The Common Carotid Artery Thrombus and Embolic Stroke in the Setting of COVID-19 Infection

Abstract

Since the outbreak of the COVID-19 in Wuhan, China in 2019, there have been increasing reports of large vessel thrombosis and associated embolic stroke in patients with COVID-19 infection. The pathogenesis is thought to be multifactorial, including angiotensin-converting enzyme 2 receptor-mediated endothelial damage, rupture of atherosclerotic plaques, cytokine-storm induced-inflammation, and hypercoagulability. Here, we present a case of an otherwise-healthy COVID-19 patient who developed a right common carotid artery thrombus and embolic stroke with left sided numbness and weakness. Blood tests were significant for elevated levels of inflammatory biomarkers and di-dimer. Vessel imaging showed no evidence of underlying atherosclerosis or arterial dissection. Cardiac workup was unremarkable. The etiology of the carotid artery thrombus was likely COVID-19 related inflammation and hypercoagulability. He was started on apixaban 5mg twice daily for secondary stroke prevention. After 3 months, he was transitioned from apixaban to aspirin 81mg daily. At 4-month follow-up, he improved with only residual left arm numbness. Our case study suggests that in patients with large vessel thrombosis in the setting of Covid-19 infection, oral anticoagulation for 3 months followed by daily aspirin may be a reasonable treatment option for secondary stroke prevention.