PONE-D-24-16018Arterial floating mural thrombi are a characteristic imaging pattern in SARS-CoV-2-related ischemic strokePLOS ONE

Dear Dr. Pardo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Both of the reviewers evaluated your study, so please respond the promlems indicated by them.

Please submit your revised manuscript by Oct 03 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Yoshiaki Taniyama, MD, PhD

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical.

3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

4. Please include a separate caption for each figure in your manuscript.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This article presents a study on ischemic stroke in patients with SARSCoV2 acute infection compared to a control group created by matching for age and gender historical cases (pre covid-19 pandemic). The article is overall well written and provides interesting descriptive data that shed a light on possible pathogenetic mechanisms of stroke in SARSCoV2 patients. However, the use of a control group made of historical controls introduces a potential risk of bias that should be clearly recognized in the limitation section. Moreover other minor revisions are required:

1) Lines 61 to 66 “In addition to the common symptoms of fever, rhinorrhea, cough, and shortness of breath, SARS-CoV-2 may cause a hypercoagulable state associated with acute inflammatory changes. The risk for venous thromboembolism (VTE) is markedly increased. The risk of arterial thrombotic events such as stroke, myocardial infarction, and limb ischemia are also increased, but to a lesser extent than venous thrombosis. Stroke has been reported in 0.5-1.6 percent of hospitalized SARS-CoV-2 patients. Risk factors for arterial thrombosis included older age, male sex, history of coronary artery disease and D-dimer >230 ng/mL on presentation”

could you please provide references for these concepts? If they refer to reference 2, I think the D-dimer threshold for significantly increased risk of thrombotic events is >500. Please verify and correct.

2) lines 94-97: “The control group comprised of non-SARS-CoV-2 associated stroke patients from a pre- COVID-19 pandemic period, matched for gender and age (±5 years) with a case to control ratio of 1:1. The control patients were searched for during a period that predated the COVID-19 pandemic in Israel - between January 2018 and February 2020.”

As previously said, please add a short paragraph in the limitation section to acknowledge the risk of bias related to the choice of using historical controls (risk of introduction of unmeasured confounders such as improvements in stroke management over time, changes in medication, or lifestyle factors).

3) line 256 you wrote “infective disease”. Please correct into “infectious disease”

4) line 276-279: you wrote: “Similarly, in our study the mean interval from SARS-CoV-2 diagnosis to ischemic stroke was 3.3 (±6.7) for patients with SARS-CoV-2-related stroke without a mural thrombus. The mean time interval for the 5 patients with a mural thrombus, however, was longer at 7 (±7.64) days.”

The time interval from SARS-CoV-2 diagnosis to ischemic stroke does not seem to follow a normal distribution. I suggest to report it as median with interquartile range. Moreover, I suggest not to introduce new data in the discussion but to introduce them in the results section first.

Reviewer #2: a small interesting study on SARS-CoV2 related stroke:

please revise following aspects:

- the number of patients reported is rather low considering the center that receives about 1000 cases per year and the recruitment period of about 2 years - please comment;

-please provide 3d recosnstruction of all cases provided to enhance the visibility of the thrombus;

- is a dynamic imaging (Echo) available to see the floating characteristics of the thrombi? this would be important;

- please provide accurate quantification of carotid arterty plaques in all patients even if not stenosing;

- I would dampen this statement as up to know only case reports are reported and also the present work is a case series line 253-255 „These data suggest that large- artery mural thrombosis with distal embolization is a typical stroke mechanism in SARS- CoV-2-related stroke whereas it is exceptionally rare in the general stroke population“

- line 271-273 please add that however other studies are needed to calrify the exact underlying pathogenic mechanism; in this view please report a recent study that showed also a different composition of Sars-Cov2 related thrombi (10.1186/s40478-022-01313-y);

- please comment also the possibility of mural thrombi in non SARS-CoV2 positivie patients? what might be there predisoposiing conditions?

- line 299-303- authors should reword the sentence stating that particular attentions should be paid by neuroradiologist to analyse images to exclude possible mura thrombi on CTA imaging. In fact CTA neck vessel imaging should be always performed in stroke patients as soon as possible.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Domenico Spinelli

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Arterial floating mural thrombi are a characteristic imaging pattern in SARS-CoV-2-related ischemic stroke

PONE-D-24-16018R1

Dear Dr. Pardo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Yoshiaki Taniyama, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********