key: cord-0724904-fapjimev authors: Hosseini, Motahar; Sahajwani, Sunny; Zhang, Jackie; Toursavadkohi, Shahab; Ucuzian, Areck A. title: Delayed stroke after hospitalization for COVID-19 pneumonia from common and internal carotid artery thrombosis. date: 2020-11-10 journal: J Vasc Surg Cases Innov Tech DOI: 10.1016/j.jvscit.2020.11.001 sha: b9f4c9e3d7c5712fbd45eaad7398a6a0d138fcc9 doc_id: 724904 cord_uid: fapjimev Large vessel arterial thrombosis has been reported to complicate a subset of cases of COVID-19. Thrombosis of the extracranial carotid arterial system may lead to devastating stroke in some patients with COVID-19. We present a patient previously hospitalized with COVID-19 for oxygen supplementation who presented after discharge with delayed stroke from a right common artery (CCA) and internal carotid artery (ICA) thrombosis. The thrombotic occlusion resolved with anti-thrombotic medications and no invasive intervention. The report highlights the complicated and heterogenous nature of COVID-19 and provides one approach to managing the devastating complication of stroke from carotid arterial thrombosis. • Introduction 1 Among its many complications, stroke is an increasingly reported complication of COVID-19 1-2 1213-16 . Predisposing risk factors of COVID-19 associated stroke remains unclear. In this report, 3 we present a patient previously hospitalized with moderately severe COVID-19, readmitted with 4 a delayed stroke from CCA and ICA thrombosis, and managed successfully with anticoagulation. The patient consented to this report. Eight days prior, the patient was hospitalized at an outside hospital for one week of shortness of 18 breath, cough, blood-tinged secretions, and subjective fevers and chills. At that presentation, he 19 was febrile and mildly tachycardic, but not in distress. He was diagnosed with PCR-confirmed 20 COVID-19 pneumonia. His labs reflected chronic neutropenia and mild anemia (WBC 2.42, 21 Hgb 12.4) and new onset thrombocytopenia (PLT 105). He required 2L of oxygen though his 22 stoma for 5 days, and he defervesced on hospital day 3. He received two doses of antibiotics, 23 J o u r n a l P r e -p r o o f though his tracheal aspirate reflected only MRSA colonization. He was discharged after six days 1 without supplemental oxygen. His COVID-PCR assay was negative. Laboratories were as follows: D-Dimer 1600, HgbA1c 12 6.1, TSH 5.6, T3 80, Anticardiolipin IgM 30. No hypercoagulability panel was performed. A 13 2D transthoracic echocardiogram with agitated saline injection was unremarkable for thrombus, 14 atrial septal defect, or right to left shunt. Heparin infusion and a high dose statin was initiated for 15 secondary stroke prevention. Antiplatelets were held, as there was a concern for progression to 16 malignant edema which may require hemicraniectomy. He was not offered percutaneous 17 thrombectomy or thrombolysis, as his symptoms were present beyond three hours. During his hospitalization, the patient became increasingly responsive. He was discharged on 4 full dose apixaban and high dose statin after two weeks to a rehabilitation facility with a 5 modified Rankin score of 5, severely disabled, bedridden, incontinent and requiring constant 6 nursing care. He was discharged after three weeks of rehabilitation to home in care of family 7 after improvement in his functionality, affect and responsiveness. At three month follow up, the 8 patient was weak on the left side, but ambulating, conversive and off anticoagulation. The 3-9 month carotid duplex demonstrated no significant carotid stenosis bilaterally. We report a case of a patient recently discharged and recovered from COVID-19, re-presenting 13 nearly two weeks after the onset of his initial pneumonia symptoms with stroke from CCA and 14 ICA thrombosis. While the patient has a history of malignancy and radiation treatment, prior CT 15 scans as recently as 9 months prior to readmission demonstrated no significant atherosclerotic 16 disease or radiation arteritis in his extracranial carotid system. His cancer had been in remission 17 with no concern for recurrence. The patient had no known coagulopathies, and his only prior : Prior CT imaging from OSH 9-months prior, with evidence of normal aortic arch (A) and patent carotid arterial system along entire length (B-D) including the common carotid (yellow arrow). Panel C and D show a patent carotid bifurcation, where the right internal and external carotid arteries are identified by the red and blue arrow, respectively. Figure 2 : CTA with perfusion imaging demonstrating right MCA territory stroke with large penumbra. (A, B) CT brain with loss of grey-white matter differentiation along right MCA territory including areas of frontal, partietal, and temporal lobes (outlined with blue arrows), as well as insular cortex (red arrow), suggestive of right MCA ischemic stroke. (C, D) Perfusion map display of cerebral blood flow <30% (pink) and time-to-peak concentration >6-seconds (green), representing predicted core infarct and potential penumbra, respectively. A Novel Coronavirus from 2 Patients with Pneumonia in China SARS and MERS: recent insights 4 into emerging coronaviruses Coronavirus 2019-nCoV: A brief perspective from the front 6 line Covid-19: risk factors for severe disease and death The epidemiological characteristics of an outbreak of 2019 novel 12 coronavirus diseases (COVID-19) in China. Zhonghua liu xing bing xue za zhi= 13 Zhonghua liuxingbingxue zazhi 15 Presenting characteristics, comorbidities, and outcomes among 5700 patients 16 hospitalized with COVID-19 in the New York City area Cardiovascular considerations for patients, health care workers, and health systems 19 during the COVID-19 pandemic COVID-19: 21 consider cytokine storm syndromes and immunosuppression COVID-19: gastrointestinal manifestations and potential fecal-oral 24 transmission Central nervous system manifestations of COVID-19: A 26 systematic review Hematological findings and complications of COVID-19. American journal of 29 hematology. 2020 Large-vessel stroke 31 as a presenting feature of Covid-19 in the young COVID-19 34 presenting as stroke. Brain, behavior, and immunity COVID-19-related stroke Characteristics 38 of ischaemic stroke associated with COVID-19 COVID-19 and its implications for thrombosis and 41 anticoagulation 44 Confirmation of the high cumulative incidence of thrombotic complications in critically ill 45 ICU patients with COVID-19: an updated analysis Lower extremity arterial thrombosis associated with 47 COVID-19 is characterized by greater thrombus burden and increased rate of 48 amputation and death Journal of Vascular Surgery Cases and Innovative 2 Techniques Acute limb 4 ischemia in patients with COVID-19 pneumonia Acute ischemic stroke 6 complicating common carotid artery thrombosis during a severe COVID-19 infection Journal of Vascular Surgery Cases and Innovative 10 Techniques Acute Common Carotid Artery Bifurcation 12 Thrombus: An Emerging Pattern of Acute Strokes in Patients with COVID-19? American 13 Journal of Neuroradiology Carotid Artery Thrombus in COVID-19: Another Danger of Cytokine Storm? American 16 Journal of Neuroradiology