Case Report

Common Carotid Artery Occlusion in a Young Patient: Can Large-Vessel Stroke Be the
Initial Clinical Manifestation of Coronavirus Disease 2019?
Ali Alkhaibary1-3, Munzir Abbas1-3, Muhammad Ejaz Ahmed1,2,4, Ismail A. Khatri1,2,5, Ahmed Alkhani2,3

Key words

- BACKGROUND: The occurrence of large-vessel occlusion in young patients

- Common carotid artery

with coronavirus disease 2019 (COVID-19) infection has been exceedingly rare.
An extensive review of reported studies revealed a few reported cases. In the
present report, we have described the clinical presentation, radiological findings, and outcome of large-vessel occlusion in a young patient with COVID-19
and reviewed the pertinent reported data on this condition.

- Coronavirus
- COVID-19
- Thrombotic
- Virus
- Young

Abbreviations and Acronyms
COVID-19: Coronavirus disease 2019
From the 1College of Medicine, King Saud bin Abdulaziz
University for Health Sciences, Riyadh; 2King Abdullah
International Medical Research Center, Riyadh; and 3Division
of Neurosurgery, Department of Surgery, 4Medical Imaging
Department, and 5Division of Neurology, Department of
Medicine, King Abdulaziz Medical City, Ministry of National
Guard e Health Affairs, Riyadh, Saudi Arabia
To whom correspondence should be addressed:
Ali Alkhaibary, M.D.
[E-mail: alkhaibarya@hotmail.com]
Citation: World Neurosurg. (2020) 144:140-142.
https://doi.org/10.1016/j.wneu.2020.08.154
Journal homepage: www.journals.elsevier.com/worldneurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.

- CASE DESCRIPTION: A 31-year-old woman was in her usual state of health

until she had presented with a 3-day history of right-sided weakness, slurred
speech, and decreased vision. The patient had been taken to several hospitals
where she had been treated conservatively with analgesics and discharged.
Shortly thereafter, her weakness had become progressive. She had become
severely dysarthric and unresponsive. On arrival to the emergency department,
her physical examination revealed that she was stuporous, with a Glasgow
coma scale of 10 (eye response, 3; verbal response, 2; motor response, 5). The
National Institutes of Health Stroke Scale score was 19 on presentation. Brain
computed tomography and computed tomography venography revealed an
occluded left internal carotid artery and left middle cerebral artery with subacute left middle cerebral artery territory infarction and midline shift. Computed
tomography angiography revealed complete occlusion of the left common carotid artery. An emergent decompressive craniectomy was successfully performed. The patient was shifted to the intensive care unit. She was later found to
be positive for COVID-19.
- CONCLUSIONS: Although

INTRODUCTION
The involvement of the central nervous
system in coronavirus disease 2019
(COVID-19) infection has varied.1 The
neurological manifestations of COVID-19
have included, but are not limited to,
headache, altered levels of consciousness,
and cerebrovascular disease.1 COVID-19
infection has been associated with a prothrombotic state, leading to cerebrovascular involvement.2 Subsequently, acute
cerebrovascular disease can be the
presenting symptom of COVID-19 in the
absence of vascular disease.2
The development of infarction in patients with COVID-19 infection has been
extremely rare. A review of the reported
data revealed a few reported cases.
Considering the rarity of large-vessel occlusion in young patients with COVID-19,
we have outlined the clinical presentation, radiological findings, surgical

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rare, patients with COVID-19 can present with
large-vessel occlusion. Prompt identification of COVID-19erelated coagulopathy
is essential to assess young patients with clinical manifestations of infarction.

intervention, and outcome of large-vessel
infarction in a 31-year-old woman with
COVID-19 and reviewed the pertinent reported data on this condition.

CASE DESCRIPTION
Clinical Data
A 31-year-old woman, with hypertension
and epilepsy, was in her usual state of
health until she had presented with a 3-day
history of right-sided weakness, slurred
speech, and decreased vision. These
symptoms fluctuated throughout the day
and were associated with generalized
fatigability, headache, and somnolence.
The patient was taken to several hospitals

where she had been treated conservatively
with analgesics and discharged. However,
during those 3 days, her right-sided
weakness had worsened, she had become
severely dysarthric, and she had decreased
responsiveness. Thus, the patient was
brought to our emergency department.
She had no history of traumatic events,
previous
intracranial
hemorrhage,
bleeding disorders, rheumatologic and/or
autoimmune diseases, or recurrent
miscarriage.
On arrival to the emergency department, her physical examination revealed
she was vitally stable but stuporous with a
Glasgow coma scale of 10 (eye response, 3;
verbal response, 2; motor response, 5).
Her pupils were 3 mm bilaterally and

WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.08.154

CASE REPORT
ALI ALKHAIBARY ET AL.

LARGE-VESSEL STROKE IN COVID-19

(Figure 3). The patient was kept intubated
and moved to the intensive care unit.

Figure 1. Baseline nonecontrast-enhanced axial computed tomography scan
of the patient’s head demonstrating a subacute large left middle cerebral
middle cerebral artery territory infarct with a mass effect and mild midline
shift.

reactive to light, with no gaze preference.
The patient had a right-sided facial droop.
Her left upper and lower limbs were
localized to pain. She had no movement in
her right upper and lower limbs. The National Institutes of Health Stroke Scale
score was 19 on presentation to the
emergency department.

midline shift. The decompressive craniectomy, which involved storing the bone
flap in an abdominal subcutaneous
pocket, was successfully performed

Outcome and Follow-Up
Postoperatively, the patient was tested for
COVID-19, and the result was positive.
Thus, the patient was kept in droplet
isolation, in addition to contact isolation.
All protocols from the infection and prevention control department were performed. Because the patient had an
unremarkable medical history, except for
hypertension, all investigations were performed to exclude the possible causes of
infarction. The autoimmune workup
findings revealed an erythrocyte sedimentation rate of 83 mm/hour (reference
range, 0e20 mm/hour), C-reactive protein
of 157 mg/L (reference range, <8 mg/L),
antiedouble-stranded DNA of 24 IU/mL,
vitamin B12 of 134 pmol/L (reference
range,
138e652
pmol/L),
thyroidstimulating hormone of 0.89 mIU/L
(reference range, 0.35e4.94 mIU/L), and
indeterminate lupus anticoagulant levels.
Thrombophilia screening revealed a Ddimer of 23 mg/dL (reference range, <0.50
mg/dL), fibrinogen of 3.96 g/L (reference
range, 1.5e4.1 g/L), and antithrombin III
level of 103.2% (reference range, 75%e
125%). Additionally, an echocardiogram
showed a grossly normal left ventricle, an
ejection fraction of >55%, and an intact
transmitral spectral Doppler flow pattern.

Radiological Imaging Findings
A brain computed tomography scan
showed large left middle cerebral artery
territory hypodensity causing a mass effect
and ipsilateral lateral ventricle compression and midline shift to the right of ~0.5
cm, representing subacute infarction
(Figure 1). A computed tomography
venogram revealed the absence of
contrast opacification of the left internal
carotid artery and M1 and A1 segments,
and complete occlusion of the left
common carotid artery from the origin at
the aortic arch (Figure 2).
Surgical Intervention
The decision was made to perform emergent decompressive craniectomy, anticipating the worsening mass effect and

Figure 2. (A) Computed tomography venogram demonstrating the absence of contrast opacification in
the left internal carotid artery and M1 and A1 segments consistent with occlusion. The major venous
sinuses were patent. (B) Subsequent computed tomography angiogram showing complete occlusion
of the left common carotid artery from the origin at the aortic arch.

WORLD NEUROSURGERY 144: 140-142, DECEMBER 2020

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CASE REPORT
ALI ALKHAIBARY ET AL.

LARGE-VESSEL STROKE IN COVID-19

catastrophic, clinical manifestation. Understanding the various neurological
manifestations of COVID-19 should be of
paramount importance to physicians during the pandemic. Extensive evaluation
should be performed to exclude predisposing factors of hypercoagulability.
Further studies are required to delineate
the pathogenesis of COVID-19erelated
coagulopathy.
ACKNOWLEDGMENTS

Figure 3. (A) Nonecontrast-enhanced axial computed tomography scan of the head demonstrating
an evolving left middle cerebral artery territory infarction and improvement of the mass effect post
decompressive craniectomy. (B) Coronal computed tomography angiogram showing persistent
occlusion of the intracranial left internal carotid artery.

The institutional review board at King
Abdullah International Medical Research
Center, Ministry of National Guard Health
Affairs, Riyadh, Saudi Arabia, approved
the present study.
REFERENCES

DISCUSSION
Large-vessel infarction in young patients
with COVID-19 has been rare. A review of
the reported studies identified only a few
reported cases since the emergence of the
COVID-19 pandemic. We have reported an
additional case managed at our institution. To the best of our knowledge, the
present patient is the youngest to develop
a large-vessel occlusion as the presenting
feature of COVID-19.
In a previously reported series, most of
the reported cases (n ¼ 20; 90.9%) had
been diagnosed in males.3 In terms of the
vascular territories, stroke involving the
anterior circulation was noted in 13
patients (65%) and in the posterior
circulation in 6 patients (27.3%).3 In
addition, stroke as the initial clinical
manifestation of COVID-19 was noted in
18 patients (81.8%).3
It is evident that patients with COVID-19
have a high risk of thromboembolic disease.4 Coagulopathy and dysfunction of
endothelial cells have been implicated in
contributing to the disease process.5
However, the exact pathophysiological
mechanism leading to cerebrovascular
disease
has
remained
uncertain.3
Therefore, healthcare providers should
keep a high level of suspicion to promptly
diagnose any young patient presenting
with
signs
and
symptoms
of
cerebrovascular disease during the COVID19 pandemic.4 Gunasekaran et al.4 have
recommended close neuromonitoring of

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patients presenting with cerebrovascular
disease who have COVID-19. This will
allow for further investigations and establishment of an association of thrombotic
events in this population.3
Oxley et al.6 recently reported their case
series (n ¼ 5) on large-vessel infarction as
the initial clinical manifestation of
COVID-19 in patients aged <50 years. In
addition, during the pandemic, patients
might be reluctant to seek medical attention because of social distancing, isolation
rules, and concern of going to the hospital. Therefore, it has not been uncommon
for the clinical presentation of cerebrovascular disease to be delayed for patients
with COVID-19.6
The present patient had had a National
Institutes of Health Stroke Scale score of
19, consistent with the occurrence of a
moderate to severe stroke. All diagnostic
investigations were performed to exclude
autoimmune diseases that can cause cerebrovascular disease in young patients.
The clinical manifestations of the present
case were consistent with previously reported data. However, to the best of our
knowledge, our patient is the youngest
patient with COVID-19 to present with
cerebrovascular disease in the form of a
common carotid artery occlusion.

1. Liu K, Pan M, Xiao Z, Xu X. Neurological manifestations of the coronavirus (SARS-CoV-2)
pandemic 2019-2020. J Neurol Neurosurg Psychiatry.
2020;91:669-670.
2. Cavallieri F, Marti A, Fasano A, et al. Prothrombotic state induced by COVID-19 infection as
trigger for stroke in young patients: a dangerous
association. eNeurologicalSci. 2020;20:100247.
3. Khan M, Ibrahim RH, Siddiqi SA, et al. EXPRESS:
COVID-19 and acute ischemic stroke—a case series
from Dubai, UAE. Int J Stroke. 2020;15:699-700.
4. Gunasekaran K, Amoah K, Rajasurya V,
Buscher MG. Stroke in a young COVID-19 patient.
QJM. 2020;113:573-574.
5. Zhou F, Yu T, Du R, et al. Clinical course and risk
factors for mortality of adult inpatients with
COVID-19 in Wuhan, China: a retrospective cohort
study. Lancet. 2020;395:1054-1062.
6. Oxley TJ, Mocco J, Majidi S, et al. Large-vessel
stroke as a presenting feature of COVID-19 in the
young. N Engl J Med. 2020;382:e60.

Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 22 July 2020; accepted 21 August 2020
Citation: World Neurosurg. (2020) 144:140-142.
https://doi.org/10.1016/j.wneu.2020.08.154
Journal homepage: www.journals.elsevier.com/worldneurosurgery

CONCLUSION
Large-vessel occlusion as the initial presentation of COVID-19 is a rare, but

Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.

WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.08.154