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

Abstract

Large vessel arterial thrombosis has been reported to complicate a subset of cases of coronavirus disease 2019 (COVID-19). Thrombosis of the extracranial carotid arterial system can lead to devastating stroke in some patients with COVID-19. We have presented the case of a patient previously hospitalized with COVID-19 for oxygen supplementation who had presented after discharge with delayed stroke from a right common carotid artery and internal carotid artery thrombosis. The thrombotic occlusion resolved with antithrombotic medications and no invasive intervention. The present report highlights the complicated and heterogeneous nature of COVID-19 and provides one approach to managing the devastating complication of stroke from carotid arterial thrombosis.

Keywords: COVID-19; Carotid artery; Stroke; Thromboembolism; Thrombosis.

Fig 1

Previous computed tomography scan from an outside hospital 9 months previously, with evidence of a normal aortic arch (A) and patent carotid arterial system along the entire length (B-D), including the common carotid artery (CCA; yellow arrow). C and D, Patent carotid bifurcation, with right internal carotid artery (ICA) and external carotid artery indicated by red and blue arrows, respectively.

Fig 2

Computed tomography angiogram with perfusion imaging demonstrating right middle cerebral artery (MCA) territory stroke with large penumbra. A and B, Computed tomography scan of the brain showing loss of gray–white matter differentiation along the right MCA territory, including areas of frontal, parietal, and temporal lobes (blue arrows) and insular cortex (red arrow), suggestive of right MCA ischemic stroke. C and D, Perfusion map displaying cerebral blood flow <30% (pink) and time-to-peak concentration >6 seconds (green), representing predicted core infarct and potential penumbra, respectively.

Fig 3

Three-dimensional reconstruction (A) and raw coronal (B) and sagittal (C) views of computed tomography angiogram, with evidence of extensive thrombus in the right common carotid artery (CCA; yellow arrow) extending to proximal internal carotid artery (ICA; red arrow) and external carotid artery (blue arrow). The green arrow identifies the carotid bifurcation.

Fig 4

Computed tomography angiogram with perfusion demonstrating acute nonocclusive thrombus in the distal M1 segment of the right middle cerebral artery (MCA; yellow arrow). The red arrow identifies the right internal carotid artery (ICA).

Fig 5

Follow-up computed tomography angiogram (A-D) and three-dimensional reconstruction (E) 2 weeks after the initial stroke presentation with evidence of decreased thrombotic burden and improved patency of the right carotid artery system and right middle cerebral artery (MCA; yellow arrow). The green arrow identifies a patent right carotid bifurcation. C and D, Images showing patency along a previously occluded distal M1 branch of the MCA.