Large vessel strokes in the elderly due to COVID-19 associated with poor outcomes

Background and aims: Recent studies and observations have shown various thrombotic and thromboembolic complications from COVID-19 infection. Multiple mechanisms of hypercoagulability have been proposed: direct endothelial injury and invasion, increased circulating pro-thrombotic factors (including factor VII, fibrinogen), multiple coagulation abnormalities referred to as COVID- 19 associated coagulopathy (CAC), and others. Updated guidelines recommend high intensity DVT prophylaxis in patients with COVID-19. Previous reports have outlined multiple cases of large vessel strokes associated with COVID-19. In some cases, stroke was the presenting symptoms of COVID-19 infection. Younger patients with few or no stroke risk factors generally have better outcomes. Methods: We observed three cases of large vessel occlusion (LVO) strokes in elderly patients with symptomatic COVID-19 pneumonia and respiratory failure. Stroke diagnosis was made by clinical examination and neuroimaging including computed topography (CT) and CT angiography (Figure 1 and 2). Patient characteristics, including past medical history and stroke risk factors, are detailed in Table 1. These patients remained critically ill throughout their hospitalizations. Results: In this case series, all three patients died irrespective of aggressive therapies ranging from intravenous thrombolysis, mechanical thrombectomy (MT), and full dose anticoagulation. Conclusion: COVID-19 associated hypercoagulability increases the risk of LVO strokes, and is associated with poor outcomes in older aged, high risk patients with underlying medical comorbidities and stroke risk factors. Patients with severe infection may benefit from high intensity venous thromboembolism prophylaxis or even therapeutic dose anticoagulation, which may also lower risk of ischemic LVO strokes. (Figure Presented).