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Department of Neurology, Medical Park Ankara Hospital, Yuksek Ihtisas University, Kent Koop District, 1868 Street Batikent Avenue. No:15, Yenimahalle, Ankara 06680, Turkey
Department of Cardiology, Medical Park Ankara Hospital, Yuksek Ihtisas University, Kent Koop District, 1868 Street, Batikent Avenue. No:15, Yenimahalle, Ankara 06680, Turkey
Carotid artery dissection is one of the major causes of ischemic stroke in youngs.
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SARS-CoV-2 can cause thromboinflammatory changes in the vascular structure.
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COVID-19 may be a risk factor for CAD, although there is a lack of sufficient evidence.
Abstract
The “Corona Virus Disease 2019 (COVID-19)”, caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), progressed rapidly since its first outbreak, and quickly developed into a pandemic. Although COVID-19 mostly presents with respiratory symptoms, researchers have started reporting neurologic manifestations such as cerebrovascular diseases in patients, with COVID-19 as the pandemic has progressed. Herein, we report a case of 38-year-old female patient identified with a left common carotid artery dissection, with COVID-19. Clinicians must keep in mind that COVID-19 can cause vascular complications such as carotid artery dissections in the ensuing period, even after the acute phase, although there is currently a lack of sufficient evidence to identify any causal association between COVID-19 and arterial dissections.
Amid the ongoing Corona Virus Disease 2019 (COVID-19) pandemic, caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), although neurological signs and diseases have recently been reported, the disease mostly presents with respiratory symptoms [
]. In a retrospective study focusing on the neurological signs associated with COVID-19, some 5.7% of patients suffering from severe infection were noted to develop cerebrovascular disease (CVD) [
]. Although CVDs are common in the elderly, younger patients with no known risk factors have been presenting with stroke more commonly, since the onset of the COVID-19 pandemic [
]. The current manuscript presents a case of unilateral common carotid artery (CCA) dissection in a young patient with COVID-19, with, aiming to draw attention to the neurovascular events seen during the COVID-19 pandemic.
2. Case presentation
A 38-year-old female patient presented to the cardiology outpatient clinic with a reported 10-day history of palpitation, shortness of breath and chest pain. It was understood that the patient had presented to an external facility with complaints of fever and fatigue approximately 1 month earlier, and had received therapy after being diagnosed with COVID-19. The patient’s medical history was unremarkable for any systemic disease, smoking or alcohol use; a cardiovascular system examination revealed normal findings; and blood pressure was 110/75 mmHg, pulse was 82 bpm and body temperature was 36.6 °C. A complete blood count and routine blood chemistry showed no abnormalities, and troponin-I was <0.01 ng/mL. An electrocardiogram (ECG) revealed normal sinus rhythm; an exercise ECG recorded no acute ST or ischemia-related changes; and a transthoracic echocardiogram showed no abnormal findings. When the anamnesis detailed, the patient reported pain radiating to the head and the left side of the neck for the last three days that was, gradually increasing in intensity. A computed tomography angiography (CTA) performed on the basis of this indication revealed a focal dissection in the proximal left CCA and an associated focal periarterial hematoma (Fig. 1). The patient was thus sent for a neurological examination, revealing normal findings, while cranial magnetic resonance imaging (MRI) findings were within normal ranges, and a diffusion-weighted cranial MRI showed no acute ischemic lesion. Thereupon, the patient was interrogated again about the etiology of the carotid artery dissection (CAD). The patient had no history of hereditary connective tissue disorder or any recent history of trauma to the head or neck regions. The patient was diagnosed with CCA dissection, and was placed on a therapy of low-molecular-weight heparin (LMWH). The patient was switched to oral warfarin therapy and developed no neurological deficits during follow-up, and the ache to the head and neck resolved almost completely. A CTA performed two months after the initial presentation revealed that the periarterial hematoma associated with focal dissection in the left CCA had largely regressed (Fig. 2).
Fig. 1Focal common carotid artery dissection. Axial (a) and sagittal (b) CT angiography images shows focal periarterial haematoma related to focal dissection (arrows in a and b).
Fig. 2Two months after focal common carotid artery dissection, it has been showed that the amount of periarterial haematoma related to focal dissestion was declined in axial (a) and sagittal (b) CT angiography images (arrows in a and b).
Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and the GBD Stroke Experts Group. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010.
Treatment of internal carotid artery dissection with Willis covered stent: a case report of recurrent limb weakness and no response to medical therapy.
] that could have caused CAD were detected on CTA. The patient's medical history contained no signs of connective tissue disorder, no minor traumas to the head or cervical region, and no heavy lifting, violent coughing fits or vomiting that could be involved in a CAD etiology [
]. Previous studies have reported that infections during childhood and young adulthood are risk factors for ischemic stroke, while a respiratory system infection such as COVID-19, may be a potential risk factor for spontaneous CAD [
] have been reported in patients diagnosed recently with COVID-19, which suggests that COVID-19 may be a trigger factor for CVD. Clinical features such as younger age and lack of any known stroke risk factors may suggest that the strokes detected in patients with a history of COVID-19 may be attributable to SARS-CoV-2 [
]. On this basis, the temporal association of these two conditions in the present case, and the absence of any other predisposing factors suggests, but cannot prove, that COVID-19 is a triggering factor for CAD. That said, given the large number of infected patients during the COVID-19 pandemic, this association may also be coincidental.
Recent reports have identified the important role played by vascular dysfunction in the COVID-19 pathogenesis [
]. Coronavirus enters cells via the ACE-II receptors and TMPRSS2 proteases, and SARS-CoV-2 is thought to trigger endothelial inflammation, microangiopathy, vasculitis and thrombosis in vascular structures [
]. Viral diseases can lead to impairments in the vascular endothelial, leading to inflammation and associated thrombosis. Hyperinflammatory immune response can arise in SARS-CoV-2, and a cytokine storm can occur secondary to endothelial IL-6 release, bringing about thromboinflammatory changes in the vascular structure and the surrounding tissues [
As seen in the present case, CADs can cause moderate to severe acute-onset unilateral head and neck pain that differs in character to previous episodes of pain, but without eliciting focal neurological deficits [
Treatment of internal carotid artery dissection with Willis covered stent: a case report of recurrent limb weakness and no response to medical therapy.
Anticoagulant or antiaggregant drugs, endovascular therapies and surgery are among the treatment options in CADs, among which, the endovascular treatment options are resorted to if the stenosis persists, despite anticoagulant therapy in appropriate doses, if the dissection progresses or if an aneurysm develops as a complication [
Treatment of internal carotid artery dissection with Willis covered stent: a case report of recurrent limb weakness and no response to medical therapy.
]. The present case responded dramatically to anticoagulant therapy, and so an endovascular procedure was not considered.
4. Conclusion
COVID-19 can be a potential risk factor for CAD, even in young patients at no known risk, although there is currently a lack of sufficient evidence in this regard. As seen in the present case, CADs can be observed in mild cases who recover from COVID-19 without developing a cytokine storm. It must be kept in mind that COVID-19 can cause vascular complications in the ensuing period, even after the acute phase, although long-term case series and studies are required to identify any causal relationship between COVID-19 and CAD.
Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and the GBD Stroke Experts Group. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010.
Treatment of internal carotid artery dissection with Willis covered stent: a case report of recurrent limb weakness and no response to medical therapy.
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