key: cord-0685353-73mv3g54 authors: Mazzacane, Federico; Zito, Antonio; Magno, Serena; Persico, Alessandra; Mazzoleni, Valentina; Asteggiano, Carlo; Rognone, Elisa; Pichiecchio, Anna; Padovani, Alessandro; Cavallini, Anna; Morotti, Andrea title: Vessel wall magnetic resonance imaging in COVID‐19‐associated cryptogenic ischemic stroke date: 2021-10-06 journal: Eur J Neurol DOI: 10.1111/ene.15128 sha: ab8637bcc0f82e933ee9f2d11a583c671351fb60 doc_id: 685353 cord_uid: 73mv3g54 BACKGROUND AND PURPOSE: Acute ischemic stroke (AIS) is a common complication of coronavirus disease 2019 (COVID‐19), but the underlying biological mechanisms remain unclear. We aimed to describe the prevalence of vessel wall alterations in patients with cryptogenic stroke through vessel wall magnetic resonance imaging (vwMRI). METHODS: All consecutive patients admitted for AIS and COVID‐19 to a single neuro‐COVID unit from 10 November to 31 December 2020 were prospectively evaluated and underwent a complete etiologic workup for AIS. In patients with cryptogenic stroke, the diagnostic workup was completed with vwMRI study. RESULTS: After the exclusion of four patients ineligible for MRI, a total of 10 patients were included (median age = 78 years, 50% males), of whom four (40%) had a cryptogenic stroke. vwMRI showed vascular changes consistent with inflammation of intracranial artery walls in three subjects (75%). Two patients had focal and one multifocal involvement. CONCLUSIONS: vwMRI detected signs of vascular inflammation in the majority of patients with cryptogenic AIS, leading to an etiologic definition with potential therapeutical implications. Our findings are best interpreted as hypothesis‐generating, suggesting the possibility of expanding the diagnostic workup of cryptogenic stroke with vessel wall imaging. and its ability to detect a possible underlying inflammatory process involving intracranial arteries. We conducted a single-center observational prospective study on AIS associated with COVID-19. We evaluated all consecutive patients admitted for AIS to a neuro-COVID ward, a nonintensive care setting, at IRCCS Mondino Foundation, Pavia, Italy, from 10 November to 31 December 2020. COVID-19 diagnosis was based in all cases on a positive real-time reverse transcription-polymerase chain reaction assay for SARS-CoV-2 RNA in nasopharyngeal swab samples. All patients underwent a standardized etiologic workup for AIS, including 48-h electrocardiographic monitoring, epiaortic and intracranial vessel study with either computed tomographic angiography or MRI angiography, laboratory testing, and transthoracic or transesophageal echocardiography [12] . Stroke etiology was determined according to the TOAST classification [13] . In case of undetermined stroke etiology after a complete diagnostic workup, patients underwent vwMRI. All vwMRI studies were conducted with a 3-T Siemens Magnetom Skyra scanner. Our MRI protocol included standard diffusion-weighted imaging, two-dimensional (2D) axial fluid-attenuated inversion recovery, and T1, T2, and T2*sequences; in patients with cryptogenic stroke, black-blood sequences, before and after gadolinium administration, were performed. Black-blood sequences used in the study MRI protocol were T1 Turbo Spin Echo 2D sequences (echo time = 10 ms, repetition time = 523 ms; in-plane spatial resolution = 0.2 × 0.2 mm reconstructed, 0.4 × 0.4 mm acquired), oriented on axial and coronal planes, covering the circle of Willis. MRI was evaluated independently by two experienced neuroradiologists, and discrepancies were adjudicated by consensus. All patients provided written informed consent to participate, and the study protocol was approved by the local ethics committee. We screened 14 patients with AIS and COVID-19, of whom 10 were included in the study (four patients were excluded for the following reasons: two died before MRI and two could not undergo MRI due to medical instability and presence of a pacemaker, respectively). Of the remaining 10 patients, four were diagnosed with cardioembolic stroke, one with atherothrombotic stroke and one with lacunar stroke. Four of 10 patients (40%) who had cryptogenic stroke, three males and one female, median age = 57 years, underwent vwMRI. Clinical and radiological characteristics of the patients are summarized in Table 1 . In this prospective, single-center study, we observed that the majority of AIS patients with an unclear etiology after a standard workup had pathological enhancement of cerebral arteries on vwMRI. Our results are in line with a previous study reporting intracranial vessel wall abnormalities in patients with COVID-19-associated AIS [11] . Other studies have detected a high frequency of vascular abnormalities on MRI, although not related with clinically evident acute cerebrovascular events [10] . needed to confirm our findings in larger sample sizes and to provide Informed consent was obtained from all individual participants included in the study. The data that support the findings of this study are available from the corresponding author upon reasonable request. 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Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment Primary angiitis of the central nervous system: diagnosis and treatment Vessel wall enhancement and focal cerebral arteriopathy in a pediatric patient with acute infarct and COVID-19 infection Arteritis and large vessel occlusive strokes in children after COVID-19 infection COVID-19 and Guillain-Barré syndrome: a case report and review of literature Vessel wall magnetic resonance imaging in COVID-19-associated cryptogenic ischemic stroke https://orcid.org/0000-0002-2224-8002Antonio Zito https://orcid.org/0000-0001-8720-1742Andrea Morotti https://orcid.org/0000-0002-6558-1155