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Objective: To serially quantify the blood coagulation within hematoma of patients with hyper-acute intracerebral hemorrhagic (ICH) stroke using non-invasive quantitative susceptibility mapping (QSM) MRI. Introduction: A blood clot is a combination of aggregated red blood cells, fibrin, platelets, hemosiderin, and other cell debris. An accurate evaluation of clot formation within hematoma could advance the clinical management of hematoma expansion, blood pressure management, and reversal of anticoagulants. Post-ICH hemolysis changes the heme iron oxidation state from oxy to deoxyhemoglobin (deoxy-Hb) resulting in unpaired iron electrons on aggregated RBC’s deoxy-Hb inducing magnetic susceptibility (χ). Therefore, a region with a higher number of aggregated RBC deoxy-Hb molecules, the dominant component of clots, will exhibit a higher positive χ susceptibility. We hypothesized that coagulated blood within hematoma will exhibit a higher positive χ in comparison to the non-clotted which can be quantified using quantitative susceptibility mapping (QSM), which is an advanced MRI image-processing algorithm. Methods: For proof of concept, we measured susceptibilities of 5 human blood phantoms with various percentages of the clot. Twenty-four patients with acute spontaneous ICH were enrolled and serially imaged 3 times within 12-24 (T1), 36-48 (T2), and 60-72(T3) hours of last known well (LNW). A 3D anatomical and multi-echo gradient echo images were obtained using a 3T MRI system. Hematoma and edema volumes were segmented and used as a region of interest (ROI). The rate of coagulation was assessed by measuring the change in susceptibilities within the hematoma. Results: The blood phantom exhibited a linear relationship between the percent coagulation and χ (R 2 =0.91). The QSM maps showed a significant increased in hematoma susceptibility over time (T1=0.29 ± 0.04, T2=0.36 ± 0.04, T3= 0.45 ± 0.04 ppm, p Conclusion: In conclusion, we present novel surrogate imaging markers of coagulation within the hematoma of ICH.

Introduction: The American Heart Association recommends a Door-to-Recanalization/Reperfusion (DTRp) time of ≤120 minutes. We aim to identify aortic arch and carotid artery anatomy parameters associated with a delayed DTRp at a comprehensive stroke center (CSS). Methods: We performed a retrospective chart review of patients who underwent mechanical thrombectomy (MT) for an anterior circulation large vessel occlusion (LVO) at a CSS from 1/2015 to 12/2021. We compared various aortic arch and carotid artery anatomy parameters between patients who achieved DTRp in ≤120 minutes vs.>120 minutes. A blinded board-certified neuroradiologist used the pre-MT CT Angiogram to document different aortic arch and carotid artery anatomy variables. A binary logistic regression analysis was performed, controlling for age, gender, presenting mean arterial pressure (MAP), presenting serum glucose, Hb A1C, LDL, intravenous alteplase, left hemispheric location, location of occlusion [proximal (ICA or M1 segment of the middle cerebral artery) versus distal (M2 segment of the middle cerebral artery)], ASPECTS≥6, general anesthesia, transradial approach, number of passes. Results: 256 patients met our inclusion criteria. The mean age was 65.18±14.89 years. In our cohort, the presence of a bovine arch was significantly associated with a DTRp of >120 minutes (39.19% vs. 20.59%; OR, 0.37; 95 % CI, 0.15-0.94; P 0.035). Whereas, the other aortic arch and carotid artery anatomy parameters were not significantly associated with DTRp of >120 minutes, as shown in the Table. Conclusion: Among aortic arch and carotid artery anatomy parameters, the presence of a bovine arch was associated with significantly delayed DTRp of >120 minutes in our cohort.

Introduction: While the goal of IV tissue plasminogen activator (TPA) is to prevent infarction, few data exist on averted stroke. Methods: Secondary analysis of a multicenter trial from 2014-2020 comparing outcomes between patients treated for stroke by mobile stroke unit (MSU) vs standard care (SC). The analytical cohort were patients with suspected stroke treated with IV TPA. The primary outcome was a time-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours. The secondary outcome was a tissue-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours and no acute infarction/hemorrhage on imaging. We used multivariable logistic regression to evaluate associations between study exposures (demographics, comorbidities, stroke characteristics) and outcomes. Results: Among 1009 patients with a median last known well-to-TPA time of 87 minutes, 276 patients (27%) had a time-defined averted stroke (31% MSU, 21% SC) and 159 patients (16%) had a tissue-defined averted stroke (18% MSU, 11% SC). Factors independently associated with time-defined averted stroke were younger age (OR, 0.98; 95% CI, 0.96-0.99), female sex (0R, 0.51; 95% CI, 0.36-0.74), hyperlipidemia (OR, 1.81, 95% CI, 1.24-2.64), normal premorbid function (0R, 2.22; 95% CI, 1.37-3.67), lower glucose (OR, 0.996; 95% CI, 0.993-0.999), lower MAP (OR, 0.991; 95% CI, 0.983-0.998), MSU care (OR, 1.77; 95% CI, 1.21-2.62), lower NIH stroke scale (OR, 0.89; 95% CI, 0.86-0.93), and no large vessel occlusion (LVO) (OR, 0.52; 95% CI, 0.32-0.83). For tissue-based averted stroke, younger age, female sex, hyperlipidemia, lower MAP, MSU treatment, lower NIH stroke scale, and no LVO were significantly associated. Conclusion: In a modern acute stroke trial, one-in-four patients treated with TPA for stroke recovered within 24 hours and one-in-six had no demonstrable brain injury on imaging. Younger age, female sex, hyperlipidemia, lower MAP, MSU care, lower stroke severity, and no LVO may increase the odds of averting stroke.

Introduction: Compared to White patients, non-White minority populations are less likely to receive acute treatment for ischemic stroke, and when they do, it can be delayed. Hypothesis: To evaluate the interaction between arrival method (transfer vs. emergency medical services [EMS] vs. private vehicle) and race/ethnicity (non-Hispanic Black [NHB] vs. non-Hispanic White [NHW] vs. Hispanic) on door-to-arterial puncture (DTAP) time in thrombectomy. Methods: Multicenter retrospective cohort study of consecutive patients (≥18 years) treated with endovascular thrombectomy at 14 US Comprehensive Stroke Centers (1/1/2019-07/31/2020). Door (arrival) to arterial puncture (DTAP) was evaluated using a linear mixed model to estimate the effect of race/ethnicity and arrival mode on treatment time. Results: Of the 1,908 included patients, 356 (19%) of whom were Hispanic, stroke severity was similar between race/ethnicity groups, however Hispanic and NHB patients experienced significant delays in DTAP compared to NHWs (adjusted β Hisp = 0.32, 95%CI 0.08-0.55; β NHB = 0.23, 95%CI 0.04-0.41). In the final linear mixed model, more severe neurologic deficits were associated with shorter DTAP (β NIHSS per point -0.03, 95%CI -0.04- -0.03), and arrival via EMS or private vehicle versus transfer were associated with longer delays (β EMS = 0.57, 95%CI 0.41-0.74; β PV = 1.27, 95%CI 0.85-1.70). There was a significant interaction between Hispanic ethnicity and arrival by EMS (p=0.03) or private vehicle (p=0.04) in a direction favoring shorter treatment delays. Conclusions: Endovascular therapy is delayed in Hispanic and NHBs when compared to NHWs. While arrival by EMS or private vehicle (vs. inter-hospital transfer) also contributed to treatment delays, Hispanic ethnicity modified this effect such that there was less delay in DTAP. This may be related to communication barriers between caregivers and healthcare providers when a patient is suddenly disabled from stroke.

OBJECTIVEThe transradial approach (TRA) has been widely adopted by interventional cardiologists but is only now being accepted by neurointerventionalists. The benefits of the TRA over the traditional transfemoral approach (TFA) include reduced risk of adverse clinical events and faster recovery. The authors assessed the safety and feasibility of the TRA for neurointerventional cases in the pediatric population.METHODSPediatric patients undergoing cerebrovascular interventions since implementation of the TRA at the authors’ institution were retrospectively reviewed. Pertinent patient information, procedure indications, vessels catheterized, fluoroscopy time, and complications were reviewed.RESULTSThere were 4 patients in this case series, and their ages ranged from 13 to 15 years. Each patient tolerated the procedure performed using the TRA without any postprocedural issues, and only 1 patient experienced radial artery spasm, which resolved with the administration of intraarterial verapamil. None of the patients required conversion to the TFA.CONCLUSIONSThe TRA can be considered a safe alternative to the TFA for neurointerventional procedures in the pediatric population and provides potential advantages. However, as pediatric patients require special consideration due to their smaller-caliber arteries, routine use of ultrasound guidance is advised when attempting the TRA.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

© 2020 World Stroke Organization., [Background]: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. [Aim]: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. [Methods]: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). [Results]: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p ¼ 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p ¼ 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. [Conclusions]: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

BackgroundCOVID-19, caused by SARS-CoV-2, is a global pandemic that has been an immense burden on healthcare systems all over the world. These patients may be at higher risk for acute ischaemic stroke (AIS). We present our experience with AIS in patients with COVID-19.MethodsWe reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received and outcomes of AIS in patients with COVID-19.ResultsWe identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large-vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase was administered in four patients (20%) and mechanical thrombectomy was performed in five patients (25%). Respiratory symptoms preceded the onset of AIS in most of the patients (70%) by 1 to 21 days. Mortality in patients with AIS was 50% compared with 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). Three patients with AIS had clinical and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests.InterpretationLVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests.

Background: Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is a global pandemic that has been an immense burden on the healthcare systems all over the world. Studies have shown that these patients may be at higher risk for acute ischemic stroke (AIS). We present our initial experience with AIS in patients with COVID-19. Methods: We reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS by chart review. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received, and outcomes of AIS in COVID-19 patients. Results: We identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase (IV tPA) was administered in four patients (20%) and mechanical thrombectomy (MT) was performed in five patients (25%). More than half of the patients were out of window for IV tPA. Respiratory symptoms preceded the onset of stroke in most of the patients (70%), ranging between one to 21 days. The mortality in patients with AIS was 50% compared to 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). There were three patients with AIS, who had clinical, laboratory, and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests. Interpretation: LVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests. We need larger studies to further understand the association and mechanisms of AIS in COVID-19. Funding Statement: None. Declaration of Interests: All authors have stated that they have no conflicts of interest. Ethics Approval Statement: This study was approved by the institutional review board of Rutgers University.

Objectives Embolic stroke is a frequent complication of infective endocarditis yet lacks acute treatment as intravenous thrombolysis should be avoided due to high risk of intracerebral hemorrhage. Mechanical thrombectomy for large vessel occlusion may be a promising treatment but there is limited data on safety outcomes in infective endocarditis. Materials and methods In this multi-center retrospective case series, we reviewed data from patients with infective endocarditis-related large vessel occlusion who underwent mechanical thrombectomy in 9 US hospitals. Results We identified 15 patients at 9 hospitals. A minority presented with signs suggesting infection (2 patients (14%) had fever, 7 (47%) were tachycardic, 2 (13%) were hypotensive, and 8 (53%) had leukocytosis). The median National Institute of Health Stroke Score decreased from 19 (range 9-25) at presentation to 7 post-thrombectomy (range 0-22, median best score post-thrombectomy), and the median modified Rankin Scale on or after discharge for survivors was 3 (range 0-6). Approximately 57% of patients had a modified Rankin Scale between 0 and 3 on or after discharge. Hemorrhagic transformation was observed in 7/15 (47%). The mechanical thrombectomy group had 2/9 petechial hemorrhagic transformation (22%), compared to 4/6 parenchymal hematomas (67%) in the tissue plasminogen activator + mechanical thrombectomy group. Conclusions Our findings suggest that patients with large vessel occlusion due to infective endocarditis may not present with overt signs of infection. Mechanical thrombectomy may be an effective treatment in this patient population for whom intravenous thrombolysis should be avoided.

The aim of this study was to describe the feasibility, technique, and safety of distal transradial access in the anatomic snuffbox for diagnostic cerebral angiography. A retrospective review of diagnostic cerebral angiograms obtained during a 6-month period with distal transradial access was performed. Thirty-four successful procedures were performed via distal transradial access. There were 4 failed attempts. This single-center experience using distal transradial access suggests that this technique is safe and effective.

Introduction/Purpose The transradial approach (TRA) for neurointerventional procedures has recently garnered interest as an alternative to the traditional transfemoral approach (TFA) in adult patients. While the benefits of the TRA have been well reported in adult patients, there is a paucity of reports in the literature regarding its use in the pediatric and adolescent populations. The paucity of literature regarding the TRA for neurointerventional procedures in the pediatric population is likely due to fear of spasm in the narrow caliber radial artery as well as the perceived difficulty in navigating the cerebrovasculature through the TRA. At our institution we have implemented the radial first approach in most adult diagnostic and interventional cases. More recently, we have transitioned to the use of the TRA in pediatric patients as well. Here we present the first reported case series utilizing the TRA in the pediatric population, demonstrating its safety and efficacy for both diagnostic and neurointerventional procedures. Materials and methods N/A Results We retrospectively collected data on patients undergoing transradial intervention from July 2018 to Feb 2019. We have 4 pediatric patients in whom the TRA was used. Indications included JNA embolization (2), right ICA pseudoaneurysm which failed medical management (1), and right cerebellar AVM (1). In all cases, a 6F sheath with a 6F ENVOY guide catheter (Codman- DePuy Synthes, Raynam, MA) was used. One patient developed radial artery vasospasm, and 5 mg verapamil was administered intraarterially post-procedure. The patient did not have any complaints post-procedurally. All preprocedural objectives were met, and none of the interventions required changing to the TFA. The radial artery remained patent in all 4 patients post-procedurally. Conclusion The TRA is safe, effective, and well tolerated in the pediatric population. Most importantly, the risk of bleeding and arterial damage, the most common complications following interventional procedures, is essentially eliminated with the TRA. Ultrasound guided measurement of the artery to ensure caliber over 2 mm is recommended in this population to avoid complications. Disclosures N. Majmundar: None. P. Patel: None. V. Dodson: None. I. Bach: None. J. Liu: None. L. Tomycz: None. P. Khandelwal: None.

Introduction While trans-radial access (TRA) has been previously described for coronary angiography in the pediatric population, TRA has not been well described in pediatric Neuro-intervention cases. Case We present a case of flow diversion stent placement via the TRA in a 15-year-old female. The patient was found to have a traumatic right internal carotid artery dissection without any obvious pseudoaneurysm demonstrated on CTA and diagnostic angiography. She was started on anticoagulation. Three month follow-up MRA, demonstrated a new pseudoaneurysm measuring 8 mm x 6 mm with a neck of 4 mm. After discussion, we believed flow-diverting stent was optimal treatment in this patient. Her radial artery diameter was 2.1 mm. Ultrasound guided micropuncture of the radial artery was performed using single wall technique followed by placement of a 6-French sheath the right radial artery. 6F Envoy guide catheter was placed in the R ICA. The flow diverting stent was successfully placed without any adverse outcomes. Conclusion Here we present feasibility of Pediatric flow diverting stent placement thought radial approach. Many Neurointerventionalists prefer transfemoral access due to familiarity as well as size of the vessel which allows for the use of larger systems. Furthermore, the TRA is often complicated by vasospasm as well as difficulty in catheterizing the contralateral ICA and VA. While there are minimal complications, the TRA carries benefits of increased comfort, faster recovery following intervention, and a significant decrease in morbidity and mortality from femoral access. As experience grows and the technique becomes more refined, we believe that TRA will become more ubiquitous for cerebrovascular intervention in the pediatric as well as adult populations. Disclosures I. Bach: None. P. Patel: None. N. Majmundar: None. P. Khandelwal: None.

Introduction/Purpose The Transradial approach (TRA) for Neurointerventional procedures has recently garnered interest as an alternative to the traditional transfemoral approach (TFA) in adult patients. While the benefits of the TRA have been well reported in adult patients, there are a paucity of reports in the literature regarding its use in the pediatric and adolescent populations. The paucity of literature regarding the TRA for Neurointerventional procedures in the pediatric population is likely due to fear of spasm in the narrow caliber radial artery as well as the perceived difficulty in navigating the cerebrovasculature through the TRA. At our institution we have implemented the radial first approach in most adult diagnostic and interventional cases. More recently, we have transitioned to the use of the TRA in pediatric patients as well. Here we present the first reported case series utilizing the TRA in the pediatric population, demonstrating its safety and efficacy for both diagnostic and neuro interventional procedures. Materials and methods We retrospectively collected data on patient undergoing trans radial intervention from July 2018 to Feb 2019. Pertinent details collected include demographics, indication, technique, radial artery diameter, and complications. Results We have 4 patients in pediatric population where radial approach was used. Indications included Juvenile Nasopharyngeal Angiofibroma embolization (2), right ICA pseudoaneurysm which failed medical management (1), and right cerebellar AVM (1). In all cases, a 6F sheath with a 6F ENVOY guide catheter (Codman- DePuy Synthes, Raynam, MA) were used. One patient developed radial artery vasospasm, and 5 mg verapamil were administered intraarterially post procedure before removal of sheath. The patient did not have any complaints post-procedurally. All preprocedural objectives were met, and none of the interventions required changing to a transfemoral approach. The radial artery remained patent in all 4 patients post-procedurally. Conclusion TRA is safe, effective, and well tolerated in appropriately selected pediatric population. Most importantly, the risk of bleeding and arterial damage, the most common complications following these procedures, is essentially eliminated with the Transradial approach. Ultrasound guided measurement of the artery to ensure caliber over 2 mm is recommended in this population to avoid complications. Disclosures N. Majmundar: None. P. Patel: None. V. Dodson: None. I. Bach: None. J. Liu: None. P. Khandelwal: None.

Objective To describe feasibility, technique and safety of distal radial access in anatomic snuff box for cerebral angiography. Also, to describe potential advantages and limitations compared to conventional radial access at the wrist and transfemoral access. Methods We performed retrospective review of cerebral angiography procedures performed or attempted with distal radial access between October 2018 through February 2019, at University Hospital (Newark, NJ). Ultrasound measurement of radial artery in anatomic snuff box was performed in all potential candidates and different approach was performed in patients with Results Total of 25 cerebral angiography procedures were successfully performed in patients with age ranging 33–78 years, with distal radial access. Once successful access was achieved, intended vessels were catheterized in all patients. One patient had left distal radial access, rest had on Right. On an overage 3.6 (1–6) vessels were catheterized. No major complications were noted. Average procedure end to discharge time was 3 hours and 15 minutes. 2 patient reported prolonged pain at wrist, lasting 1 week. Patients who had prior angiogram with different approach, reported preference for Distal Radial approach. On the other hand, there were 4 failed attempted in the same time period. 2 were converted to conventional radial and 2 transfemoral. These failed attempts were related to severe vasospasm and were in the early part of the learning curve. Conclusion This single center experience suggests feasibility and safety of distal radial access for cerebral angiography. Most patients in this study who had angiogram by other approach, preferred distal radial approach. In addition, post procedure recovery time is significantly shorter. There should be further large-scale studies to evaluate this potentially useful and in select cases advantageous approach. Disclosures P. Patel: None. I. Bach: None. N. Majmundar: None. P. Khandelwal: None.

BackgroundUnprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown.MethodsWe performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment.ResultsOf the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7–21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (βadj=-73.2, 95% CI −153.8–7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (βadj=-3.85, 95% CI −36.9–29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (βadj=-46.44, 95% CI −62.8 to – -30.0, Padj=-2.15, 95% CI −4.2to – -0.1, P=0.05).ConclusionsIn this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.

Patients with COVID-19 may suffer from hemorrhagic complications. Our article highlights two cases of COVID-19-infected patients, who suffered severe epistaxis after initiation of intravenous recombinant tissue plasminogen activator (IV-rtPA) for acute ischemic stroke, followed by a sudden decline in their clinical status and ultimately leading to death within days. Given the global impact and mortality of COVID-19, it is essential to be aware of its unusual presentation and improve therapeutic strategies. We present two cases of individuals who suffered from a large vessel occlusion of and were candidates for both IV-rtPA and mechanical thrombectomy. They received IV-rtPA but had epistaxis so severe that they were not able to receive MT and died within the next few days. There are many potential mechanisms by which epistaxis can happen in an individual with COVID-19 who received IV-rtPA including invasion of the nasal mucosa and endothelium through angiotensin-converting enzyme 2 receptors by the virus. We also hypothesize that the coagulation abnormality seen in COVID-19 patients can be potentiated by the use of treatments such as IV-rtPA. We review these issues with a diagram illustrating the possible mechanisms.