Cerebral Venous Thrombosis Associated with COVID-19

Fellows’ Journal Club

The authors report a unique series of young patients with COVID-19 presenting with cerebral venous system thrombosis. Three patients younger than 41 years of age with confirmed Severe Acute Respiratory Syndrome coronavirus 2 infection had neurologic findings related to cerebral venous thrombosis.

Abstract

Figure 1 from Cavalcanti et al
Acute onset of cerebral venous thrombosis in multiple locations in a man with COVID-19 without any significant comorbidities except for mild autism spectrum disorder and Tourette syndrome. A, Axial view of a CT of the chest shows patchy multifocal peripheral and peribronchovascular airspace opacities with a combination of ground-glass and consolidation in different lobes. B, Axial view, CT of the head without contrast, shows effacement of the cerebral sulci suggestive of significant cerebral edema; hyperdensity is seen in the region of the superior sagittal sinus posteriorly (arrow), characteristic of dural venous thrombosis. C, CVT with sagittal reconstruction demonstrates extensive occlusive filling thrombus within the superior sagittal (white arrow), right transverse, and sigmoid sinuses; thrombosis extends from the torcula into the straight sinus (black arrow). There is occlusion of several cortical veins adjacent to the superior sagittal sinus as well. D, Digital subtraction angiography, lateral view, reveals significant venous congestion involving the entire right cerebral hemisphere with no visualization of the superior sagittal (white arrow), transverse, and sigmoid sinuses, with clot extension in the straight sinus (black arrow).

Despite the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. We report a unique series of young patients with COVID-19 presenting with cerebral venous system thrombosis. Three patients younger than 41 years of age with confirmed Severe Acute Respiratory Syndrome coronavirus 2 (SARS-Cov-2) infection had neurologic findings related to cerebral venous thrombosis. They were admitted during the short period of 10 days between March and April 2020 and were managed in an academic institution in a large city. One patient had thrombosis in both the superficial and deep systems; another had involvement of the straight sinus, vein of Galen, and internal cerebral veins; and a third patient had thrombosis of the deep medullary veins. Two patients presented with hemorrhagic venous infarcts. The median time from COVID-19 symptoms to a thrombotic event was 7 days (range, 2–7 days). One patient was diagnosed with new-onset diabetic ketoacidosis, and another one used oral contraceptive pills. Two patients were managed with both hydroxychloroquine and azithromycin; one was treated with lopinavir-ritonavir. All patients had a fatal outcome. Severe and potentially fatal deep cerebral thrombosis may complicate the initial clinical presentation of COVID-19. We urge awareness of this atypical manifestation.

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Cerebral Venous Thrombosis Associated with COVID-19
Jeffrey Ross
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