Intraluminal Carotid Artery Thrombus in COVID-19: Another Danger of Cytokine Storm?

Abstract

Coronavirus disease 2019 (COVID-19) is associated with a severe inflammatory response. Inflammation affects atherosclerotic plaque vulnerability and promotes a thrombogenic environment. We report a series of 6 patients with COVID-19 with acute ischemic stroke due to intraluminal carotid artery thrombus presenting during an 8-day period. Six patients were included (5 men) with a mean age of 65.8 years (range, 55-78 years). COVID-19 was diagnosed by detection of Severe Acute Respiratory Syndrome coronavirus 2 in 5 patients and was presumed due to typical clinical and imaging findings in 1 patient. All patients had vascular risk factors including diabetes (83%), hyperlipidemia (100%), and smoking (17%). Four patients presented with large infarcts with initial NIHSS scores of 24-30. During their hospitalization, all patients had elevated D-dimer and C-reactive protein levels, 5 patients had elevated lactate dehydrogenase and ferritin levels, 3 had elevated interleukin-6 levels, and 2 had elevated troponin levels. Inflammation related to COVID-19 may result in rupture of vulnerable atherosclerotic plaques, resulting in thrombosis and acute ischemic stroke.

Delayed stroke after hospitalization for coronavirus disease 2019 pneumonia from common and internal carotid artery thrombosis

“…Like our patient, the carotid thrombus resolved with anticoagulation and no invasive intervention. The largest series of carotid thrombotic complications from COVID-19 identified six patients with carotid thrombosis and artery-to-artery embolism leading to stroke 25 . However, typical vascular risk factors and plaque rupture from prior atherosclerosis from the pro-inflammatory state was thought to be the cause of carotid thrombosis in this series.…”

“…• Case presentation A 50-year-old male, former smoker, with history of T3N0M0 laryngeal squamous cell carcinoma status post total laryngectomy, partial pharyngectomy, laryngostomy, bilateral neck dissection, and anterolateral thigh free flap with 1 month of post-operative neck radiation three years prior to this event presented with acute stroke. He has a history of hypothyroidism, provoked identified six patients with carotid thrombosis and artery-to-artery embolism leading to stroke 25 .…”

Characteristics and outcomes of COVID-19 associated stroke: a UK multicentre case-control study

“…We found no evidence to support previous suggestions that SARS-CoV-2 infection may be associated with a younger age 7,10 or male sex 7 in stroke patients. In the case-control study from New York 7 mechanisms, promoting generation of thrombus in the heart 20 or large vessels 10,21 or via small vessel occlusion 22 . Which of these mechanisms manifests in a given patient may be determined by thatindividual's conventional vascular risk factors such as atrial fibrillation, large vessel atheroma, hypertensionor type 2 diabetes mellitus.…”

COVID-19 related stroke in young individuals

“…There are many reports of early COVID-19 presenting with thrombotic events, which has led to the consensus to start anticoagulation therapy early in the COVID-19 disease course before any thrombotic event. There are reports in the literature specifically addressing macrothrombosis in the internal carotid artery in patients with mild respiratory symptoms of COVID-19 14 , 15 and stroke as a presenting symptom of the disease. 12 A multicentre series of 26 patients with COVID-19 and either ischaemic or haemorrhagic events reported that 27% were younger than 50 years.…”