CASE STUDY A C TA Vol. 21, No.

3, 2023, 305-323
NEUROPSYCHOLOGICA
Received: 11.04.2023
Accepted: 28.08.2023 QUALITY OF LIFE OF A PATIENT AFTER
A – Study Design
ENDARTERECTOMY OF THE INTERNAL
B – Data Collection
C – Statistical Analysis
CAROTID ARTERY (ICA) FOLLOWING
D – Data Interpretation
E – Manuscript Preparation
AN ACUTE ISCHEMIC STROKE (AIS)
F – Literature Search
G – Funds Collection DURING COVID-19
Ksenia Cielebąk1[A-E,G] , Mikołaj Kobos2[A,C-F] ,
Jolanta Góral-Półrola3[A-D,G]
1 Chair of Neuropsychology and Neurorehabilitation, Andrzej Frycz-Modrzewski
Kraków University, Kraków, Poland
2 2nd Department of Internal Medicine, The Joseph Dietl Specialist Hospital, Kraków,

Poland
3 The Old Polish University, Kielce, Poland

SUMMARY
Background: The aim of the study was to evaluate the quality of life of a patient af-
terendarterectomy (CEA) of the Internal Carotid Artery (ICA) following
an Acute ischemic stroke (AIS) during COVID-19.
Case study: A right-handed, 51-year-old patient, a visual artist, single, in good health
and no chronic illnesses to date, became infected with SARS-CoV-2
and contracted COVID-19. The presence of SARS-CoV-2 virus was
confirmed by a RT PCR antigen test. The patient was hospitalized,
and required mechanical ventilation at an Intensive Care Unit (ICU) be-
fore an acute ischemic stroke (AIS) onset. Except for untreated hyper-
tension, her medical history was unremarkable. Her blood pressure
was 180/100 mm Hg; her pulse was 76 beats per minute and was reg-
ular. AIS from the left middle cerebral artery (MCA) has resulted pri-
marily in damage to the left hemisphere, and secondary effects on
the right side resulting in body weakness and mild anomic apha-
sia. Magnetic resonance imaging (MRI) confirmed stroke and detected
brain tissue damaged by an AIS. It revealed hyperintense foci in the
T2 and FLAIR sequences, 21 mm in size in the left hemisphere of the
brain. In search of the cause of AIS, CT angiography was performed.
It revealed a large (90%) ICA occlusion. The patient was admitted to
the emergency room at the Vascular Surgery Clinic with an Endovas-
cular Subunit. The revascularization procedure (CEA) was perform-
ed under general endotracheal anesthesia with the use of the protocol
and techniques (elaborated at the Department of Vascular Surgery and
Endovascular Procedures, The John Paul II Hospital in Krakow). The
CEA procedure improved her general health: she regained the ability
to name objects and her HRQOL also improved in her perception. The
improvement achieved was statistically significant. She returned to
painting and functions well in society.
Conclusions: The patient’s perception of HRQoL measured by the SF-36 domains
was better after the CEA: a significant improvement in self-reported
overall health has occured. The HRQoL outcome measures may be
valuable in future clinical trials of comparing different methods of treat-
ment offered after AIS.

Key words: Covid-19, NeuroCOVID-19, AIS, CEA, Anomia, HRQOL

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INTRODUCTION
Coronavirus disease 2019 (COVID-19)1, infectious respiratory disease caused
by SARS-CoV-2 virus (Hui et al 2020), was first diagnosed and described in
November 20192, in central China (Wuhan city, Hubei province). This disease
during a series of cases initiating a pandemic of this disease, and has become
a global pandemic, affecting millions of people. Globally, as of 2nd August 2023,
there have been 768 983 095 confirmed cases of COVID-19, including 6 953 743
deaths, reported to WHO. As of 30 July 2023, a total of 13 492 099 754 vaccine
doses have been administered3.
Since the beginning tens of thousands of scientific articles have been written
providing insight into the multifaceted (multiple and complex) symptomatology
across multiple body systems: including the respiratory, osteoarticular, circulatory
and gastrointestinal systems in patients who have experienced COVID-19
(Huang et al 2020; Sadeghi et al 2020; Gorbalenya et al 2020; Fiani et al 2021;
Taquet et al 2021), as well as the central nervous system, named NeuroCOVID-
19 in the literature (Aknin et al 2021; MacQueen & MacQueen 2021; Pąchalska
et al 2021).
Aknin et al (2021), based on an extensive review of the literature, divided the
neurological symptoms and complications that occur following SARS-CoV-2 in-
fection and COVID-19 survival into:
1. mild, which include loss of smell (anosmia), loss of taste (ageusia), latent blink-
ing (heterophila), headache and dizziness, disorientation, among others;
2. severe which include cognitive impairment, seizures, delirium, psychosis and
strokes.
Acute ischemic stroke (AIS), is a life-threatening recognized complication of
coronavirus disease 2019 (COVID-19) infection. Clinical characteristics and out-
comes of COVID-19 patients with a history of stroke in Wuhan, China were re-
ported by Qin et al (2020). Also case series with stroke in patients with
SARS-CoV-2 infection were described (Morassi et al 2020). One of the very first
documented studies was also article about SARS-CoV-2 and stroke in a New
York healthcare system (Yaghi et al 2020). Cerebral ischemic and hemorrhagic
complications of coronavirus disease were also documented by Sweid et al
(2020), and other authors (Tan et al. 2020; Hu et al 2023).
Increasing number of reports suggest association between inflammation, en-
dothelial dysfunction, and coagulopathy might be the pathophysiologic mecha-
nisms involved in the development of arterial thrombotic events. (Tan et al 2020;
Mao et al 2020; Sashindranath & Nandurkar 2021; Sagris et al 2021; Mbonde et

1
Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. The species Severe
acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Mi-
crobiol 5, 536–544 (2020). https://doi.org/10.1038/s41564-020-0695-z.
2
The first COVID-19 case originated on November 17, according to Chinese officials searching for ‘patient
zero’, businessinsider.com, 13 marca 2020 [dostęp 2020-03-21] (ang.).
3
WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-19) Dashboard With Vaccination Data.

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al 2022). It was found that severe course of the COVID-19 may increase the risk
of AIS similar to the increased risk of 3.2-fold to 7.8-fold seen within the first 3
days after other respiratory tract infections (Merkler et al 2020; Warren-Gash et
al 2018; Oxley et al 2020).
While we already know that AIS can occur as a result of COVID-19, but risk
factors, in-hospital events, and outcomes are not well studied in large cohorts.
Qureshi et al (2021) identified risk factors, comorbidities, and outcomes in pa-
tients with COVID-19 with or without acute ischemic stroke and compared with
patients without COVID-19 and acute ischemic stroke. The authors analyzed the
data from 54 health care facilities using the Cerner deidentified COVID-19 dataset.
The dataset included patients with an emergency department or inpatient en-
counter with discharge diagnoses codes that could be associated to suspicion
of or exposure to COVID-19 or confirmed COVID-19.
Tan et al (2020) performed a systematic review to characterize the clinical
characteristics, neuroimaging findings, and outcomes of AIS in COVID-19 pa-
tients. A literature search was performed in PubMed and Embase using a suitable
keyword search strategy from 1st December 2019 to 29th May 2020. All studies
reporting AIS occurrence in COVID-19 patients were included. A total of 39 stud-
ies comprising 135 patients were studied. The pooled incidence of AIS in COVID-
19 patients from observational studies was 1.2% (54/4466) with a mean age of
63.4 ± 13.1 years. It was found that AIS was infrequent in patients with COVID-
19 and usually occurs in the presence of other cardiovascular risk factors such
as hypertension, diabetes, hyperlipidemia, atrial fibrillation. The risk of discharge
to destination other than home or death increased 2-fold with occurrence of acute
ischemic stroke in patients with COVID-19.
Nannoni et al (2021) characterize the incidence, risk factors, clinical-radio-
logical manifestations, and outcome of COVID-19-associated stroke. Three med-
ical databases were systematically reviewed for published articles on acute
cerebrovascular diseases in COVID-19 (December 2019-September 2020). The
review protocol was previously registered (PROSPERO ID = CRD42020185476).
Data were extracted from articles reporting ≥5 stroke cases in COVID-19. The
data were complied with the PRISMA guidelines and used the Newcastle-Ottawa
Scale to assess data quality. Data were pooled using a random-effect model.
The authors found that of 2277 initially identified articles, 61 (2.7%) were entered
in the meta-analysis. Out of 108,571 patients with COVID-19, acute CVD oc-
curred in 1.4% (95%CI: 1.0-1.9). The most common manifestation was AIS (87.4%),
and less common was intracerebral hemorrhage (11.6%). There were also other
causes of AIS: one of them was critical stenosis of the internal carotid artery
(ICA), a symptom that greatly increases the risk of recurrence of TIA or even full-
blown stroke (Katzan et al. 2021; Qureshi et al (2021; Hydzik et al 2023).
Treatment for patients with AIS is guided by the time from the onset of stroke,
the severity of neurologic deficit, and findings on neuroimaging. The most im-
portant rule to treat AIS, is to restore blood flow to the brain as soon as possible.
Type and description of treatment is presented in Table 1.

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Table 1. Type and description of treatment

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As a result of AIS, various major consequences appear that affect the patient’s
state of health and his subsequent functioning in society. All of them cause to
lower his health-related quality of life (HRQOL). The concept of Health Related
Quality of Life (HRQoL) is used as an important parameter for measuring out-
come in modern medicine and is highly important in the assessment of the mul-
tifaceted impact of disease on the patient’s life and evaluation of the utility and
disability associated with various health states (Ware & Sherbourne 1992; Cu-
nillera et al 2010). HRQoL is defined as the way health is empirically estimated
to affect QoL or use the term to only signify the utility associated with a health
state (Karimi et al 2018).
HRQoL measures encompass emotional, physical, social, and subjective feel-
ings of well-being and hence can be used in identifying and prioritizing areas of
need of individual patients and patients with special needs [Trystuła 2017].
HRQOL measures are also useful in the evaluation of the effectiveness and cost-
benefit of various old and emerging prophylactic, therapeutic, and rehabilitative
interventions [Pąchakska, Kaczmarek, Kropotov 2014]. These instruments facil-
itate patient caregiver communication and clinical decision-making and uncover
hidden problems.
A poorer HRQOL is reported much more often by the survivors of AIS in com-
parision with the general population. [Sturm et al 2004; Paul et al 2005; Kwok et
al 2006]. Although HRQOL is a multidimensional concept, it is usually measured
by physical or mental attributes associated with overall health status (Hobart et
al 2002; Carod-Artal & Egido 2009). For stroke survivors, the physical attributes of
HRQOL include the interference they perceive in performing physical activities such
as the ability to walk 1 block or by responses to pain levels associated with per-
forming activities (eg, work outside the home and housework), and mental at-
tributes are often measured by the perception of subjective feelings of interference
in participating in social activities (Hobart et al 2002; Carod-Artal & Egido 2009).
HRQOL associated with the health status of patients is one of the most ob-
jective characteristics of the effectiveness of broadly understood treatment in all
its areas, and thus also in vascular surgery regardless of the operating method
used [Kakkos et al 2017]. From the observations and examinations of clinicians it
is known that the given treatment/surgery method is effective when it leads to im-
provement of health, without complications that make the patient not coped with
everyday life, and after returning home and the social environment his real life be-
gins drama. Those factors have a direct impact on the patients’ quality of life.
Therefore the aim of the study was to evaluate quality of life of a patient after
endarterectomy (CEA) of Internal Carotid Artery (ICA) of Acute ischemic stroke
(AIS) during COVID-19 disease.

CASE STUDY
A right-handed, 51-year-old patient, visual artist, a single, with good health
and no chronic illnesses to date, became infected with SARS-CoV-2 and con-

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Fig.1. MRI of the brain in the FLAIR sequence; Transverse plane: A) and B) hyperintense foci in
the anterior part of the right thalamus and the anteromedial part of the left thalamus, of a vascular
nature
Source: own material

tracted COVID-19 in November 2021. Allegedly flu symptoms (a runny nose,

cough, a scratchy throat, a fever of up to 39.5 degrees Celsius, and fatigue) ap-
peared first. After a few days, shortness of breath joined in.
The presence of SARS-CoV-2 virus was confirmed by RT PCR antigen test.
The patient was hospitalized, and required mechanical ventilation on Intensive
Care Unit (ICU) before acute ischemic stroke (AIS) onset. Except for untreated
hypertension, her medical history was unremarkable. Her blood pressure was
180/100 mm Hg; her pulse was 76 beats per minute and was regular. AIS from
left middle cerebral artery (MCA) has resulted primarily effects in damage to the
left hemisphere, an secondary effects present on the right side weakness of the
body and mild anomic aphasia). The mean duration of AIS from COVID-19 symp-
toms onset was 11 days, and the mean NIHSS score was 19 (moderate to severe
stroke). Laboratory investigations revealed an elevated mean d-dimer (11.2 mg/L)
and fibrinogen (6.2 g/L). However antiphospholipid antibodies were not found.
The patient was consulted by an interdisciplinary team: a neurologist, neuropsy-
chiatrist and neuropsychologist to see how the AIS affected her nervous system.
Magnetic resonance imaging (MRI) confirmed stroke and detected brain tissue
damaged by an AIS It revealed hyperintense foci in the T2 and FLAIR se-
quences, 21 mm in size in the left hemisphere of the brain (Fig. 1).
In search of the cause of AIS, CT angiography was performed. It revealed
large (90%) of ICA occlusion. The patient was admitted to the emergency room at
the Vascular Surgery Clinic with the Endovascular Subunit. The revascularization
procedure (CEA) was recommended to reduce the risk of additional strokes be-
cause the carotid artery was severely narrowed.

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EVERSION ENDARTERECTOMY PROCEDURE

(BY EXCISION)
The procedure of eversion endarterectomy (by excision) was performed under
general endotracheal anesthesia with the use of the protocol and techniques
(elaborated at the Department of Vascular Surgery and Endovascular Proce-
dures, The John Paul II Hospital in Krakow [Trystuła 2017]. A transverse skin in-
cision was made on the anterolateral surface of the neck about 6-7 cm long, at
the level of the thyroid cartilage. The right common carotid artery (RCCA), ex-
ternal carotid artery (RECA) and internal carotid artery (RICA were reached and
dissected. After inserting a shunt for the collateral circulation (as cerebral ante-
grade protection), the RICA was cut off from the RCCA at the level of the RCCA
division. The wall of the RICA was turned up (like a sleeve), which caused it to
detach from the atherosclerotic plaque. This made possible to remove the de-
tached atherosclerotic plaque. The continuity of the vessel was reconstructed
by suturing the RICA back to the RCCA at the site of severance, with a non-ab-
sorbable suture, removing the shunt before the vessel wall was fully sutured.
Once homeostasis was achieved, a drain was placed and the surgical wound
was closed in layers with sutures. A wound dressing was applied. The procedure
was performed by experienced vascular surgeons (with about 5. 000 procedures
previously performed) [see: Trystula 2017].

Ethics statement
According to the guidelines of the Helsinki Declaration (2008), the patient par-
ticipating in the experiment was informed in detail about the test procedure and
they provided written consent for their participation in the project. The study pro-
tocols received ethical approval from the Ethical Committee of the Regional Med-
ical Chamber (KB6/16).

NEUROPSYCHOLOGICAL TESTING
The neuropsychological testing was designed to detect cognitive disorders in
the patient, and to serve as a quantifiable outcome to assess the impact of endar-
terectomy.

Confrontational word retrieval (naming)

We used the Polish version of the Boston Naming Test (BNT) (Pąchalska 1994)
to study confrontational word retrieval. This is an adaptation of the test introduced
in 1983 by Edith Kaplan, Harold Goodglass and Sandra Weintraub (1983), a widely
used neuropsychological assessment tool for measuring confrontational word re-
trieval in people with aphasia or other language disorders caused by a variety of
brain dysfunctions (Nicholas et al 1988; del Toro et al 2010). The BNT contains 60
drawings graded in difficulty (Goodglass et al 2001), because patients with anomia
often have greater difficulties with naming not only difficult and low frequency ob-
jects, but also easy and high frequency objects (Nicholas et al 1988).

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Fig. 2. Results obtained in Polish version of the Boston Naming Test (BNT) by the patient in the
study I (before CEA), study II (two weeks after CEA), study III (3 months after CEA) and study IV
(6 months after CEA)

It was found that in study I (before CEA), the patient named 29 of 60 drawings,
which means moderate anomic aphasia. In study II (two weeks after CEA), the
patient named 51 of 60 drawings, which is indicting mild anomic aphasia. In study
III (3 months after CEA) the patient named 57 of 60 drawings, which is the norm
for her age, indicating no anomic aphasia (Fig. 2). In study IV (6 months after CEA)
the patient named 59 of 60 drawings, which is almost 100% of norm in naming.

HEALTH-RELATED QUALITY OF LIFE

ASSESSMENT (HRQOL)
The HRQOL was tested with the use of the Medical Outcomes Study Short-
Form 36 (SF-36) validated to assess HRQOL in post-TIA and post-stroke pa-
tients, as well as in patients with critical carotid artery stenosis undergoing
revascularization (Trystuła 2017; Pąchalska & Trystuła 2020). It was aimed to
evaluate the differences between the patient’s results before and after CEA pro-
cedures. It includes a 36-item, patient-reported survey of patient health, and their
measure of health status. The SF-36 consists of eight scaled scores, which are
the weighted sums of the questions in their section. Each scale is directly trans-
formed into a 0-100 scale on the assumption that each question carries equal
weight. The eight sections are:
• vitality
• physical functioning
• bodily pain
• general health perceptions
• physical role functioning

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Fig. 3. Assessment of the patient's health-related quality of life (HRQoL) across eight spheres of
the SF-36. The four bars show sequentially the mean score obtained in study I (before CEA), study
II (two weeks after CEA), study III (3 months after CEA) and study IV (6 months after CEA)

• emotional role functioning

• social role functioning
• mental health.
In the current study, SF-36 scores are presented in a way in which higher
scores correspond to fewer complaints, indicating better health and higher quality
of life (Trystuła, Tomaszewski, Pąchalska 2019).
The patient’s perception of HRQoL measured by the SF-36 domains is illus-
trated in Fig. 3. In study I (before CEA), the patient was found to have a reduced
health-related quality of life across all eight spheres of the SF-36. Study II, con-
ducted two weeks after CEA showed significant improvement in HRQoL compared
to study I. This improvement was associated with a significant reduction in com-
plaints about both mental and physical health. In study III, 3 months after CEA,
there was a further increase in the HR-QoL score. In study IV, six months after
CEA, there was a further significant improvement in HRQoL, which was statisti-
cally significant compared to baseline in study I and study II, 2 weeks after CEA.

Return to painting
One of the most important achievements achieved after the CEA operation is
the return to painting. The artist, who lost the ability to paint as a result of a stroke
and could not paint even the simplest geometric forms, not to mention the human
figure, began to intensively copy the works of other authors. We will present here
the last work painted after 5 months of training after CEA (Fig. 4).
The patient emphasized many times that she was very happy that she sur-
vived such serious illnesses and surgery. What’s more, she was proud to be able
to paint again, and even have recognition among connoisseurs and sell her
newly painted paintings.

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Fig. 4. The last work painted after 5 months of training after CEA

DISCUSSION
Tan et al. 2020 performed a systematic review to characterize the clinical char-
acteristics, neuroimaging findings, and outcomes of AIS in COVID-19 patients.
A literature search was performed in PubMed and Embase using a suitable key-
word search strategy from 1st December 2019 to 29th May 2020. All studies re-
porting AIS occurrence in COVID-19 patients were included. A total of 39 studies
comprising 135 patients were studied. The pooled incidence of AIS in COVID-
19 patients from observational studies was 1.2% (54/4466) with a mean age of
63.4±13.1 years. The mean duration of AIS from COVID-19 symptoms onset
was 10 ± 8 days, and the mean NIHSS score was 19±8. Laboratory investigations
revealed an elevated mean d-dimer (9.2±14.8 mg/L) and fibrinogen (5.8±2.0 g/L).
Antiphospholipid antibodies were detected in a significant number of cases.
Our patient was younger (51 years old) but other characteristics were similar
to those presented in the article Tan et al (2020). The mean duration of AIS from
COVID-19 symptoms onset was 11 days, and the mean NIHSS score was 19.
Also laboratory investigations revealed an elevated mean d-dimer (11.2 mg/L)
and fibrinogen (6.2 g/L). However antiphospholipid antibodies were not found. It
was found that the mean duration of AIS from COVID-19 symptoms onset was
10 ± 8 days, and the mean NIHSS score was 19±8. Laboratory investigations re-
vealed an elevated mean d-dimer (9.2±14.8 mg/L) and fibrinogen (5.8±2.0 g/L).
Requena et al. (2020) wrote that an increased rate of thrombotic events has
been associated to Coronavirus Disease 19 (COVID-19) with a variable rate of
AIS. Therefore he directed the study for finding the rate of acute stroke in COVID-
19 patients and identify those cases in which a possible causative relationship
could exist. A single-center analysis of a prospective mandatory database. All
studied patients had confirmed COVID-19 and stroke diagnoses from March
2nd to April 30th. Demographic, clinical, and imaging data were prospectively col-

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lected. Final diagnosis was determined after full diagnostic work-up unless im-
possible due to death. Of 2050 patients with confirmed SARS-CoV-2 infection,
21 (1.02%) presented an AIS and 4 (0.2%) suffered an intracranial hemorrhage.
After the diagnostic work-up, in 60.0% ischemic and all hemorrhagic strokes pa-
tients an etiology non-related with COVID-19 was identified. Only in 6 patients
the stroke cause was considered possibly related to COVID-19, all of them re-
quired mechanical ventilation before AIS onset. The authors also found that the
presence of acute stroke in patients with COVID-19 was below 2% and most of
them previously presented established stroke risk factors. Without other potential
cause, stroke was an uncommon complication and exclusive of patients with a
severe pulmonary injury.
We want to emphasize that in our patient in whom the stroke cause was con-
sidered as related possibly to COVID-19, additionally etiology non-related with
COVID-19 was identified (ICA stenosis), and that she, like the AIS patients pre-
sented by Requena et al. (op. cit), also required mechanical ventilation on In-
tensive Care Unit (ICU) before acute ischemic stroke (AIS) onset. However our
patient did not presented any established stroke risk factors except for ICA steno-
sis without family history of this condition.
Shahjouei et al. (2021) published the largest study that comprehensively pre-
sents the characteristics and stroke subtypes of stroke in SARS-CoV-2–infected
patients at a multinational level. These authors stated that stroke is reported as
a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)
infection in several reports. However, data are sparse regarding the details of
these patients in a multinational and large scale. The authors conducted a multi-
national observational study on features of consecutive AIS, intracranial hemor-
rhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected
patients. They also further investigated the risk of large vessel occlusion, stroke
severity as measured by the National Institutes of Health Stroke Scale, and
stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke
Treatment) criteria among patients with acute ischemic stroke. In addition, we
explored the neuroimaging findings, features of patients who were asymptomatic
for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions
and countries’ health expenditure on outcomes. It was fund that among the 136
tertiary centers of 32 countries who participated in this study, 71 centers from 17
countries had at least one eligible stroke patient. Of 432 patients included, 323
(74.8%) had AIS, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral ve-
nous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%)
patients were <55 years of age, and 105 (24.4%) patients had no identifiable vas-
cular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 pa-
tients) had large vessel occlusion; 10% had small artery occlusion according to
the TOAST criteria.
It was also observed a lower median National Institutes of Health Stroke Scale
(8 [3–17] versus 11 [5–17]; P=0.02) and higher rate of mechanical thrombectomy
(12.4% versus 2%; P<0.001) in countries with middle-to-high health expenditure

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when compared with countries with lower health expenditure. Among 380 pa-
tients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%)
were asymptomatic at the time of admission for SARS-CoV-2 infection.
Our patient had also interval onset of the SARS-CoV-2 and stroke and she
was asymptomatic at the time of admission for SARS-CoV-2 infection.
It was concluded that a considerably higher rate of large vessel occlusions,
a much lower rate of small vessel occlusion and lacunar infarction, and a consid-
erable number of young stroke when compared with the population studies before
the pandemic. The rate of mechanical thrombectomy was significantly lower in
countries with lower health expenditures.
The majority of AIS neuroimaging patterns observed was large vessel throm-
bosis, embolism or stenosis of ICA (62.1%, 64/103), followed by multiple vascular
territory (26.2%, 27/103). A high mortality rate was reported (38.0%, 49/129). We
report the pooled incidence of AIS in COVID-19 patients to be 1.2%, with a high
mortality rate. Elevated d-dimer, fibrinogen and the presence of antiphospholipid
antibodies appear to be prominent in COVID-19 patients with concomitant AIS, but
further mechanistic studies are required to elucidate their role in pathogenesis.
Nannoni et al (2021) found that patients with COVID-19 developing acute
cerebrovascular diseases, compared to those who did not, were older (pooled
median difference = 4.8 years; 95%CI: 1.7-22.4), more likely to have hypertension
(OR=7.35; 95%CI: 1.94-27.87), diabetes mellitus (OR=5.56; 95%CI: 3.34-9.24),
coronary artery disease (OR=3.12; 95%CI: 1.61-6.02), and severe infection (OR=
5.10; 95%CI: 2.72-9.54). Compared to individuals who experienced a stroke without
the infection, patients with COVID-19 and stroke were younger (pooled median dif-
ference = -6.0 years; 95%CI: -12.3 to -1.4), had higher NIHSS (pooled median diffe-
rence = 5; 95%CI: 3-9), higher frequency of large vessel occlusion (OR=2.73; 95%CI:
1.63-4.57), and higher in-hospital mortality rate (OR=5.21; 95%CI: 3.43-7.90).
Shahjouei et al. (2021) pointed out that thei study results showed a consider-
able number of young strokes. The authors found out that 36% of the AIS pa-
tients in the study were <55 years of age and 46% were <65 years of age. These
proportions are considerably higher than the population-based reports before
the pandemic (12.9%–20.7%) (Cabral et a; 2017; Kissela et al 2012). The me-
dian age of AIS patients in our study was 68 (58–78) years. We would like to
point out that our patients with COVID-19 and AIS was also young (51 years
old). Although the definition of young stroke is debatable, the majority of the stud-
ies considered 50 or 55 years as the cutoff (Cabral et al 2017). A case series
from New York on 32 AIS patients with SARS-CoV-2 showed a median of 63
years for these patients. This finding was significantly lower than AIS patients
without SARS-CoV-2 in the same study and same interval (median, 70 years) or
the historical cohort of AIS patients presented to the same center in 2019 (me-
dian, 68.5 years) (Yagi et al 2020). A multinational study on 174 AIS patients with
SARS-CoV-2 infection reported a median age of 71 years (Ornello et al 2018).
Our patients with COVID-19 and AIS had also higher NIHSS (19 moderate to
severe stroke), and she had large vessel occlusion (90% of ICA occlusion).

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The internal carotid endarterectomy (CEA), i.e. surgical removal of atheroscle-

rotic plaque and thrombi, from a longitudinal incision of the carotid arteries, with
subsequent reconstruction of the wall continuity, and when the diameter of the
vessels is too small, also with sewing a patch from the vascular prosthesis. This
method offering cutting off the internal carotid artery from the common carotid
artery and removing the atherosclerotic plaque by eversion of the internal carotid
artery wall (eversive method). After cleaning the wall of atherosclerotic lesions,
the internal carotid artery is sawing back into the common carotid artery (see
also: Trystuła 2017).
As it was stated by Trystuła (2017), the patients, such as ours, should be of-
fered radical treatment of the cause of AIS, i.e. CEA revascularisation. Qualification
for urgent surgery in the case of symptomatic stenosis of ICA is determined by the
degree of stenosis and its symptomatic character; on the scale of severity, this
includes the TIA, temporary loss of vision in one eye (amarosis fugax), and AIS.
It is especially important to propose an urgent CEA in the case when the athe-
rosclerotic plaque has an irregular shape, is long and extensive, as it was in our
patient, or features of plaque ulceration are found within it. It is worth to empha-
size that in the case of major stroke there is obligatory to use neuroprotection
(distal or proximal depending upon the anatomic and hemodynamic conditions
of intracerebral and intracranial arteries) during CAS and shunt protection during
CEA [Kakos et al 2017; Trystuła 2018].
HRQOL, which of course strongly links to successful CEA [Cohen et al 2011;
Shan et al. 2015; Trystuła et al 2018], is also associated with resolution of symp-
toms, including hemiparesis, muscle weakness and aphasia. Anomic aphasia,
which was found in the patient we studied, is one type of fluent aphasia, along
with Wernicke’s aphasia, transcortical sensory aphasia and conductive aphasia [Ka-
plan et al 1983; del Toro et al 2010]. We can agree with Trystuła et al (2019) found-
ings that Carotid revascularization has a major positive impact on stroke survivor
patient-reported HRQoL, because we found similar results in our patient. However
it should be also stressed that HRQOL could be associated with long-term COVID-
19 sequelae, i.e. longCOVID and post-COVID syndrome. Fortunately, our patient
did not develop such symptoms until 6 months after contracting COVID-19.
How can we explain such a big change in our patient’s perception of herself
after the CEA procedure?
The basic mechanism lies in better blood supply to the brain after removal of
atherosclerotic plaque and unblocking of ICA. This ensures better functioning of
the brain and better exchange of information between one and the other hemi-
sphere of the brain, The development of the logical and spatial coherence of the
self system is conditioned by the proper functioning of the entire brain. This is
ensured not only by properly functioning structures, but also by connections
within each hemi - sphere, between both hemispheres and their connections
with subcortical structures (Pąchalska, Kaczmarek and Kropotov 2014). Differ-
ences in the functioning of the right and left hemispheres of the brain within the
self system are illustrated in Fig. 5.

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 Cielebąk et al., Endarterectomy of Internal Carotid Artery (ICA)

It can be seen that the dominant hemisphere of the brain (usually the left in
right-handed persons) is closely related to language functions. Therefore, it pro
– vides logical coherence possible thanks to linguistic images, which includes
language models, grammar and vocabulary, as well as internal narration and dia
logue. An important role is also played by the ability of linguistic expression,
which is enabled by efficiently functioning articulatory organs and limbs (writing
and signalling language statements). Based on this, language texts are created,
among which a special role is played by narrative and external dialogue that en-
ables contact with other people. Patterns of neural network connections that
evoke thoughts (and thus behaviours) that promote the well-being of the body
are permanently encoded, while useless ones disappear (Carter 1999; Pąchal-
ska, Kaczmarek, Kropotov 2014). The subdominant hemisphere of the brain is
closely related to nonlinguistic functions (generally the right in right-handed per-
sons). Thus, it provides spatial coherence based on nonlinguistic images: image
models and „body grammar,” i.e., images evoked by facial expressions, gestures
and a sequence of movements (pantomime).
This enables, through the use of the facial expressions, phonic organs (vo-
calization), limbs (gestures) and the whole body (pantomime, „body language”)
nonlinguistic expression. This creates nonlinguistic messages: acoustic (voice,
sound) and visual (drawing, gesture). People with brain damage exhibit distur-
bances in logical or spatial coherence depending on the location of the damage
(structures and neural connections) in the right or left hemisphere of the brain.
Linguistic representations are more or less disintegrated, which makes creating
language constructions more difficult, as a result of which the process of creating

Fig. 5. Differences in the functioning of the right and left hemispheres of the brain within the Self
system
Source: Pąchalska, 2019: 362, with permission from AW Medsportress

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 Cielebąk et al., Endarterectomy of Internal Carotid Artery (ICA)

ideas about yourself and the world is disturbed, which is why the image of oneself
and, as a result, the whole system of the self is disintegrated. Damage to the
subcortical structures and connections is also not without significance, however,
the picture of disorders is different, something which is described in more detail
as detailed in another work (Pąchalska, Kaczmarek, Kropotov 2014),
Such brain work allows the return of the naming function, which of course oc-
curred in our patient. Regaining the ability to name, in turn, improved the imag-
ination and contributed to better drawing and painting. As a consequence, the
patient regained self-confidence, joy of life, and thus improved her self-esteem,
which translated into an improved quality of life.

To sum up
Obtained results are important from a practical point of view (application di-
mension) because they can have a direct impact on the course of surgery, and
thus on the final outcome of treatment and the quality of life of the stroke sur-
vivors. They can also play a big role in the approach to treating the patient by of-
fering him a larger package of assistance activities, allowing to increase his
quality of life.
The revascularization procedures as well as pre- and postoperative standards
of care for patients after AIS elaborated and utilized at the Department of Vascular
Surgery with Endovascular Procedures in the John Paul II Hospital, Krakow, may
be of use in conducting further research to discover the optimal effectiveness of
CEA. It also creates a possibility of introducing these procedure in other clinical
centers.

Study limitations
We are aware of the potential limitations of this study. The most important of
these stem from the fact that this is case study treated in a single center. We are
planning to extend our research on this subject in the future.

CONCLUSIONS
Patients’ perception of HRQoL measured by the SF-36 domains was better
after the CEA: significant improvement in self-reported overall health appears.
HRQoL outcome measures may be of value in future clinical trials of comapring
different methods of treatment offered after AIS.

Acknowledgements
Recognition is due to the whole team of neuropsychologists from the Reinte-
gration and Didactic Center of the Polish Neuropsychological Association. In par-
ticular, we would like to thank Prof. Maria Pąchalska for her immense help in
interpreting the results, and Prof. Mariusz Trystuła for his invaluable comments
while writing this article.

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Corresponding author:
Ksenia Cielebąk
Chair of Neuropsychology and Neurorehabilitation
Andrzej Frycz Modrzewski Kraków University,
Herlinga-Grudzińskiego 1 30-750 Kraków, Poland
e-mail: [email protected]

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