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. 2024 Oct 25;19(10):e0311622.
doi: 10.1371/journal.pone.0311622. eCollection 2024.

Arterial floating mural thrombi are a characteristic imaging pattern in SARS-CoV-2-related ischemic stroke

Keshet Pardo  1   2 , Omer Harnof  2 , Rani Barnea  1   2 , Jonathan Naftali  1   2 , Gilad Kenan  2   3 , Eithan Auriel  1   2 , Shlomi Peretz  2   3
Affiliations

Arterial floating mural thrombi are a characteristic imaging pattern in SARS-CoV-2-related ischemic stroke

Keshet Pardo et al. PLoS One. .

Abstract

Background: Acute ischemic stroke (AIS) is a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to explore neurovascular imaging patterns in patients with SARS-CoV-2-related AIS.

Methods: We retrospectively analyzed clinical and radiological data of patients hospitalized with AIS and a positive PCR test for SARS-CoV-2 prior to AIS onset. The control group comprised of AIS patients from a pre-COVID-19 pandemic period matched for gender and age.

Results: Thirty-five SARS-CoV-2-related stroke patients, and 35 controls were included. Fifty-seven percent of SARS-CoV-2 patients had either mild or asymptomatic disease. A distinctive imaging pattern of floating arterial mural thrombus was detected in 5 patients of the SARS-CoV-2 group. In 4 patients thrombus was attached to a stenotic atherosclerotic plaque in the proximal internal carotid artery. In the 5th patient a cardiac CTA showed multiple floating thrombi in the descending aorta. In the control group, floating thrombus was only detected in one patient. Treatment with dual antiplatelet therapy was associated with thrombus dissolution and good clinical outcome. Patients with floating thrombi had a longer time from SARS-CoV-2 diagnosis to stroke onset (mean 7.4 versus 3.4 days).

Conclusions: Floating arterial mural thrombi attached to atherosclerotic plaques are unique characteristic source of AIS in SARS-CoV-2 patients. They may lead to ischemic stroke in patients with mild or asymptomatic infection up to 1-2 weeks from SARS-CoV-2 diagnosis. Patients with embolic AIS and SARS-CoV-2 diagnosis should perform high resolution cranio-cervical vascular imaging to evaluate floating thrombi as a potential embolic source.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. CTA of an 81-year-old patient with SARS-CoV-2-related stroke that was attributed to large vessel atherosclerosis.
A. CTA on admission demonstrates a moderate ulcerated atherosclerotic stenosis of the LICA at the bifurcation with a floating thrombus (yellow arrow). B. CTA after 4 days of treatment with dual antiplatelet and a prophylactic dose of low molecular weight heparin demonstrates complete dissolution of the thrombus with a remaining stenotic plaque. C. 3D reconstruction of the left Carotid bifurcation, on admission.
Fig 2
Fig 2. CTA of a 69-year-old patient with SARS-CoV-2-related stroke attributed to an embolic source.
A and C: CTA on admission demonstrates multiple large thrombi in the descending aorta (yellow arrows) with only mild underlying atherosclerosis. B and D: CTA after 3 months of treatment with full anticoagulation shows complete resolution of the thrombi. E. 3D reconstruction of the descending Aorta, on admission.
See this image and copyright information in PMC

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