Original Research
Neuroradiology/Head and Neck Imaging
May 17, 2023

Continued Infarction Growth and Penumbral Consumption After Reperfusion in Vaccine-Naive Patients With COVID-19: A Case-Control Study


BACKGROUND. Neurologic sequelae of SARS-CoV-2 include potentially malignant cerebrovascular events arising from complex hemodynamic, hematologic, and inflammatory processes occurring in concert.
OBJECTIVE. This study concerns the hypothesis that despite angiographic reperfusion COVID-19 promotes continued consumption of at-risk tissue volumes after acute ischemic stroke (AIS), yielding critical insights into prognostication and monitoring paradigms in vaccine-naive patients experiencing AIS.
METHODS. This retrospective study compared 100 consecutive COVID-19 patients with AIS presenting between March 2020 and April 2021 with a contemporaneous cohort of 282 AIS patients without COVID-19. Reperfusion classes were dichotomized into positive (extended thrombolysis in cerebral ischemia [eTICI] score = 2c–3) and negative (eTICI score < 2c) groups. All patients underwent endovascular therapy after initial CT perfusion imaging (CTP) to document infarction core and total hypoperfusion volumes.
RESULTS. Ten COVID-positive (mean age ± SD, 67 ± 12 years; seven men, three women) and 144 COVID-negative patients (mean age, 71 ± 16 years; 76 men, 68 women) undergoing endovascular reperfusion, with antecedent CTP and follow-up imaging, comprised the final dataset. Initial infarction core and total hypoperfusion volumes (mean ± SD) were 1.5 ± 18 mL and 85 ± 100 mL in COVID-negative patients and 30.5 ± 34 mL and 117 ± 80.5 mL in COVID-positive patients, respectively. Final infarction volumes were significantly larger in patients with COVID-19, with median volumes of 77.8 mL versus 18.2 mL among control patients (p = .01), as were normalized measures of infarction growth relative to baseline infarction volume (p = .05). In adjusted logistic parametric regression models, COVID positivity emerged as a significant predictor for continued infarct growth (OR, 5.10 [95% CI, 1.00–25.95]; p = .05).
CONCLUSION. These findings support the potentially aggressive clinical course of cerebrovascular events in patients with COVID-19, suggesting greater infarction growth and ongoing consumption of at-risk tissues, even after angiographic reperfusion.
CLINICAL IMPACT. SARS-CoV-2 infection may promote continued infarction progression despite angiographic reperfusion in vaccine-naive patients with large-vessel occlusion AIS. The findings carry potential implications for prognostication, treatment selection, and surveillance for infarction growth among revascularized patients in future waves of infection by novel viral strains.


Key Finding
In this case-control study of vaccine-naive patients with and those without COVID-19 with infarct growth after endovascular reperfusion during acute ischemic stroke, COVID-19 was a significant predictor for absolute infarct growth of 15 cm3 or more (OR, 5.10 [95% CI, 1.00–25.95]; p = .05).
The study provides important context in quantitative terms for the potentially aggressive nature of large-vessel occlusion ischemic stroke in vaccine-naive patients infected by SARS-CoV-2.

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Information & Authors


Published In

American Journal of Roentgenology
Pages: 517 - 525
PubMed: 37195793


Submitted: March 9, 2023
Revision requested: March 27, 2023
Revision received: April 18, 2023
Accepted: May 5, 2023
Version of record online: May 17, 2023


  1. COVID-19
  2. CT
  3. CT perfusion imaging
  4. ischemic stroke
  5. penumbral imaging



Seena Dehkharghani, MD [email protected]
Department of Radiology, New York University Langone Medical Center, Center for Biomedical Imaging, 660 1st Ave, 2nd Fl, New York, NY 10016.
Department of Neurology, New York University Langone Health, New York, NY.
Andre Vogel, MD
Department of Radiology, New York University Grossman School of Medicine, New York, NY.
Nora Jandhyala, MD
Department of Radiology, New York University Grossman School of Medicine, New York, NY.
Charlotte Chung, MD, PhD
Department of Radiology, New York University Langone Medical Center, Center for Biomedical Imaging, 660 1st Ave, 2nd Fl, New York, NY 10016.
Liqi Shu, MD
Department of Neurology, Brown University, Providence, RI.
Jennifer Frontera, MD
Department of Neurology, New York University Langone Health, New York, NY.
Shadi Yaghi, MD
Department of Neurology, Brown University, Providence, RI.


Address correspondence to S. Dehkharghani ([email protected]).
Version of record: Aug 23, 2023
S. Dehkharghani is a consultant for RapidAI and Regeneron Pharmaceuticals and owns a patent and intellectual property for microwave stroke detection tools. The remaining authors declare that there are no other disclosures relevant to the subject matter of this article.

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