Circumferential Fibrosis of the Ascending Aorta After COVID Infection.

After recovering from severe COVID-19 infection, 2 women presented with chest pain. Computed tomographic angiography suggested acute ascending aortic dissection. At operation in both patients, the ascending aorta was encased in dense fibrous tissue, within which were focal collections of mononuclear cells, including many plasma cells. There was no entry tear or dissection. Such findings we have not encountered previously, and PubMed search of "periaortic fibrosis and COVID-19" yielded no similar cases or possible relation.

SARS-CoV-2 antibody research in patients with unprovoked pulmonary embolism in COVID-19 pandemic period.

OBJECTIVE: Due to the coronavirus disease 2019 (COVID-19) pandemic, a significant increase has been observed in patients diagnosed with pulmonary embolism (PE) in our clinic. In addition to COVID-19-related PE, the increase in the number of patients with unprovoked or idiopathic PE was also noteworthy. Although it is not surprising that PE due to immobilization was observed in elderly patients and patients with comorbidities at risk for PE during the pandemic, it is important to investigate the increase in the number of unprovoked PE. Thus, we aimed to show that a previous COVID-19 infection may be a risk factor in these patients by examining the presence of severe acute respiratory syndrome-causing coronavirus (SARS-CoV-2) antibodies in patients diagnosed with unprovoked PE. MATERIALS AND METHODS: The participants of the study consisted of 45 consecutive patients who were diagnosed with PE in our clinic, had no risk factors for PE, were considered unprovoked (idiopathic) PE, and had no history of COVID-19. SARS-CoV-2 antibody titers were measured in the serum samples of the patients for detecting immunity as a result of encountering COVID-19. RESULTS: Of the 45 patients diagnosed with PE, 24 (53.3%) patients were diagnosed with computed tomography pulmonary angiogram (CTPA), and 21 (46.7%) patients were diagnosed with perfusion single-photon emission computed tomography (Q-SPECT/CT). Immunity acquired after encountering COVID-19 was checked with the NCP kit, which revealed positive results in 9 (20%) patients. CONCLUSION: It should be kept in mind that some of the patients diagnosed with idiopathic PE during the pandemic may have embolism due to asymptomatic COVID-19. In addition, it is now known that COVID-19 also creates a tendency toward thrombosis in asymptomatic patients.

Computed Tomography Pulmonary Angiography Utilization in the Emergency Department During the COVID-19 Pandemic.

PURPOSE: To determine if computed tomography pulmonary angiography (CTPA) ordering increased significantly during the COVID-19 pandemic in an emergency department (ED) setting; if positive findings for pulmonary embolism (PE) increased to the same degree; and whether COVID-positive patients have a higher incidence of PE than COVID-negative patients at ED presentation. MATERIALS AND METHODS: We conducted a retrospective review of CTPA performed in our ED between June and December in 2019 and 2020. We collected data on patient demographics, symptoms, COVID-19 status, lab and imaging results, and risk factors for PE. We used a Wilcoxon rank sum to analyze quantitative variables and χ2 or Fisher test for categorical variables. We used logistic regression to identify predictive factors for PE. RESULTS: CTPA ordering increased from 432 studies in 2019 to 699 in 2020 (+61.8%, P<0.0001), but detection rates for PE remained stable (11.3% vs. 10.2%, P=0.61). In 2020, 10 of 91 COVID-positive patients undergoing CTPA had positive studies. On regression analysis, COVID-19 was not a significant predictor of PE at ED presentation (odds ratio 1.029, 95% confidence interval: 0.959-1.103). COVID-positive patients were more likely to have nondiagnostic imaging (7.7% vs. 2.5% [COVID-negative] and 0.8% [not tested], P=0.007). CONCLUSIONS: While CTPA ordering increased significantly during the pandemic, our positivity rate remained stable, suggesting that this increase was appropriate. COVID-positive patients who underwent CTPA in the ED did not have a higher incidence of PE than other patients. Clinicians should use clinical judgment to weigh the likelihood of PE against the risk of nondiagnostic results when determining whether to expose COVID-positive patients to high-dose radiation and contrast with CTPA on initial presentation.

Bilateral pediatric pial arteriovenous fistulas accompanying a giant arachnoid cyst with torticollis: A case report.

RATIONALE: Pial arteriovenous fistula (PAVF) occurs when intracranial arteries communicate directly with veins. PAVFs are very rare congenital vascular lesions that are commonly seen in infants and children. Arachnoid cysts are congenital cavitation often filled with cerebrospinal fluid. We present a very rare associated occurrence of bilateral pediatric PAVF and a giant arachnoid cyst presenting as torticollis in a child. So far, this is the first case. PATIENT CONCERNS: A 6-year-old male child was referred to our facility from a local hospital due to severe torticollis. DIAGNOSES: An enhanced computed tomography scan revealed 2 slightly high-density masses at the anterior pontine cistern, right circumferential cistern, as well as left posterior occipital region. The same computed tomography scan revealed a giant arachnoid cyst in the left occipital as well as the temporal region with a thin cerebral cortex adjacent to the cyst. INTERVENTIONS: Digital subtraction angiography confirmed that the 2 high-flow lesions were PAVFs. The patient was treated with a combination of detachable coils and Onyx Liquid Embolic System (Onyx HD-500) (Covidien/ev3 Neurovascular) via the transarterial endovascular route while the giant arachnoid cyst was managed conservatively. OUTCOMES: The torticollis resolved 2 days after the procedure. He is currently well with no neurologic deficit. LESSONS: We advocate that in cases of PAVF with accompanying cyst, the cyst should be managed conservatively if it is not associated with intracranial hemorrhage or focal neurologic deficit.

Acute confusional state as a prognostic sign of COVID-19 large-vessel occlusion (LVO).

COVID-19 is well known for its respiratory symptoms, but severe presentations can alter haemostasis, causing acute end-organ damage with poor outcomes. Among its various neurological presentations, cerebrovascular events often present as small-vessel strokes. Although uncommon, in predisposed individuals, large-vessel occlusions (LVOs) can occur as a possible consequence of direct viral action (viral burden or antigenic structure) or virus-induced cytokine storm. Subtle presentations and complicated stroke care pathways continue to exist, delaying timely care. We present a unique case of COVID-19 LVO manifesting as an acute confusional state in an elderly man in April 2020. CT angiography revealed 'de novo' occlusions of the left internal carotid artery and proximal right vertebral artery, effectively blocking anterior and posterior circulations. Delirium can lead to inaccurate stroke scale assessments and prolong initiation of COVID-19 stroke care pathways. Future studies are needed to look into the temporal relationship between confusion and neurological manifestations.

Chest pain mimicking pulmonary embolism may be a common presentation of COVID-19 in ambulant patients without other typical features of infection.

BACKGROUND: Radiological and pathological studies in severe COVID-19 pneumonia (SARS-CoV-2) have demonstrated extensive pulmonary immunovascular thrombosis and infarction. This study investigated whether these focal changes may present with chest pain mimicking pulmonary emoblism (PE) in ambulant patients. METHODS: CTPAs from outpatients presenting with chest pain to Leeds Teaching Hospital NHS Trust 1st March to 31 May 2020 (n = 146) and 2019 (n = 85) were compared. Regions of focal ground glass opacity (GGO), consolidation and/or atelectasis (parenchymal changes) were determined, and all scans were scored using British Society for Thoracic Imaging (BSTI) criteria for COVID-19, and the 2020 cohort was offered SARS-CoV-2 antibody testing. RESULTS: Baseline demographic and clinical data were similar between groups with absence of fever, normal lymphocytes and marginally elevated CRP and D-Dimer values. Evidence of COVID-19 or parenchymal changes was observed in 32.9% (48/146) of cases in 2020 compared to 16.5% (14/85) in 2019 (P = 0.007). 11/146 (7.5%) patients met BSTI criteria for COVID-19 in 2020 compared with 0/14 in 2019 (P = 0.008). 3/39 patients tested had detectable COVID-19 antibodies (2 with parenchymal changes and 1 with normal parenchyma) however 0/6 patients whose CTPA met BSTI criteria "likely/suspicious for COVID-19" and attended antibody testing were SARS-CoV-2 antibody positive. CONCLUSIONS: 32.8% ambulatory patients with suspected PE in 2020 had parenchymal changes with 7.5% diagnosed as COVID-19 infection by imaging criteria, despite the absence of other COVID-19 symptoms. These findings suggest that localized COVID-19 pneumonitis with immunothrombosis occurs distal to the bronchiolar arteriolar circulation, causing pleural irritation and chest pain without viraemia, accounting for the lack of fever and systemic symptoms.

Aortoenteric fistula after endovascular mycotic aortic aneurysm exclusion: lessons learned during the COVID-19 era.

We report a case of aortoenteric fistula 2 years following endovascular aortic aneurysm repair (EVAR) for mycotic aneurysm presenting as upper gastrointestinal bleeding. Initial CT angiogram did not reveal the bleeding or connection to bowel, but endoscopy was suspicious of endograft in the duodenum. Management required a multidisciplinary approach. To stabilise the patient and to control bleeding, a 'bridging' endograft extension was performed. This was followed by open surgical removal of the EVAR endograft and lower limb in situ revascularisation. During postoperative recovery, the patient developed atypical, staged multisystemic symptoms (cardiac, pulmonary and neurological). With increasing awareness of the COVID-19 pandemic, the patient was found SARS-CoV-2-positive, which explained the progression of his symptoms. This was also reflected on other case reports in literature later.

Pulmonary embolisms in patients with COVID-19: a prevalence study in a tertiary hospital. / Tromboembolismo pulmonar en pacientes con COVID-19: estudio de prevalencia en un hospital terciario.

INTRODUCTION: SARS-CoV-2, the virus responsible for the current pandemic, predominantly affects the respiratory tract, and a growing number of publications report the predisposition of patients with COVID-19 to develop thrombotic phenomena. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COVID-19; to determine the possible relationship between the severity of pulmonary involvement and D-dimer levels; to analyze the location of pulmonary embolisms in patients with COVID-19 and to compare it with the location in patients without COVID-19. METHODS: This retrospective study analyzed all CT angiograms of the pulmonary arteries done in patients with suspected pulmonary embolisms between March 15 and April 30, 2020 and compared them with studies done in the same period one year earlier. RESULTS: We included 492 pulmonary CT angiograms (342 (69.9%) in patients with COVID-19 and 147 (30.1%) in patients without COVID-19). The prevalence of pulmonary embolisms was higher in patients with COVID-19 (26% vs. 16.3% in patients without COVID-19, p=0.0197; relative risk=1.6). The prevalence of pulmonary embolisms in the same period in 2019 was 13.2%, similar to that of the group of COVID-19-negative patients in 2020 (p=0.43). There were no significant differences in D-dimer levels or the location of pulmonary embolisms between the two groups. CT showed moderate or severe pulmonary involvement in 78.7% of the patients with COVID-19. CONCLUSIONS: Patients with COVID-19 have an increased prevalence of pulmonary embolisms (26%), and most (78.7%) have moderate or severe lung involvement on CT studies. The location of pulmonary embolisms and the degree of elevation of D-dimer levels does not differ between patients with COVID-19 and those without.

Stroke etiologies in patients with COVID-19: the SVIN COVID-19 multinational registry.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) is associated with a small but clinically significant risk of stroke, the cause of which is frequently cryptogenic. In a large multinational cohort of consecutive COVID-19 patients with stroke, we evaluated clinical predictors of cryptogenic stroke, short-term functional outcomes and in-hospital mortality among patients according to stroke etiology. METHODS: We explored clinical characteristics and short-term outcomes of consecutively evaluated patients 18 years of age or older with acute ischemic stroke (AIS) and laboratory-confirmed COVID-19 from 31 hospitals in 4 countries (3/1/20-6/16/20). RESULTS: Of the 14.483 laboratory-confirmed patients with COVID-19, 156 (1.1%) were diagnosed with AIS. Sixty-one (39.4%) were female, 84 (67.2%) white, and 88 (61.5%) were between 60 and 79 years of age. The most frequently reported etiology of AIS was cryptogenic (55/129, 42.6%), which was associated with significantly higher white blood cell count, c-reactive protein, and D-dimer levels than non-cryptogenic AIS patients (p

Our early experience with mesenteric ischemia in COVID-19 positive patients.

Literature has been published stating that thrombosis is occurring at higher rates in patients who are positive for COVID-19. This experience is more with limb ischemia. Reports of mesenteric ischemia are coming in from different parts of the globe. We share our early experience of managing two patients with acute mesenteric ischemia.

Recurrent coronary thrombotic events in a moderate case of COVID-19.

We describe the case of a healthy patient with moderate COVID-19 infection without thrombophilia nor coronary disease background who presented with a relapsing thrombotic occlusion of the right coronary artery despite normal oxygenation, adequate antiaggregation and prophylactic anticoagulation. Prophylactic anticoagulation recommendations in COVID-19 were inadequate for this patient. Further data are needed to propose full-dose therapeutic anticoagulation for patients with coronary thrombosis and COVID-19 infection. This could nevertheless be considered even in mild forms of COVID-19.

Prevalence of Thrombotic Complications in ICU-Treated Patients With Coronavirus Disease 2019 Detected With Systematic CT Scanning.

OBJECTIVES: Severe coronavirus disease 2019 is associated with an extensive pneumonitis and frequent coagulopathy. We sought the true prevalence of thrombotic complications in critically ill patients with severe coronavirus disease 2019 on the ICU, with or without extracorporeal membrane oxygenation. DESIGN: We undertook a single-center, retrospective analysis of 72 critically ill patients with coronavirus disease 2019-associated acute respiratory distress syndrome admitted to ICU. CT angiography of the thorax, abdomen, and pelvis were performed at admission as per routine institution protocols, with further imaging as clinically indicated. The prevalence of thrombotic complications and the relationship with coagulation parameters, other biomarkers, and survival were evaluated. SETTING: Coronavirus disease 2019 ICUs at a specialist cardiorespiratory center. PATIENTS: Seventy-two consecutive patients with coronavirus disease 2019 admitted to ICU during the study period (March 19, 2020, to June 23, 2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All but one patient received thromboprophylaxis or therapeutic anticoagulation. Among 72 patients (male:female = 74%; mean age: 52 ± 10; 35 on extracorporeal membrane oxygenation), there were 54 thrombotic complications in 42 patients (58%), comprising 34 pulmonary arterial (47%), 15 peripheral venous (21%), and five (7%) systemic arterial thromboses/end-organ embolic complications. In those with pulmonary arterial thromboses, 93% were identified incidentally on first screening CT with only 7% suspected clinically. Biomarkers of coagulation (e.g., d-dimer, fibrinogen level, and activated partial thromboplastin time) or inflammation (WBC count, C-reactive protein) did not discriminate between patients with or without thrombotic complications. Fifty-one patients (76%) survived to discharge; 17 (24%) patients died. Mortality was significantly greater in patients with detectable thrombus (33% vs 10%; p = 0.022). CONCLUSIONS: There is a high prevalence of thrombotic complications, mainly pulmonary, among coronavirus disease 2019 patients admitted to ICU, despite anticoagulation. Detection of thrombus was usually incidental, not predicted by coagulation or inflammatory biomarkers, and associated with increased risk of death. Systematic CT imaging at admission should be considered in all coronavirus disease 2019 patients requiring ICU.

Deep vein thrombosis with pulmonary thromboembolism in a case of severe COVID-19 pneumonia.

A 53-year-old man with diabetes came to the emergency department with fever and dry cough for 5 days, swelling of the left leg for 2 days, shortness of breath and chest pain for 1 hour. He had raised temperature, tachycardia, tachypnoea, reduced oxygen saturation and swollen tender left leg on examination. The frontal chest radiograph showed bilateral ground-glass opacities; he tested positive for COVID-19 with elevated D-dimer. The colour Doppler examination of the left leg revealed acute deep vein thrombosis (DVT) of the common femoral and the popliteal veins. The chest CT showed bilateral diffuse ground-glass opacities predominantly involving peripheral zones and the lower lobes. The CTPA revealed left pulmonary thromboembolism (PTE), treated with low-molecular-weight heparin. COVID-19 predominantly affects the respiratory system. DVT and PTE are common in COVID-19 but lethal. They should be diagnosed early by clinical and radiological examinations and treated promptly with anticoagulants.