The COVID-19 pandemic has brought the world to a near standstill as a highly contagious coronavirus spreads rapidly around the world, causing sudden and severe illness with high mortality, and threatening to overwhelm healthcare systems. This has resulted in the disruption of the normal course of human events with widespread stay-at-home orders, closure of businesses, prohibition of public events, and cancellation of elective medical treatments and surgery. In this issue of Vascular Disease Management, we have the report of a patient who presented with stroke symptoms while on a cruise ship during the early stages of the pandemic and who was treated with carotid endarterectomy 2 months later. The rapid medical response and multifaceted care across international boundaries provides a compelling patient story during this volatile and uncertain time.
The coronavirus originated in mid-December 2019 with the first cluster of cases linked to a seafood and live animal market in Wuhan, China. On January 11, 2020, the first death due to the virus was reported, and by January 22, China had reported 17 deaths with 571 confirmed cases as the virus rapidly spread to other countries, including Hong Kong, South Korea, Japan, and the United States. On January 23, the central government of China imposed a lockdown of Wuhan, a city of 11 million people, in an effort to quarantine the center of the outbreak. Several days earlier, the patient described in this report had boarded the Diamond Princess cruise ship, which departed Yokohama, Japan, on January 20, carrying approximately 3,700 passengers and crew. On January 25, the ship arrived in Hong Kong and a passenger who had become ill departed the ship; he was tested in Hong Kong and was found to have SARS-CoV-2 infection. On February 3, after making six stops in three countries, the ship returned to Japan. Japanese authorities were notified of the COVID-19 diagnosis in the passenger who had disembarked in Hong Kong, and the ship was quarantined. On February 5, Diamond Princess passengers were quarantined in their cabins and on that day, the patient described in this report developed sudden left-sided weakness. The next day, the patient reported to the ship’s medical clinic and was transferred to the Yokohama City University Medical Center, where imaging confirmed right- sided cerebral infarcts and magnetic resonance angiopgraphy (MRA) showed right carotid stenosis. The patient had no cough or respiratory symptoms, but because of low-grade fever and because the patient had come from the quarantined cruise ship, he was tested for SARS-CoV-2 and was found to be infected.
Initially, this patient might have been considered for carotid endarterectomy since it is known that patients with mild strokes may benefit from carotid endarterectomy to protect against recurrent stroke and death, particularly if performed within 2 weeks of the acute event. Indeed, carotid endarterectomy for treatment of acutely symptomatic carotid stenosis is listed as a Tier 3 procedure (do not postpone) in the current Society for Vascular Surgery guidance during the COVID-19 pandemic. This, however, would not have been a consideration in this patient, because he soon developed symptomatic COVID-19 pneumonia requiring supplemental oxygen. Fortunately, he responded to the excellent medical care he received at the Yokohama Medical Center and was discharged from the hospital one month later, following two negative tests for SARS-CoV-2.
But what if the patient’s condition had deteriorated and he had died? This case would have been counted as a COVID-19 death, not unlike the escalating number of coronavirus deaths worldwide, and the element of cerebrovascular disease may have gone unnoticed. While most people with coronavirus infection have mild to moderate symptoms, it is well known that elderly people and those with underlying health problems are particularly vulnerable to severe virus-induced illness and death. This patient was 71 years old with a history of hypertension and hyperlipidemia. The most common comorbidities among COVID-19 deaths in New York are hypertension, diabetes, hyperlipidemia, and coronary artery disease, with 86% of deaths involving at least one comorbidity. Furthermore, the patient was on a cruise ship with 2,666 passengers with a median age of 69 years (interquartile range 62-73) which is a favorable, contained environment for the rapid spread of the highly contagious pathogen. Similar conditions exist in retirement and nursing homes, which also have experienced rapid outbreaks of the COVID-19 contagion. Initial efforts at local quarantine have been ineffective as the number of infections and deaths has grown exponentially, requiring worldwide containment and control measures.
When the patient returned to his home in Santa Clara, California in March, the world had changed. Stay-at-home and social distancing orders were in place, hospitals were emptied in anticipation of a surge of coronavirus cases, scheduled medical and surgical treatments were cancelled, and patients were afraid to go to hospitals for fear of being infected with the virus.
Physicians’ offices and clinics had few patients, being replaced by telemedicine and video interaction. In this new environment, the patient was seen by a neurologist via a video consultation, who reviewed the patient’s condition and history remotely, and scheduled a carotid duplex ultrasound that revealed a mobile intramural filling defect with an 85% stenosis of the internal carotid artery. What now? The patient was past the 2-week high-risk period for recurrent stroke following an acute stroke event, and had also tested negative for SARS-CoV-2 on two occasions before leaving Japan. Was the patient still at risk for recurrent stroke? Should carotid endarterectomy be performed? Did the patient still present a risk for coronavirus transmission?
The rationale of proceeding with carotid endarterectomy at this time was based on the patient’s relatively mild post-stroke neurologic deficit and ominous findings on duplex ultrasound, and this is well described in the case report. Similarly, the planning and precautions taken to mitigate risk and prevent any potential exposure of the operating room team and medical personnel to the coronavirus are well presented. Dr. Singh and his surgical team are to be commended for their sound judgement, careful preparation, and surgical skill. Of particular note is the finding at surgery of perivascular inflammation surrounding the carotid bifurcation, and the mobile, pedunculated plaque in the carotid artery, demonstrated in the video accompanying the case report. These observations confirmed the ultrasound findings and the unstable nature of the lesion, with high risk for embolization and recurrent stroke or death. Furthermore, the soft, friable and hemorrhagic characteristics of the lesion suggest that perhaps the patient’s stroke was not simply a manifestation of carotid bifurcation atherosclerosis and stenosis that by chance occurred at the time of the coronavirus outbreak, but was related to the SARS-CoV-2 infection.
While it has been thought that the coronavirus primarily attacks the lung, with respiratory failure it is now clear that the virus has systemic effects which can impact every major organ in the body. SARS-CoV-2 infection drives a cytokine response that can be profound, with a cytokine storm and hyperinflammatory response leading to rapid decline. It can also be manifested in a variety of ways, with patients presenting with symptoms indistinguishable from myocardial infarction, with elevated cardiac enzymes and evidence of myocarditis. COVID-19 patients may also experience strokes and neurologic symptoms. While this occurs most often in elderly patients, strokes have recently been reported in younger patients age 30-50, who have presented with sudden thrombosis in the carotid and cerebral vessels. Large vessel occlusions, both arterial and venous with thromboembolism, are increasingly being recognized in COVID-19 patients.
Thus, it is possible that this patient’s stroke was a result of coronavirus inflammatory responses with hypercoagulability and thrombosis in the carotid bifurcation, with or without plaque rupture. The gross and pathologic appearance of the unusual, mobile, pedunculated lesion 2 months later appears to be consistent with such a mechanism, and further analyses are ongoing. Nonetheless, this appears to be the first well-documented report of carotid endarterectomy in a patient with COVID-19 related stroke.
The surgical team and healthcare workers are to be congratulated for the excellent outcome in this patient and for highlighting the importance of pre-operative diagnosis, preparation and planning, surgical skill, and patient care, as is well described in this report. We very much appreciate your dedication and selfless work during this coronavirus pandemic. We recognize that we are in the early phases of this pandemic and there is much to be learned (this case report is a good beginning). We are grateful to the scientists, epidemiologists, physicians, and healthcare and governmental agencies working together to combat this global crisis.
Disclosure: Dr. Zarins reports no conflicts of interest regarding the content herein.
Manuscript submitted April 27, 2020, final version accepted April 27, 2020.
Address for correspondence: Christopher K. Zarins, MD, Walter Clifford Chidester and Elsa Rooney Chidester Professor of Vascular Surgery, Emeritus, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94304. Email: firstname.lastname@example.org.