Major Stroke After Spontaneous Carotid Artery Dissection with Associated Thrombus in a Patient with COVID-19: Carotid Angioplasty, Clot Aspiration Under Balloon Guiding Catheter-Assisted Flow Arrest, Stenting, and Mechanical Thrombectomy; Is COVID-19 a Risk Factor for Carotid Dissection and Stroke?

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), progressed rapidly after its first outbreak and quickly developed into a pandemic. SARS-CoV-2 is known to cause interstitial pneumonia and acute respiratory distress syndrome (ARDS), but there is growing evidence of numerous neurological manifestations, including encephalopathy, limbic and brainstem encephalitis, Guillain-Barré syndrome, and stroke, predominantly ischemic but also hemorrhagic. These manifestations may reflect either direct viral infection or dysregulation of the immune response, which converge in hyperinflammatory processes and dysfunction of the coagulation system, explaining the increasing reports of stroke and arterial dissection. A 39-year-old male patient with a past medical history significant for arterial hypertension was brought to our emergency room (ER) with mixed aphasia and right hemiplegia after being found unresponsive at home. He was last seen well 2 h before admission. There was no history of any recent trauma, fall, heavy lifting, or fever, but he had had a persistent dry cough during the last 2 days. He had no other significant medical or surgical history and took no chronic medications. On clinical examination, his vital signs were normal. General physical examination was unrevealing for any evidence of connective tissue disorder. A nasopharyngeal swab was positive for ribonucleic acid (RNA) of novel COVID-19. The patient’s National Institutes of Health Stroke Score (NIHSS) upon admission was 20 points. Noncontrast cranial CT study showed loss of gray-white matter differentiation involving the left caudate nucleus, internal capsule, and lentiform nucleus. CT angiography (CTA) revealed near-total occlusion of the left internal carotid artery (ICA) in the postbulbar segment caused by a focal, short, steno-occlusive lesion, as well as occlusion of the left middle cerebral artery (MCA) frontal branch and intraluminal filling defects in the proximal M2 segment of the temporal branch. CT perfusion (CTP) confirmed a sizeable area of hypoperfusion in the left hemisphere. Diagnostic angiography confirmed a postbulbar flow-limiting narrowing of the left ICA with an associated large thrombus, proximal occlusion of the frontal MCA branch, and a long, partially occlusive embolus across the temporal MCA branch. The patient underwent a successful and uneventful endovascular procedure, which consisted of carotid revascularization under proximal flow arrest and aspiration, followed by stenting and intracranial stentriever-assisted thrombectomy. After the procedure, the patient’s neurological status improved significantly with complete recovery from his neurological deficits during admission. Post-procedure noncontrast cranial CT ruled out hemorrhagic changes and was found grossly unchanged compared to the admission study. The patient was discharged after 5 days with an NIHSS of 0 and a modified Rankin Scale (mRS) score of 0. The main topic of this chapter is the management of spontaneous carotid dissection with associated thrombus causing major ischemic stroke in a COVID-19 patient with an unremarkable medical past.