Article, Neurology

Symptomatic internal carotid artery thrombosis in acute carbon monoxide intoxication

Internal carotid artery thro”>Case Report

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American Journal of Emergency Medicine

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Symptomatic internal carotid Artery thrombosis in acute carbon monoxide intoxication

Abstract

Stroke has been rarely associated with carbon monoxide (CO) intoxication. We report a symptomatic internal carotid artery (ICA) thrombosis in a patient with acute CO intoxication.

A 46 year-old Pakistani woman was found unconscious in the bathtub after the explosion of gas water heater. Two hours after the explosion she was comatose, with left gaze deviation and right hemiparesis. Acute CO intoxication was diagnosed (COHb 18,4%). The admission computed tomography (CT) was unremarkable, but aspirin was started due to the presence of focal deficits. She underwent a session of Hyperbaric oxygen therapy followed by invasive mechanical ventilation with hyperoxygenation. However, there was progressive Neurological deterioration, and a second CT scan showed a malignant infarction in the left ICA territory. Cervical vessel ultrasound showed an adherent thrombus causing a 50% stenosis at the origin of the left ICA, which was otherwise lesion-free. Laboratory investigation (including Hb electrophoresis and pro- thrombotic states screening) and electrocardiogram, Holter 24-hour monitoring, and transthoracic and transesophageal echocardio- grams were unremarkable. ICA was reanalyzed completely 3 days later. Patient was kept on aspirin and statin and recovered partially (Rankin 3 after 16 months of follow-up).

The temporal coincidence between CO intoxication and arterial thrombosis suggests a causal relationship. Previous reports of thrombosis associated with CO intoxication reinforces this associa- tion. CO intoxication may occasionally present with focal Neurological deficits, but our observation highlights the need to exclude coexisting acute neurological diseases. An association between CO intoxication and the formation of an adherent thrombus in a lesion-free vessel is also described.

Stroke has been rarely associated with carbon monoxide intoxication (CO). In fact, we found only 3 case reports of stroke, among 13 cases of carbon monoxide poisoning with thromboem- bolic events [1-3]. We report a case of ICA thrombus and stroke in a patient with acute CO intoxication.

A previously healthy 46-year-old Pakistani woman was found unconscious in the bathtub after the explosion of gas water heater. There was no history of trauma. At the emergency department, 2 hours after the explosion, she was comatose, with left gaze deviation and right hemiparesis (NIHSS 24). An acute CO intoxication was diagnosed (COHb 18,4%). The admission CT was unremarkable. Carbon monoxide poisoning was considered to account for the neurological deficits. A coexisting stroke was considered unlikely, but aspirin was started. A session of hyperbaric oxygen therapy was

done, followed by invasive mechanical ventilation with hyperox- igenation. Despite Intensive care support, there was progressive neurological deterioration. She repeated the CT scan, which showed a malignant infarction in the left internal carotid artery territory. A cervical vessel ultrasonography showed an adherent thrombus, causing a 50% stenosis at the origin of left internal carotid artery (ICA) (Fig. 1). The arterial layer was otherwise lesion-free, without laminations, calcifications, bosselated appearance or a double lumen aspect. The transcranial Doppler revealed left anterior and Middle cerebral artery stenosis. Three days later, there was complete ICA recanalization and regression of the intracranial stenosis.

The patient partially recovered (NIHSS 14). Laboratory investi- gation, including coagulation, Hb electrophoresis, and prothrombo- tic states screening was normal. Electrocardiogram, Holter 24-hour monitoring, and transthoracic and transesophageal echocardio- grams were also unremarkable. A brain magnetic resonance imaging (MRI) scan was performed 20 days after admission and disclosed ischemic and CO-injury signs concentrated in left ICA territory (Fig. 2). Patient was kept on aspirin and statin and was Rankin 3 after 16 months of follow-up.

The temporal coincidence between carbon monoxide intoxication and arterial thrombosis suggests a possible causal relationship

Fig. 1. Cervical arteries ultrasound–left ICA thrombus: at the level of the left carotid bifurcation, a hipoechoic mass in continuity with the intima layer was observed, suggestive of an adherent thrombus causing 50% stenosis. Signs of an underlying atherosclerotic plaque or arterial dissection were absent. Three days later, there was complete recanalization of the vessel.

0735-6757/(C) 2014

Fig. 2. MRI scan: left frontoparietal cortical linear hiperintensity in T2/FLAIR (a) and T1 (b) (laminar necrosis); left striatum hyperintense signal in T2/FLAIR (c) and T1 (d); left globus pallidus diffusion restriction (e).

between the two events. Previous reports of cerebral, cardiac, mesenteric, deep venous, and pulmonary thrombosis associated with carbon monoxide inhalation reinforce our conviction.

CO intoxication has been associated with a wide range of manifestations, which do not correlate with initial carboxyhe- moglobin level [4]. Patients may occasionally present with focal neurological deficits, along with altered mental status and other Classic symptoms.

In our patient, ischemic stroke coexisted with acute carbon monoxide intoxication, accounting for the focal deficits observed at presentation. This suggests that patients with acute CO intoxication and focal deficits should be thoroughly evaluated for coexisting neurological pathology, including stroke. Both entities have effica- cious therapies that should be instituted as soon as possible.

An adherent thrombus was found in an apparently lesion-free ICA artery. Focal adherent thrombus in lesion-free carotids have been previously reported in cases of severe Iron deficiency anemia, thrombocytosis and Hematological malignancies [5,6]. The mechanism of thrombosis remains elusive, but an association with small focal atheroma has been documented [5]. Carbon monoxide may have a procoagulant action [7]. Therefore, we speculate that carbon monoxide might have facilitated thrombo- sis in our patient. Thus, CO intoxication should be added to the list of pathological factors associated with of this type of adherent thrombi.

Remarkably, signs of carbon monoxide brain damage were concentrated in left ICA territory. Indeed, MRI shows striatum T2/ FLAIR hypersignal, globus pallidus diffusion restriction, and cortical laminar necrosis (Fig. 1), and these findings have been associated with carbon monoxide Hypoxic brain damage [8,9]. Ischemia secondary to ICA thrombosis may have sensitized the correspon- dent territory to CO injury, generating a pattern of hemispheric CO anoxic encephalopathy.

Tiago Teodoro, MD Neurology Department Hospital de Santa Maria

Lisbon, Portugal E-mail address: [email protected]

Ruth Geraldes, MD, MSc Teresa Pinho e Melo, MD

stroke unit, Neurology Department

Hospital de Santa Maria

Lisbon, Portugal

http://dx.doi.org/10.1016/j.ajem.2013.11.047

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