Stroke in patients with COVID-19: Clinical and neuroimaging characteristics

Abstract

Acute cerebrovascular disease, particularly ischemic stroke, has emerged as a serious complication of infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent of the Coronavirus disease-2019 (COVID-19). Accumulating data on patients with COVID-19-associated stroke have shed light on specificities concerning clinical presentation, neuroimaging findings, and outcome. Such specificities include a propensity towards large vessel occlusion, multi-territory stroke, and involvement of otherwise uncommonly affected vessels. Conversely, small-vessel brain disease, cerebral venous thrombosis, and intracerebral hemorrhage appear to be less frequent. Atypical neurovascular presentations were also described, ranging from bilateral carotid artery dissection to posterior reversible encephalopathy syndrome (PRES), and vasculitis. Cases presenting with encephalopathy or encephalitis with seizures heralding stroke were particularly challenging. The pathogenesis and optimal management of ischemic stroke associated with COVID-19 still remain uncertain, but emerging evidence suggest that cytokine storm-triggered coagulopathy and endotheliopathy represent possible targetable mechanisms. Some specific management issues in this population include the difficulty in identifying clinical signs of stroke in critically ill patients in the intensive care unit, as well as the need for a protected pathway for brain imaging, intravenous thrombolysis, and mechanical thrombectomy, keeping in mind that "time is brain" also for COVID-19 patients. In this review, we discuss the novel developments and challenges for the diagnosis and treatment of stroke in patients with COVID-19, and delineate the principles for a rational approach toward precision medicine in this emerging field.

Keywords: Cerebrovascular disease; Coagulopathy; Coronavirus; Hemorrhagic stroke; Neurological complications; SARS-CoV-2.

Fig. 1

Flowchart suggesting stroke pathway during COVID-19 pandemic. Strategies to minimize exposure from SARS-CoV-2 and to speed up the evaluation process are presented (top panel), as well as proposed research definitions to be used in admitted patients (bottom panel), in order to assess the causality link between stroke and COVID-19 infection (“possible” and “probable” COVID-19-associated stroke). Abbreviations: COVID-19, coronavirus disease 2019, CT, computed tomography, EVT, endovascular thrombectomy, IVT, intravenous thrombolysis, PCR, polymerase chain reaction, SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Fig. 2

Neuroimaging features of COVID-19-associated stroke. A-B: A 80-year-old man with COVID-19 and critical ARDS developed acute left-sided weakness. Brain CT-angiography showed a distal complete occlusion of the right middle cerebral artery (A). Brain CT demonstrated a large fronto-insulo-temporal ischemic lesion within the vascular territory of the right middle cerebral artery (B). C-D: A 75-year-old man with COVID-19 and critical ARDS abruptly developed severe hypoxemia due to suspected pulmonary thromboembolism and left-sided hemiparesis. Brain CT showed infarctions in multiple vascular territories, including one lesion in the right parietal region (C) and in the left cerebellar hemisphere (D). E-F: A 68-year-old man with severe COVID-19 presented delirium followed by dysarthria and left lower limb paresis. MRI showed two punctiform ischemic lesions characterized by diffusion restriction on DWI in the left superior frontal gyrus (E) and in the pons (F). Abbreviations: ARDS, acute respiratory distress syndrome, COVID-19, coronavirus disease 2019, CT, computed tomography, DWI, diffusion weighted imaging; MRI, magnetic resonance imaging.