Severe arterial thromboembolism in patients with Covid-19

Abstract

Introduction: The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has emerged early December 2019 and was recently confirmed by the World Health Organization (WHO) to be a public health emergency of international concern. Earlier reports have shown coagulopathy in patients with severe coronavirus disease 2019 (Covid-19).

Main symptoms and important clinical findings: We present four critically ill Covid-19 patients, who were admitted to our hospital. They were treated with supportive care, oral chloroquine, and standard 2500 or 5000 International Units (IU) of dalteparine subcutaneously once daily. Two patients died during the course of their stay as a consequence of severe large vessel arterial thromboembolism. The other two patients survived but symptoms of paralysis and aphasia persisted after cerebral ischemia due to large vessel arterial thromboembolism. Patients showed no signs of overt disseminated intravascular coagulation (DIC) in their laboratory analysis.

Conclusion: This case series suggest that even in absence of overt DIC, arterial thromboembolic complications occur in critically ill patients with Covid-19. Further studies are needed to determine which parameters are useful in monitoring coagulopathy and which dose of anti-thrombotic therapy in Covid-19 patients is adequate, even when overt DIC is not present.

Keywords: Anti-coagulant therapy; COVID-19; Coagulopathy; Disseminated intravascular coagulation; Imaging; Thrombosis.

Fig. 1

CTA of the carotid arteries. On the upper left panel, maximum intensity projection (MIP) of the left carotid bifurcation is shown, on the upper right panel a MIP of the right carotid bifurcation. White arrows indicate decreased contrast opacification in the internal carotid arteries, the actual thrombus could not be visualized. In the lower panel an axial MIP of the circle of Willis. The arrows indicate near complete absence of vascular enhancement in the vascular territories of the anterior and part of the medial cerebral arteries due to diffuse arterial thrombosis.

Fig. 2

Unenhanced CT-scan of the brain showing bilateral, diffuse ischemia in multiple vascular territories with haemorrhagic transformation of ischemic areas.