The mechanisms and phenotype of ischemic stroke associated with coronavirus disease 2019 (COVID-19) remain uncertain. A retrospective study was conducted in patients with COVID-19 presenting with ischemic stroke from March 1 to May 25, 2020, and cases with large-vessel occlusion were identified. To provide baseline institutional stroke data within and outside the COVID-19 pandemic, all consecutive ischemic stroke and TIA admissions (COVID and non-COVID) to the hospital during a 10-week period from March 1 to May 10, 2020, were collected and compared with data from the same time period in 2019. Among 20 patients with COVID-19 and acute ischemic stroke, 15 (75%) had large-vessel occlusion. These patients were young (mean age, 46.5 years), male (93%), without major burden of traditional cardiovascular risk factors, and had a severe stroke presentation. Largevessel occlusions were observed in multiple vessels (40%), uncommonly affected vessels, and atypical locations with a large thrombus burden. Systemic thrombosis separate from large-vessel occlusion was not uncommon (26%). At short-term follow-up, stroke etiology remained undetermined in 46% of patients and functional outcome was poor. The above findings raise the possibility of stroke related to mechanisms induced by the COVID-19 infection itself, including a hypercoagulable state and/or endothelial damage. In addition, they document the severe presentation and poor outcomes of large-vessel occlusion in COVID-19 ischemic stroke. ABBREVIATIONS: CCA ¼ common carotid artery; COVID-19 ¼ coronavirus disease 2019; LVO ¼ large-vessel occlusion; SARS CoV-2 ¼ Severe Acute Respiratory Syndrome coronavirus-2 C oronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by infection with the Severe Acute Respiratory Syndrome coronavirus-2 (SARS CoV-2). 1,2 There are now multiple reports of COVID-19 affecting the central nervous system, ranging from meningitis/encephalitis to stroke. [3][4][5] In a single-center study of 214 hospitalized patients with COVID-19 from Wuhan, China, where the infection first occurred, up to 36.4% of patients had neurologic manifestation, including acute cerebrovascular disease with severe and nonsevere infection in 5.7% and 0.8% of these patients, respectively. 3 In addition, there are also reports of ischemic stroke being caused by large-vessel occlusion (LVO) in patients with COVID-19 without significant pre-existing cardiovascular risk factors. 6 While the reasons for ischemic stroke in COVID-19 are unclear, hypotheses of an inflammatory cytokine storm-triggered hypercoagulable state, endothelial damage, and arrythmias have been postulated. 7,8 However, as it stands, the mechanisms, phenotype, and optimal management of ischemic stroke associated with COVID-19 still remain uncertain.There is an urgent need to identify associations and predictors of severity, morbidity, and mortality in patients with ischemic stroke and COVID-19, especially in the LVO subgroup, given that it is most disabling.

These comprehensive and novel clinical imaging data will prove useful in refining stroke guidelines and advancing stroke care in India.

Highlights When comparing stroke admissions from March 1 st -May 10 th in 2019 and 2020 at a single comprehensive stroke center in Middle East, there was a 41.9% increase in stroke admissions in 2020. A higher rate of large vessel occlusion (LVO) and significant delay in initiation of mechanical thrombectomy after hospital arrival was observed in 2020. Among all COVID-19 admissions in 2020, 5.24% patients suffered stroke including 3.21% with ischemic and 2% with hemorrhagic stroke. Patients with COVID-19 and ischemic stroke were significantly younger, predominantly male, had fewer vascular risk factors, had more severe clinical presentation, and higher rate of LVO ccompared to ischemic stroke patients without COVID-19 For hemorrhagic stroke, COVID-19 patients did not differ from non-COVID-19 patients.

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