COVID-19-associated ischemic stroke accompanied by chronic cerebral ischemia due to bilateral internal carotid artery stenoses combined with cerebral aneurysm. A case of simultaneous microsurgical treatment

The case of successful treatment of a patient who underwent COVID-19-associated acute ischemic stroke against the background of combined vascular pathology in the form of hemodynamically significant stenoses of extracranial sections of both internal carotid arteries and saccular aneurysm of the M1 segment of the right middle cerebral artery bifurcation is described. The technique of simultaneous microsurgical treatment of aneurysm and stenosis from the ipsilateral side followed by microsurgical reconstruction of the stenosed carotid artery from the contralateral side was applied. Clinical and functional outcomes were positive: reconstruction of internal carotid arteries on both sides and aneurysm clipping without intra- and postoperative ischemic and hemorrhagic complications were achieved. Immunohistochemical study of the removed atherosclerotic plaques revealed positive expression of S-protein antigen of SARS-CoV-2 localized in fibroblasts and smooth muscle cells, as well as in macrophages infiltrating the plaque.

1. Gupta V., Chinchure S., Goel G., Jha A. N., Gupta A., Narang K. S. Coil embolization of intracranial aneurysms with ipsilateral carotid stenosis: technical considerations. Turk Neurosurg. 2014;24(4):587–592. Doi: 10.5137/1019-5149.JTN.9165-13.1. PMID: 25050688.

2. Bobinov V. V., Rozhchenko L. V., Petrov A. E., Samochernykh N. K., Samochernykh K. A. Endovascular treatment of patients with combined cerebral aneurysms and stenoses of precerebral arteries. Atherosclerosis and dyslipidemias. 2023;2(51):18–22. (In Russ.). Doi: 10.34687/2219-8202.JAD.2023.02.0002.

3. Khripun A. I., Priamikov A. D., Mironkov A. B., Asratian S. A., Tyurin I. N., Suryakhin V. S., Abashin M. V., Mikhailenko V. P. Diagnosis and treatment of extracranial internal carotid artery lesion combined with cerebrovascular malformation. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N. I. Pirogova. 2017;(8):4–12. (In Russ.). Doi: 10.17116/hirurgia201784-12.

4. Khan U. A., Thapar A., Shalhoub J., Davies A. H. Risk of intracerebral aneurysm rupture during carotid revascularization. J Vasc Surg. 2012;56(6):1739–1747. Doi: 10.1016/j.jvs.2012.07.027. PMID: 23182485

5. Suh B. Y., Yun W. S., Kwun W. H. Carotid artery revascularization in patients with concomitant carotid artery stenosis and asymptomatic unruptured intracranial artery aneurysm. Ann Vasc Surg. 2011;25(5):651–655. Doi: 10.1016/j.avsg.2011.02.015.

6. Korotkikh A. V., Nekrasov D. A., Khilchuk A. A., Scherbak S. G., Sarana A. M. Simultaneous internal carotid artery stenosis and ipsilateral anterior communicating artery saccular aneurysm treatment: a case report. Radiol Case Rep. 2020;15(7):1083–1086. Doi: 10.1016/j.radcr.2020.05.010.

7. Radak D., Sotirovic V., Tanaskovic S., Isenovic E. R. Intracranial aneurysms in patients with carotid disease: not so rare as we think. Angiology. 2014;65(1):12–16. Doi: 10.1177/0003319712468938.

8. Sadeghmousavi S., Rezaei N. COVID-19 infection and stroke risk. Rev Neurosci. 2020;32(3):341–349. Doi: 10.1515/revneuro-2020-0066.

9. Vogrig A., Gigli G. L., Bnà C., Morassi M. Stroke in patients with COVID-19: Clinical and neuroimaging characteristics. Neurosci Lett. 2021;743:135564. Doi: 10.1016/j.neulet.2020.135564.

10. Sagris D., Papanikolaou A., Kvernland A., Korompoki E., Frontera J. A., Troxel A. B., Gavriatopoulou M., Milionis H., Lip G. Y. H., Michel P., Yaghi S., Ntaios G. COVID-19 and ischemic stroke. Eur J Neurol. 2021;28(11):3826–3836. Doi: 10.1111/ene.15008.

11. Varga Z., Flammer A. J., Steiger P., Haberecker M., Andermatt R., Zinkernagel A. S., Mehra M. R., Schuepbach R. A., Ruschitzka F., Moch H. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020;395(10234):1417–1418. Doi: 10.1016/S0140-6736(20)30937-5.

12. Lozhkina N. G., Gushchina O. I., Evdokimova N. E., Parkhomenko O. M. Sars-Cov-2 infection accelerates atherosclerosis and leads to myocardial infarction: hypothesis or objective reality?. Pulse: Medical & pharmaceutical journal. 2021;23(3):95–102. (In Russ.). Doi: 10.26787/nydha-2686-6838-2021-23-3-95-102.

13. Gupta N., Zhao Y. Y., Evans C. E. The stimulation of thrombosis by hypoxia. Thromb Res. 2019;181:77–83. Doi: 10.1016/j.thromres.2019.07.013. PMID: 31376606.

14. Siddiqui A., Vora N., Edgell R. C., Callison R. C., Kitchener J., Alshekhlee A. Rupture of a cerebral aneurysm following carotid endarterectomy. J Neurointerv Surg. 2012;4(5):e27. Doi: 10.1136/neurintsurg-2011-010091. PMID: 21990531.

15. Usachev D. I., Lukshin V. A., Yakovlev S. B. Topical issues of reconstructive surgery of the main arteries of the head. P. 1. Moscow: IP “T. A. Alekseev”, 2020. 360 p. (In Russ.).