key: cord-0977319-4an6yrm4 authors: Álvarez Moreno, Yadira; Bú Figueroa, Janeth; Bú Figueroa, Efraín; Soto Fonseca, Marco; Escober Torres, Javier title: Internal carotid artery thrombosis in COVID 19 date: 2020-09-30 journal: Colombia medica DOI: 10.25100/cm.v51i3.4560 sha: 956a0eebe386801665fef10486b8b5ac26aa7f81 doc_id: 977319 cord_uid: 4an6yrm4 CASE DESCRIPTION: 37-year-old female with PCR-RT swab for COVID-19 positive, with neurological manifestation as a result of internal carotid artery occlusion. CLINICAL FINDINGS: Nasal congestion and sneezing of 5 days duration; pulsatile headache in the left hemicranium 3 days prior to admission, with intensity 6/10 according to the visual analogue scale, accompanied by phosphenes, photophobia and diplopia; with subsequent developing right hemiparesis over a 26-hour period. TREATMENT AND RESULT: She was given medical management with oral antiplatelet agents and anticoagulants (subcutaneous and oral) during his hospitalization, it was not possible to perform thrombolysis and thrombectomy due to the high risk of complications. He was discharged at 14 days, without functional limitation, symmetrical strength in upper and lower limbs, bilateral visual acuity 20/20, denying headache. CLINICAL RELEVANCE: The case presented here describes a pattern in how data supporting an association between COVID-19 and stroke in young populations with or without typical vascular risk factors, sometimes with only mild respiratory symptoms, is increasing. Prospective studies are required to further evaluate this association, as well as anticoagulation studies to prevent these potentially life-threatening events. COVID-19 is a new disease caused by the SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Coronavirus 2) that is spreading rapidly around the world 1 . COVID-19 has affected more than 39.2 million people and caused more than 1,100,000 deaths worldwide 2 and although it is primarily a respiratory disease, scientific studies suggest that it can lead to a hypercoagulable state and thrombotic complications 3, 4 . Recent publications from China, France and New York raise the possibility that COVID-19 may increase the risk of ischemic stroke 5, 6 . Neutrophil activation is an important clinical feature in COVID-19; being the first to respond to the invasion of pathogens and tissue damage that mediate the death of pathogens by oxidative explosion and phagocytosis 7 . Activated neutrophils that fail to extravasculate are partially degranulated in the circulation 8 which, due to their low floating densities, are known as low-density granulocytes. These cells are also found in immune-mediated inflammatory diseases 9 . They are particularly prone to expel their contents, with antimicrobial agents stored in their granules, a process known as neutrophil extracellular trap formation (NET) 10, 11 . Excessive NET formation leads to the formation of aggregates 12 that occlude vessels 13 and ducts 14 , causing damage to tissues. With inflammation, prothrombotic coagulopathy and endothelial injury as mechanisms involved 15 . The authors declare that they have no conflicts of interest in the publication of this article No funding has been received from private or public entities for the preparation of this document Internal Carotid Artery Thrombosis in COVID 19: Case report Acute viral infections, oxidative stress, hypoxia, and turbulent blood flow have been established to act as triggers that increase the short-term risk of ischemic stroke and other arterial thrombotic events, such as myocardial infarction 15 . We report a case of a 37-year-old female patient with a positive PCR-RT swab for COVID-19, with a neurological manifestation as a result of internal carotid artery occlusion. This case report follows the CARE Guidelines 16 . 37-year-old woman, environmental health technician; with a history of rheumatic fever during childhood, hypertension and smoking for 2 years; denies traumatic events and use of oral contraceptives. She presented to the hospital emergency center, reporting nasal congestion and sneezing of 5 days duration; pulsatile headache in the left hemicranium 3 days prior to admission, with intensity 6/10 according to the visual analogue scale, accompanied by phosphenes, photophobia and diplopia; with subsequent developing right hemiparesis over a 26-hour period; who delayed seeking emergency care for fear of COVID-19. She denies fever, anosmia, ageusia, seizures, cough, chest or abdominal pain. When presented to the hospital, the score on the National Institutes of Health Stroke Scale (NIHSS) was 8 (scores range from 0 to 42, with higher numbers indicating greater severity of stroke). Upon admission, BP: 130/80 mmHg, HR: 62 beats per minute, RR: 18 breaths per minute, SatO 2 : 98%, T: 37.3° C. Visual acuity decreased in the left eye (20/40), eye movements and visual fields preserved, without alterations to the fundus. Left carotid pulse of decreased intensity compared to contralateral. There were no signs of pulmonary and / or cardiac involvement. Decreased strength and reflexes in the right half body (4/5), lucid, oriented. Rest of physical examination within normal parameters. Complementary tests are requested (Table 1) ; Simple phase brain tomography, without evidence of focal and / or diffuse lesions. However, the USG Carotid Doppler describes the absence of flow in the left internal carotid artery (ICA) due to the presence of echogenic material immediately at the bifurcation of the common carotid artery ( Fig. 1 Carotid Doppler Ultrasound video). Low molecular weight heparin (Enoxaparin 60 mg subcutaneous every 12 hours) is started at a therapeutic dose, antiplatelet therapy (Acetylsalicylic Acid 100mg and Clopidogrel 75 mg orally every day) and statins (Rosuvastatin 40mg orally every day). Due to exposure to positive cases of COVID-19 in her working place, previous mild respiratory symptoms and the presence of ICA thrombosis; RT-PCR for SARS-CoV-2 was requested; with positive result. The case was evaluated by the neurology, vascular surgery and neurosurgery services; who consider that, given the findings described and that; the hours of evolution at the time of diagnosis, the patient is not a candidate for fibrinolysis or thrombectomy, due to the high risk of later complications. Therefore, it was recommended to continue with the established medical management. On his fourteenth day hospital, there was a clear improvement in his symptoms, maintaining standing, without functional limitation, symmetrical strength in upper and lower limbs, bilateral 20/20 visual acuity, denial of headache. The patient was discharged with secondary preventive medication, consisting of: Rivaroxaban 20 mg every day, Rosuvastatin 20 mg every day, Amlodipine 10 mg every day, Acetylsalicylic acid 100 mg every day, Clopidogrel 75 mg every day and Esomeprazole 40 mg every day. One month after the onset of symptoms, a control evaluation was performed, in which no visual or Figure 2 . Angio-CT of the Neck and Thorax Absence of contrast medium from the internal carotid artery. Rest of normal study. Angio -IRM See description in Figure 2 . Internal Carotid Artery Thrombosis in COVID 19: Case report functional limitation was evidenced. A follow up Brain Magnetic Angio-Resonance Imaging (MRI-Angio) is described in Figure 2 . The antiplatelet drugs were withdrawn from their treatment due to adverse effects associated with them (bleeding in the gums) and proton pump inhibitors, and the internal medicine outpatient was called back in 15 days for reevaluation. Due to the persistence of the occlusion of the internal carotid artery and the lack of alternatives for the intervention of this process and the latent risk of formation of new sites of occlusion; the prognosis is uncertain. For this reason, constant vigilance and monitoring will set the tone. To this day, the patient continues on oral anticoagulants; rest at home and has not merited further hospitalization. The endgame of COVID-19 typically involves a cytokine storm, a phlogistic phenomenon fueled by well-understood positive feedback loops that govern cytokine production and overwhelm counter-regulatory mechanisms 17 , manifested in patients with moderate and This pattern of severe inflammation is a reason for attention in the field of vascular neurology because it has been shown an increased risk of cardiovascular complications. These findings were mainly attributed to the hyperinflammatory response with localized vascular compromise 18 . The hypercoagulable state and endothelial dysfunction as complications of COVID 19 19 and the sum of risk factors such as smoking, hypertension, dyslipidemia and sedentary lifestyle, increase the risk of thromboembolic complications of the great vessels, as evidenced in the case presented. A multicenter study of 26 patients with COVID-19 and ischemic or hemorrhagic events reported that 27% were younger than 50 years 20 . In addition, the report indicated that two of the 15 patients with great vessel stroke were younger than 50 years and no prior stroke risk factors. Mohamud et al. 21 , described a series of 6 COVID-19 patients with acute ischemic stroke due to an intraluminal thrombus of the carotid artery. Six patients with a mean age of 65.8 years (range, 55-78 years) were included. All patients had a history of vascular risk factors, such as diabetes (83%), hyperlipidemia (100%), and smoking (17%). Oxley et al. 5 , published a series of cases of COVID 19 patients with cerebrovascular event in those under 50 years of age, in which the case of a previously healthy 33-year-old female patient with a history of headache, cough and chills stands out. of a week of evolution, who Internal Carotid Artery Thrombosis in COVID 19: Case report later presented progressive dysarthria with numbness and weakness in the left arm and left leg during a period of 28 hours and NIHSS 19 points. Imaging studies revealed partial ischemic infarction in the territory of the right middle cerebral artery with a partially occlusive thrombus in the right carotid artery at the cervical bifurcation. Echocardiographic and magnetic resonance imaging of the head and neck did not reveal the origin of the thrombus. Although it was not counted in a timely manner due to logistical limitations, with common markers of acute inflammation such as IL-6, ferritin and D-dimer; alteration of CRP, VES and LDH was found. Additionally, to rule out other common etiologies of thrombogenesis in the patient, laboratory studies for autoimmunity were performed, all of them were negative. The concept of COVID-19 as an endothelial disease provides a unifying pathophysiological picture of this aggressive infection and also a framework for a rational treatment strategy, at a time when we have a really modest evidence base to guide our therapeutic attempts and confront this pandemic 17 . Data supporting an association between COVID-19 and stroke in young populations with or without typical vascular risk factors, sometimes with only mild respiratory symptoms, is increasing. Prospective studies are required to further evaluate this association, as well as anticoagulation studies to prevent these potentially life-threatening events. Keep in mind that, otherwise healthy young patients, who have a stroke during the pandemic, the diagnosis of COVID-19 should be thoroughly investigated. In contrast, in patients with mild respiratory symptoms of COVID-19, a low threshold for stroke investigation should be maintained if they exhibit neurological symptoms. Equipo de investigación e investigación del nuevo coronavirus de China. un nuevo coronavirus de pacientes con neumonía en China Informes de situación del coronavirus (COVID-2019); 2020. citado: 20 de agosto de 2020 Coagulopatía y anticuerpos antifosfolípidos en pacientes con COVID-19 Incidencia de complicaciones trombóticas en pacientes críticos de UCI con COVID-19 Accidente cerebrovascular de vasija grande como característica de presentación de Covid-19 en los jóvenes SARS-CoV-2 y accidente cerebrovascular en un sistema de salud de Nueva York Neutrófilos: primeros respondedores multitarea de inmunidad y homeostasis tisular El desarme programado del proteoma de neutrófilos reduce la magnitud de la inflamación Las trampas extracelulares de neutrófilos inducen disfunción endotelial en el lupus eritematoso sistémico mediante la activación de la metaloproteinasa 2 de la matriz Las trampas extracelulares de neutrófilos matan bacterias A NET o no a NET: opiniones actuales y estado de la ciencia sobre la formación de trampas extracelulares de neutrófilos. Diferencia de muerte celular Las trampas extracelulares de neutrófilos agregadas limitan la inflamación al degradar citocinas y quimiocinas Las ADNasas del huésped previenen la oclusión vascular por trampas extracelulares de neutrófilos La cromatina de neutrófilos descondensada externalizada ocluye los conductos pancreáticos e impulsa la pancreatitis Factores de riesgo de accidente cerebrovascular, genética y prevención Explicaciones y elaboraciones de CARE 2013: Directrices para la presentación de informes de casos COVID-19 es, en definitiva, una enfermedad endotelial Efectos potenciales de los coronavirus en el sistema cardiovascular: una revisión Curso clínico y factores de riesgo para la mortalidad de pacientes adultos hospitalizados con COVID-19 en Wuhan, China: un estudio de cohorte retrospectivo Resultados y espectro de eventos neurovasculares importantes entre pacientes con COVID-19: una experiencia de 3 centros Trombo de arteria carótida intraluminal en COVID-19: ¿otro peligro de tormenta de citocinas ? To collaborators: Dr. Lenin Bulnes, Dr. Melvin Castillo The informed consent of the patient was requested prior to writing the manuscript. It authorizes the use of the information in your clinical record, safeguarding your personal identity data.