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SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Large-vessel strokes in patients younger than 50 years of age have been described as presenting symptoms for patients found to have COVID-19 Most patients with COVID-19 present with constitutional and respiratory symptoms, symptoms which range from asymptomatic disease to life-threatening disease including acute respiratory distress syndrome, acute kidney injury, multi-organ failure and death Here, we report a case of a patient presenting with both arterial and venous clots in the setting of COVID-19 that represents an extreme presentation of an entity now known as COVID-19 associated coagulopathy (CAC) CASE PRESENTATION: Our patient is a 74 year old female with past medical history of hypertension, hyperlipidemia and diabetes who presented after her daughter noticed that she was experiencing difficulty with balance She was taken to an outside hospital (OSH) where she was found to have left sided weakness and right sided gaze deviation History was notable for recent diagnosis of UTI as well as a new cough, dyspnea and dizziness that developed earlier in the day While at the OSH she suddenly became more unresponsive and was intubated for airway protection Her initial head CT showed a hyperdense right middle cerebral artery Intravenous tissue plasminogen activator was administered for her stroke and subsequently she was transferred to our hospital for further management A CTA head and neck was performed which showed a proximal right MCA occlusion (image 1) CT perfusion showed large infarct core as well as poor ASPECTS score (3-4) and she was therefore not a candidate for mechanical thrombectomy Incidentally, further chest imaging revealed a large pulmonary embolism (PE) in the right pulmonary artery, multiple segmental PE\'s and diffuse ground glass opacities (image 2) COVID-19 testing returned positive Bilateral lower extremity duplex was performed, this was significant for right soleal vein thrombus (image 3) The patient was started on a heparin infusion given her significant CAC despite the high risk of hemorrhagic transformation of her stroke Her condition improved and she was extubated on hospital day (HD) 4 and discharged to a skilled nursing facility on HD 20 Prior to discharge she was transitioned from heparin to rivaroxaban DISCUSSION: This case demonstrates the severity of CAC Our patients was found to have a large right MCA stroke, PE and right lower extremity DVT She was worked up extensively for other etiologies of her stroke but they were unrevealing The etiology of stroke was thought to be embolic of undetermined source and was most likely in the setting of COVID-19 CONCLUSIONS: CAC can be catastrophic for patients and can present with both arterial and venous thromboses Further studies are needed to elucidate the underlying pathophysiology of CAC and the optimal anticoagulation as well thrombolytic dosage regimens for thromboses secondary to CAC Reference #1: Avula A, Nalleballe K, Narula N, et al COVID-19 presenting as stroke [published online ahead of print, 2020 Apr 28] Brain Behav Immun 2020;S0889-1591(20)30685-1 doi:10 1016/j bbi 2020 04 077 Reference #2: Becker RC COVID-19 update: Covid-19-associated coagulopathy [published online ahead of print, 2020 May 15] J Thromb Thrombolysis 2020;1‐14 doi:10 1007/s11239-020-02134-3 DISCLOSURES: No relevant relationships by Daniel Condit, source=Web ResponseNo relevant relationships by Anand Muthu Krishnan, source=Web ResponseNo relevant relationships by Rudra Ramanathan, source=Web ResponseConsultant relationship with Boston Scientific Please note: $1001 - $5000 Added 06/01/2020 by Patrick Troy, source=Web Response, value=Consulting feeAdvisory Committee Member relationship with Boston Scientific Please note: $1001 - $5000 Added 06/01/2020 by Patrick Troy, source=Web Response, value=Consulting fee
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