discharge, and the total mortality incidence was eight (36.3%) (Table 1).
Table 1. Demographics, procedure details, outcomes, and laboratory findings
Variables Mean ± standard deviation; N (%)
Age (years) 59.5 ± 16.0
Female gender 12 (55.5)
Comorbidities
 Hypertension 10 (45.0)
 Chronic heart disease 3 (13.6)
 Chronic lung disease 0 (0.0)
 Chronic kidney disease 1 (4.5)
 Chronic liver disease 0 (0.0)
 Diabetes mellitus 2 (9.1)
 Atrial fibrillation 3 (13.6)
 No comorbidities 12 (54.4)
COVID-19 characteristics
 Neurological insult as initial  manifestation of COVID-19 10 (45.5)
 Duration between COVID-19  symptoms and neurological  insults (days) 8.8 ± 4.4
 Fever 11 (50.0)
 Cough 11 (50.0)
 Pneumonia 9 (40.9)
Cerebrovascular insult
 Hemorrhagic stroke 3 (13.6)
 Ischemic stroke 19 (86.4)
Hemorrhagic stroke characteristics and outcomes
 5.0 mm dissecting PICA aneurysm HH3, flow diversion
 15 mm PCOM aneurysm HH4, clipped
 1.4 mm anterior choroidal  artery aneurysm HH1, flow diversion
Ischemic stroke characteristics and outcomes
 Involved vessels 1.4 ± 0.7
  ICA 3 (15.8)
  M1 11 (57.9)
  M2 1 (5.3)
  Absent LVO 2 (10.5)
  CVT 2 (10.5)
 NIHSS at admission 13.8 ± 8.0
 Onset to groin access (min) 272.2 ± 169.5
 Mechanical thrombectomy 16 (84.2)
  General endotracheal anesthesia 13 (81.3)
  MT technique
   Contact aspiration 2 (12.5)
   Stent retriever 1 (6.25)
   Contact aspiration    + stent retriever 13 (81.3)
  Procedure duration (min) 42.2 ± 36.3
  Number of passes 2.1 ± 1.3
  Rescue stenting 3 (18.8)
  TICI 2B/3 16 (100)
 Symptomatic intracerebral  hemorrhage 3 (13.6)
Laboratory findings
 CRP (mg/dl) 20.8 ± 37.9
 D-dimer (ng/dl) 3497.4 ± 6754.3
 Fibrinogen (mg/dl) 329.5 ± 235.4
 Interleukin-6 (pg/dl) 41.6 ± 62.0
Outcomes at discharge
 mRS 3–6 11 (50)
 Mortality 8 (36.4)
COVID-19: coronavirus disease 2019; CRP: C-Reactive Protein; CVT: Cerebral Venous Thrombosis; ICA: Internal Carotid Artery; LVO: Large Vessel Occlusion; MT: mechanical thrombectomy; NIHSS: National Institute of Health Stroke Scale; PCOM: Posterior Cerebral Communicating Artery; PICA: Posterior Inferior Cerebellar Artery; TICI: thrombolysis in cerebral infarction.
Laboratory studies showed an elevated D-dimer (3497.4 ± 6754.3 ng/dl), CRP (20.8 ± 37.9 mg/dl), and IL-6 (41.6 ± 62.0 pg/dl).
Vital stroke metrics across a tertiary telestroke network demonstrated a significant decline in AIS admissions by 23% (p = 0.001) and telestroke consults by 48% (p = 0.001) compared to a similar period in previous years. Conversely, MT procedures showed a non-significant increase by 50% (p = 0.112) during the same period (Table 2).
Table 2. Frequency of telestroke consults, acute ischemic stroke admissions, and MT
Variable Prior years 2020 P-value Percent change
March–April Total March–April Total
Telestroke consults 202 616 106 496  0.001 48
AIS admission 91 219 70 257  0.001 23
MT procedures 16 31 24 69 0.112 50
AIS: Acute Ischemic Stroke; MT: mechanical thrombectomy.
Bold values indicate significant value (p < 0.05).
The result of the pooled analysis of ischemic stroke due to LVO data is presented in Table 3. In summary, the total sample size was 39 patients. The mean age was 59.4 years with 26 (66.7%) males. The NIHSS at admission was 19.0 with an average of 1.5 involved vessels. 89.7% of the patients underwent MT with the majority (85%) using a Solumbra technique. On average, 2.3 attempts were required to retrieve the clot with 77.1% of cases achieving TICI 2B/3. Notably the complication rate was 15.4%, and the mortality rate was 45.9%.
Table 3. Pooled analysis: patient characteristics, treatment details, complications, and mortality for patients with LVO in the setting of COVID-19
No. of patients Mean age Male NIHSS Involved vessels MT treatment Solumbra No. of attempts TICI 2b/3 Complications Mortality
Wang et al.5 5 52.8 4 22.8 2.2 5 4 2.8 3 0 3
Escalard et al.7 10 59.5 8 22 1.5 10 NA 3.5 9 4 6
Valderrama et al.8 1 52 1 NA 3 1 NA NA 0 0 0
Avula et al.9 3 78.7 1 26 1.5 0 NA NA NA 0 3
Oxley et al.4 5 40.4 4 16.8 1 4 NA NA NA 0 0a
Current series 15 64.6 8 15.1 1.4 15 13 1.4 15 2 5
Total n – – 26 – – 35 17 – 27 6 17
Total N 39.0 39 39.0 38.0 39.0 39.0 20.0 30.0 35.0 39.0 37.0
Percentage/mean – 59.4 66.7 19.0 1.5 89.7 85.0 2.3 77.1 15.4 45.9
COVID-19: coronavirus disease 2019; LVO: Large Vessel Occlusion; MT: mechanical thrombectomy; NIHSS: National Institute of Health Stroke Scale; TICI: thrombolysis in cerebral infarction. aTwo patients were still in the hospital.