MASSIVE STROKE IN A CRITICALLY ILL COVID-19 POSITIVE PATIENT DESPITE DUAL ANTI-PLATELET THERAPY AND VTE PROPHYLAXIS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Current evidence suggests that COVID-19 infection leads to increased incidence of thrombotic events in critically ill patients [1]. Studies regarding the benefits of anticoagulation in COVID-19 patients have yielded mixed results[2,3]. The literature is unclear as to an effective strategy for VTE prevention in COVID-19 patients. In this case we will present a COVID-19 positive critically ill patient who suffered a large ischemic cerebrovascular accident despite receiving daily VTE prophylaxis and dual anti-platelet therapy. CASE PRESENTATION: Our patient is a 66-year-old female with a past medical history of uterine cancer receiving chemotherapy at the time of admission. Patient presented with hypoxemic respiratory failure secondary to COVID-19 pneumonia. Initial head CT scan demonstrated no definite acute intracranial findings. Patient was intubated without complications and admitted to the ICU. She was continued on her home doses of Plavix 75mg daily and Aspirin 81mg daily and started on subcutaneous Enoxaparin 40mg once daily for VTE prophylaxis. On hospital day #15 patient’s sedation was discontinued in preparation for spontaneous breathing trial, yet she did not return to baseline mental status. On hospital day #18 head CT scan was performed which revealed interval development of large late subacute/chronic left anterior and middle cerebral artery territory infarction (Image 1). At this time our patient is still receiving treatment for complications of COVID-19 pneumonia and has had no change in her mental status. DISCUSSION: In this case report our patient with COVID-19 pneumonia suffered an ischemic stroke despite dual anti-platelet therapy and VTE prophylaxis. Thrombotic complications are common in critically ill COVID-19 patients with an incidence reported to be as high as 31% [1]. One study found decreased mortality in critically ill COVID-19 patients receiving therapeutic anticoagulation [2]. However, another found a significant incidence of thrombotic events despite anticoagulation [3]. The role of dual anti-platelet therapy in conjunction with standard VTE prophylaxis has not been studied. Currently no cases of a COVID-19 patient suffering a thrombotic event while on dual anti-platelet therapy and VTE prophylaxis have been reported. A limitation of this case is that our patient was actively being treated for cancer, a known pro-thrombotic state, which may have contributed to her thrombotic event. CONCLUSIONS: This case report demonstrates that despite dual anti-platelet therapy and VTE prophylaxis our COVID-19 patient suffered a thrombotic event. These findings suggest that COVID-19 VTE prevention requires enhanced anticoagulation strategies compared to usual VTE prevention regimens. Further studies examining the role of dual anti-platelet therapy as well as various doses of anticoagulation are needed to elucidate effective strategies for VTE prevention in COVID-19 patients. Reference #1: Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19 [published online ahead of print, 2020 Apr 10]. Thromb Res. 2020;S0049-3848(20)30120-1. doi:10.1016/j.thromres.2020.04.013 Reference #2: Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18(5):1094-1099. doi:10.1111/jth.14817 Reference #3: Llitjos JF, Leclerc M, Chochois C, et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients [published online ahead of print, 2020 Apr 22]. J Thromb Haemost. 2020;10.1111/jth.14869. doi:10.1111/jth.14869 DISCLOSURES: No relevant relationships by Mark Guirguis, source=Web Response No relevant relationships by Michael Nicholson, source=Web Response No relevant relationships by Yuriy Takhalov, source=Web Response