PROFOUND ENDOTHELIAL DYSFUNCTION AS A CAUSE OF STROKE IN COVID-19: A CASE REPORT

Abstract

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: There are recent reports of neurological manifestations (NMs) from COVID-191. We present a healthy male who developed multiple strokes likely from direct endothelial dysfunction (ED). CASE PRESENTATION: 66M with GERD presents with 5 days of cough, fever, and chills. He was febrile and hypoxic. Work-up revealed CRP 19 mg/dL, ferritin 594 ng/mL, D-dimer 2.01 mg/L, positive COVID-19 PCR, and normal lipid panel. He had wheezing and no NMs. He was treated with antibiotics, enoxaparin, and oxygen. On day 14 he acutely developed altered mental status, aphasia, and unilateral weakness. CT head revealed acute left ischemic infarct. CTA head/neck revealed proximal left ICA dissection. Aspirin and Atorvastatin were given. Further studies revealed D-dimer 0.4 mg/L, no inheritable hypercoagulopathy, and negative TTE and lower extremity venous duplex. MRI brain confirmed multiple acute infarcts. Left ICA thrombectomy and stent placement were performed. It was found that there was a pseudo-dissection with a ruptured plaque and an overlying thrombus resulting in a 75% stenosis. DISCUSSION: Arterial complications from COVID-19 have recently been reported.3 Studies from Wuhan, China showed that 36.7% of COVID-19 patients had NMs, most commonly dizziness (16.8%) and headache (13.1%); 5.7% had acute ischemic stroke. These patients had severe respiratory symptoms and developed neurologic signs in 1-2 days.1 Another study revealed that stroke occurred in elevated CRP (51.1 vs 12.1 ng/L) and D-dimer (6.9 vs 0.5 mg/L)2. It is believed that the virus directly invades and injures endothelial cells (ECs), changes prothrombotic factors, and promotes a hypercoagulable state secondary to a profound inflammatory response4. ACE-2-receptors on ECs are used for viral adhesion. Viral replication causes EC apoptosis, which promotes vasoconstriction, organ ischemia, tissue edema, and microvascular prothrombotic sequelae.5 In our case, COVID-19 had profound ED distal to the carotid artery bifurcation. Arterial bifurcations are sites of turbulent blood flow that are athero-prone.6 The stroke occurred in the setting of moderate elevations of D-dimer, suggesting an alternate mechanism.2 Plaque rupture occurred with prophylactic anticoagulation and normal lipid panel. At the time of the stroke, D-dimer and inflammatory markers largely normalized. His late onset NMs indicate that prothrombotic sequelae and ED persist after the cytokine storm has improved.1 Further studies are needed to investigate the duration of cytokine storm and prothrombotic state, and appropriate screening measures. CONCLUSIONS: Clinicians must be cognizant of NMs from COVID-19 such as thromboembolic strokes from direct ED. Reference #1: 1. Mao L et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. Epub 2020 Apr 10. Reference #2: 2. Li Y, Wang M, Zhou Y, Chang J. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Available at SSRN: https://ssrn.com/abstract=3550025. 2020 Mar 3. Reference #3: 3. Oxley, Thomas et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. Epub 2020 Apr 28. 4. Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. Epub 2020 Apr 27. 5. Ferrario CM et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation. 2005;111:2605-10. 6. Ku DN, Giddens DP, Zarins CK, Glagov S. Pulsatile flow and atherosclerosis in the human carotid bifurcation: positive correlation between plaque location and low oscillating shear stress. Atherosclerosis. 1985 May-Jun; 5:293-302 DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Luke Alessi, source=Web Response No relevant relationships by David Capone, source=Web Response No relevant relationships by Olga McAbee, source=Web Response No relevant relationships by Heidi Roppelt, source=Web Response No relevant relationships by Fredric Weinbaum, source=Web Response No relevant relationships by Daisy Young, source=Web Response