COVID-19-associated ischaemic stroke due to underlying carot
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SARS-CoV-2 has been linked to thrombosis in both asymptomatic and symptomatic patients with COVID-19. The incidence of thrombotic events in patients infected with SARS-CoV-2 is as high as 79%. Within these events, arterial thrombosis ranked low in occurrences with approximately 3.7% of cases. Still, COVID-19 thrombotic events prove to be unpredictable in location and association with other medical conditions. The cause of venous and arterial thrombosis has been linked to an overwhelming innate immune response to SARS-COV-2 leading to systemic inflammation, coagulopathy and localised endotheliitis.

Authors report a case on a previously asymptomatic COVID-19-positive patient presenting with an acute ischaemic stroke and an incidental left internal carotid artery thrombus. The patient’s medical, social and family history and hypercoagulability screening excluded any other explanation for the left carotid thrombus or stroke, except for testing positive for the COVID-19.

This case explores the known hypercoagulable state associated with COVID-19 and the effect of the virus on the host’s immune response. It also questions whether administration of recombinant tissue plasminogen activator (t-PA), according to the American Heart Association guidelines, following a negative head CT for haemorrhagic stroke is safe without prior extended imaging in this patient population.

They recommend, in addition to obtaining a non-contrast CT scan of the brain, a CT angiogram or carotid duplex of the neck be obtained routinely in patients with COVID-19 exhibiting stroke symptoms before t-PA administration as the effects may be detrimental. This recommendation will likely prevent fragmentation and embolisation of an undetected carotid thrombus.

Learning points
- A high index of suspicion is needed when dealing with acute ischaemic presentations in those with COVID-19.

- COVID-19 hypercoagulability, apart from its pulmonary manifestations, can also present as large-vessel thrombosis, especially in the carotid artery.

- The unpredictable nature of COVID-19 arterial complications affecting multiple vascular beds requires extended imaging evaluation beyond the traditional stroke work-up.

- Careful administration of tissue plasminogen activator is required and should be judged on an individual case basis to avoid complications of incomplete thrombus lysis with potential thromboembolisation to brain tissue.