Symptomatic internal carotid artery thrombosis in acute carbon monoxide intoxication Tiago Teodoro MD PII: DOI: Reference:

S0735-6757(13)00833-4 doi: 10.1016/j.ajem.2013.11.047 YAJEM 54001

To appear in:

American Journal of Emergency Medicine

Received date: Accepted date:

15 November 2013 19 November 2013

Please cite this article as: Teodoro Tiago, Symptomatic internal carotid artery thrombosis in acute carbon monoxide intoxication, American Journal of Emergency Medicine (2013), doi: 10.1016/j.ajem.2013.11.047

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ACCEPTED MANUSCRIPT Title Symptomatic internal carotid artery thrombosis in acute carbon monoxide intoxication

1. Tiago Teodoro Neurology Department, Hospital de Santa Maria

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2. Ruth Geraldes

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Author names and affiliations

Stroke Unit, Neurology Department, Hospital de Santa Maria

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3. Teresa Pinho e Melo

Stroke Unit, Neurology Department, Hospital de Santa Maria

Corresponding author and contact details

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Tiago Teodoro, MD

Av. Prof. Egas Moniz

Portugal

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1649-028 Lisboa

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Neurology Department, Hospital de Santa Maria

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Mobile Phone: 00351965030281

Key words: Carbon monoxide intoxication, stroke, carotid artery thrombosis

ACCEPTED MANUSCRIPT Abstract

Background

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Stroke has been rarely associated with carbon monoxide (CO) intoxication. We report a

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symptomatic internal carotid artery (ICA) thrombosis in a patient with acute CO intoxication.

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Case Report

A 46 year-old Pakistani woman was found unconscious in the bathtub after the

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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 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 hyperoxigenation. However, there

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was progressive neurological deterioration and a second CT scan showed a malignant infarction in the left ICA territory. Cervical vessels ultrasound showed an adherent

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thrombus causing a 50% stenosis at the origin of left ICA, which was otherwise lesionfree. Laboratory investigation (including Hb electrophoresis and prothrombotic states

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screening) and EKG, Holter 24h, trans-thoracic and trans-esophageal ecocardiograms were unremarkable. ICA reanalyzed completely 3 days later. Patient was kept on

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aspirin and statin and recovered partially (Rankin 3 after 16 months of follow-up). Conclusions:

The temporal coincidence between CO intoxication and arterial thrombosis suggests a causal relationship. Previous reports of thrombosis associated to CO intoxication reinforce this association. 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.

ACCEPTED MANUSCRIPT Title Symptomatic internal carotid artery thrombosis in acute carbon monoxide intoxication

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Background

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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 thrombo-embolic events1-3. We report a case of internal carotid artery (ICA)

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thrombus and stroke in a patient with acute carbon monoxide (CO) intoxication.

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Case Report

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 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

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(COHb 18,4%). The admission CT was unremarkable. Carbon-monoxide poisoning was considered to account for the neurogical deficits. A coexisting stroke was considered

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unlikely, but aspirin was started. A session of hyperbaric oxygen therapy was done, followed by invasive mechanical ventilation with hyperoxigenation. Despite intensive

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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

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cervical vessels 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 investigation, including coagulation, Hb electrophoresis, prothrombotic states screening was normal. EKG, Holter 24h, trans-thoracic and trans-esophageal echocardiograms were also unremarkable. A Brain MRI scan was performed 20 days after admission and disclosed

ACCEPTED MANUSCRIPT ischemic and CO-injury signs concentrated in left ICA territory (Fig. 2). Patient was kept

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on aspirin and statin and was Rankin 3 after 16 months of follow-up.

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Discussion

The temporal coincidence between carbon monoxide intoxication and arterial

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thrombosis suggests a possible causal relationship between the two events. Previous reports of cerebral, cardiac, mesenteric, deep venous and pulmonary thrombosis

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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 carboxyhemoglobin level4. Patients may occasionally present with focal neurological deficits, along with altered mental status and other classical

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symptoms.

In our patient, ischemic stroke coexisted with acute carbon monoxide intoxication,

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accounting for the focal deficits observed at presentation. This suggests that patients with acute CO intoxication and focal deficits should be thoroughly evaluated for

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coexisting neurological pathology, including stroke. Both entities have efficacious therapies that should be instituted as soon as possible.

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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 malignancies5-6. The mechanism of thrombosis remains elusive, but an association with small focal atheroma has been documented5. Carbon monoxide may have a procoagulant action7. Therefore, we speculate that carbon monoxide might have facilitated thrombosis 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

ACCEPTED MANUSCRIPT thrombosis may have sensitized the correspondent territory to CO injury, generating a

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pattern of hemispheric CO anoxic encephalopathy.

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References

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1. El Khashab M, Nejat F. Hemorrhagic cerebral infarction in carbon monoxide poisoning: a case report. Cases J 2009;2:96. 2. Breton J, Caroff J, Martin R, Dehouve A, Dehouve P. [Fatal obstruction of the basilar trunk following benign carbon monoxide poisoning]. Med Leg Dommage Corpor 1969;2(4):409-11. 3. Ahmad A, Sharma VK. Early subcortical ischemic infarction and delayed leucoencephalopathy after carbon monoxide poisoning. Intern Emerg Med 2012;7 Suppl 1:S33-4. 4. Hampson NB, Dunn SL. Symptoms of carbon monoxide poisoning do not correlate with the initial carboxyhemoglobin level. Undersea Hyperb Med 2012;39(2):657-65. 5. de Bray JM, Devuyst G, Boulliat J, Fortrat JO, Dubas F, Rossetti AO, et al. Focal thrombi in the common carotid artery. Cerebrovasc Dis 2004;17(1):82-6. 6. Bouly S, Le Bayon A, Blard JM, Touze E, Leys D, Mas JL, et al. [Spontaneous thrombosis of lesion-free carotid arteries: a retrospective analysis of eight patients]. Rev Neurol (Paris) 2005;161(1):61-6. 7. Nielsen VG, Hafner DT, Steinbrenner EB. Tobacco smoke-induced hypercoagulation in human plasma: role of carbon monoxide. Blood Coagul Fibrinolysis 2013;24(4):405-10. 8. O'Donnell P, Buxton PJ, Pitkin A, Jarvis LJ. The magnetic resonance imaging appearances of the brain in acute carbon monoxide poisoning. Clin Radiol 2000;55(4):273-80. 9. Hopkins RO, Fearing MA, Weaver LK, Foley JF. Basal ganglia lesions following carbon monoxide poisoning. Brain Inj 2006;20(3):273-81.

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Figure 1. Cervical arteries ultrassound – left ICA thrombus: at the level of the left carotid bifurcation, an hipoecoic mass in continuity with the intima layer was observed, suggestive of 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.

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Fig. 2 - MRI scan: left fronto-parietal 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

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restriction (e).

Symptomatic internal carotid artery thrombosis in acute carbon monoxide intoxication.

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