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| LETTER TO EDITOR |
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| Year : 2022 | Volume
: 24
| Issue : 3 | Page : 170-171 |
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A case of right internal carotid artery thrombosis in case of mild COVID-19 pneumonia
Debashish Paul1, Rahul Goyal1, Bhavana Hooda2, Kaminder Bir Kaur3
1 Department of Anaesthesiology, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anaesthesiology, Research and Referral Hospital, Delhi, India
3 Graded Specialist, Millitary Hospital, Ambala, Haryana, India
| Date of Submission | 19-Sep-2021 |
| Date of Acceptance | 29-Nov-2021 |
| Date of Web Publication | 01-Jul-2022 |
Correspondence Address:
Maj (Dr) Rahul Goyal
Resident Anaesthesiology, Armed Forces Medical College, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmms.jmms_121_21
How to cite this article:
Paul D, Goyal R, Hooda B, Kaur KB. A case of right internal carotid artery thrombosis in case of mild COVID-19 pneumonia. J Mar Med Soc 2022;24, Suppl S1:170-1 |
| Introduction | |  |
The novel coronavirus has a wide range of clinical spectrum; the disease may be as mild that it may just pass off without producing any symptom or maybe life-threatening like Severe Acute Respiratory Syndrome coronavirus 2 along with coagulopathies. The pathogenesis of coagulopathies in severe disease is still not fully understood but the suggested mechanism states that the hypoxia and intense inflammation causes endothelial dysfunction thus leading to thromboembolism. Several evidence have shown the benefits of anticoagulant therapy in severe COVID pneumonia where as there is not much data in mild cases. Since knowledge and expertise in this pandemic are changing every day and this change is very dynamic, we want to bring up the case of “mild covid pneumonia” presenting with Right internal carotid artery (ICA) thrombosis. This type of reporting will definitely enhance the data and further management policy.
| Case Report | | |
We had a case, 55-year-old male presented with complaint of left-sided weakness upper limb and lower limb with facial asymmetry (deviation toward the right) following diagnosed with a case of mild COVID pneumonia 22 days before the presenting symptoms. He was completely asymptomatic before that without any suggestive symptoms or comorbidities. The patient immediately underwent magnetic resonance imaging brain which was suggestive of acute nonhemorrhagic right middle cerebral artery (MCA) territory infarct and right MCA thrombosis. The patient reported to our center and on examination had weakness on left side upper limb and lower limb with power (1/5), intact Glasgow coma scale score but agitated, deep tendon reflexes of the left side were decreased and plantar on the left side was mute. Noncontrast computed tomography and CT angiography were suggestive of eccentric pedunculated filling defect arising from the posteromedial wall of ICA origin and extending in ICA for approximately 15 mm as Trans luminal thrombus with 78% occlusion of ICA. The patient was accepted for right carotid endarterectomy under general anesthesia with invasive monitoring. Therapeutic Injection LMWH was stopped hours before the surgery. Standard monitoring such as ECG, SPO2, NIBP, Temp, and NIRS was placed with left radial artery cannulation for invasive blood pressure monitoring was established. Intraoperative period was without any untoward incident. Total carotid clamping time was 15 min and there were no significant changes in NIRS values. Following extubation, the patient was shifted for intensive care monitoring which was uneventful too.
| Discussion | | |
There are studies which suggest that the incidence of stroke on COVID pneumonia is around 1.4% and has been mainly found in patients with severe infection or those with preexisting vascular risk. There is also a difference in the pattern of presentation as most of the strokes in COVID pneumonia are ischemic in nature and involve large vessels.[1]
There is evidence that inflammation promotes the development of atherosclerosis and is also associated with plaque rupture.[2]
The proinflammatory state resulting from COVID-19 infection contributed to plaque instability and rupture, with subsequent thrombosis. Cytokine storms do play a role in cases of severe COVID-19 in clot formation and subsequent infarction but mostly in high-risk patients such as the history of vascular disease, diabetes, hyperlipidemia, and smoking. Surprisingly in our case, our patient had no risk factors.
There is a case series of patients with no-or-mild COVID-19 symptoms, presented with stroke symptoms, suggesting that even mild cases of COVID-19 can result in thrombogenicity, inflammation, and ultimately plaque rupture and thrombosis.[3]
In previous studies examining complications related to corona virus-related diseases, most complications were seen in critically ill patients.[4] This case is an addition to the present data of having cases of stroke in mild COVID pneumonia.
Severe COVID pneumonia has been known for its hypercoagubility and anticoagulant therapy has been one of the mainstay treatments in the course of disease. However, a large population with mild disease generally do not receive any type of anticoagulation as it is considered to be not beneficial. In our case, the patient had no known comorbidities but presented a major thrombus located in the major artery. It is the time to rethink the management protocol as more and more data will pitch in.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Nannoni S, de Groot R, Bell S, Markus HS. Stroke in COVID-19: A systematic review and meta-analysis. Int J Stroke 2021;16:137-49.  |
| 2. | Paoletti R, Gotto AM Jr., Hajjar DP. Inflammation in atherosclerosis and implications for therapy. Circulation 2004;109:I20-6. |
| 3. | Mohamud AY, Griffith B, Rehman M, Miller D, Chebl A, Patel SC, et al. Intraluminal carotid artery thrombus in COVID-19: Another danger of cytokine storm? AJNR Am J Neuroradiol 2020;41:1677-82. |
| 4. | Umapathi T, Kor AC, Venketasubramanian N, Lim CC, Pang BC, Yeo TT, et al. Large artery ischaemic stroke in severe acute respiratory syndrome (SARS). J Neurol 2004;251:1227-31. |
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