Watershed infarction in COVID-19:  The necessity of neuroimaging in  patients with subtle neurological symptoms

Mohammad Amin Najafi; Alireza Zandifar; Mohsen Kheradmand; Luis Octavio Tierradentro-Garcia; Fariborz Khorvash; Arastoo Vossough; Mohammad Saadatnia

doi:10.18502/cjn.v22i3.13797

Mohammad Amin Najafi Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
Alireza Zandifar Department of Radiology, Division of Neuroradiology, Children’s Hospital of Philadelphia, Philadelphia, USA
Mohsen Kheradmand Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
Luis Octavio Tierradentro-Garcia Department of Radiology, Division of Neuroradiology, Children’s Hospital of Philadelphia, Philadelphia, USA
Fariborz Khorvash Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
Arastoo Vossough Department of Radiology, Division of Neuroradiology, Children’s Hospital of Philadelphia, Philadelphia, USA
Mohammad Saadatnia Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

DOI: https://doi.org/10.18502/cjn.v22i3.13797

Keywords: COVID-19; Stroke; Brain; Magnetic Resonance Imaging; Clinical Characteristics; White Matter; Cerebrovascular Disorders

Abstract

Background: Cerebrovascular diseases comprise a significant portion of neurological disorders related to coronavirus disease 2019 (COVID-19). We evaluated the clinical and imaging characteristics of a cohort of COVID-19 patients with stroke and also identified patients with watershed infarcts.

Methods: In this cross-sectional study, seventy-three COVID-19 patients with ischemic stroke were included between October 2020 and January 2021. Patients were evaluated based on the following clinical and imaging features: severity of COVID-19 (critical/
non-critical), stroke type, presence/absence of clinical suspicion of stroke, medical risk factors, Fazekas scale, atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) criteria classification, and presence or absence of watershed infarction. Clinical outcomes were assessed based on Modified Rankin Scale (MRS) and mortality.

Results: Most cases of ischemic stroke were due to undetermined etiology (52.1%) and cardioembolism (32.9%). In terms of imaging pattern, 17 (23.0%) patients had watershed infarction. Watershed infarction was associated with the clinically non-suspicious category [odds ratio (OR) = 4.67, P = 0.007] and death after discharge (OR = 7.1, P = 0.003).Patients with watershed infarction had a higher odds of having high Fazekas score (OR = 5.17, P = 0.007) which was also shown by the logistic regression model (adjusted OR = 6.87, P = 0.030). Thirty-one (42%) patients were clinically non-suspected for ischemic stroke. Critical COVID-19 was more common among patients with watershed infarct and clinically non-suspicious patients (P = 0.020 and P = 0.005, respectively). Patients with chronic kidney disease (CKD) were more prone to having stroke with watershed pattern (P = 0.020).

Conclusion: Watershed infarct is one of the most common patterns of ischemic stroke in patients with COVID 19, for which clinicians should maintain a high index of suspicion in patients with critical COVID-19 without obvious clinical symptoms of stroke.