Cerebral Venous Thrombosis Associated with COVID-19 Infection: An Observational, Multicenter Study

Abstract

<b><i>Background and Purpose:</i></b> Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. <b><i>Methods:</i></b> This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. <b><i>Results:</i></b> Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge. <b><i>Conclusion:</i></b> COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

Diagnostic and Therapeutic Challenges of Cerebral Venous Thrombosis in SARS-CoV-2 Infection: A Case Report and Review of Literature

“…The main exclusion criteria used were (1) lack of cerebral venous thrombosis, (2) cerebral venous thrombosis without COVID-19, and (3) lack of DOAC use. Seven publications, as of 16 July 2021, were found depicting the use of DOACs in patients with CVT and COVID-19 ( Table 1 ) [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ].…”

“…Here, we present a case of a young female who presented with an isolated headache and was found to have left transverse sinus thrombosis, secondary to SARS-CoV-2 infection. We also performed a literature search, focusing on cases that used DOACs for the management of CVT, in the context of SARS-CoV-2 infection (Table 1) [1,[8][9][10][11][12][13][14]. Abbreviations: a-computed tomography (CT); b-computed tomography venography (CTV); c-coronavirus disease 2019 (COVID-19); d-milligrams (mg); e-twice daily (BID); f-magnetic resonance imaging (MRI); g-fluid-attenuated inversion recovery (FLAIR); h-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); i-reverse transcriptase-polymerase chain reaction (RT-PCR); j-once daily (QD); k-polymerase chain reaction (PCR); l-millimeters (mm); m-intravenous (IV); n-magnetic resonance venography (MRV); o-modified Rankin Scale (mRS).…”

“…Here, we present a case of a young female who presented with an isolated headache and was found to have left transverse sinus thrombosis, secondary to SARS-CoV-2 infection. We also performed a literature search, focusing on cases that used DOACs for the management of CVT, in the context of SARS-CoV-2 infection ( Table 1 ) [ 1 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ].…”

Lessons learned in stroke care during COVID-19 pandemic and preparing for future pandemics in the MENA+ region: A consensus statement from the MENA+-SINO

“…Additionally a series of 21 patients with stroke related to COVID-19 from UAE had shown 90% of stroke victims are from south Asian origin with multiple risk factors [ 27 ]. Up to date the largest study of cerebral venous thrombosis patients in relation to COVID-19 infection published was conducted in the MENA+ region [ 28 ]. Furthermore an important paper suggesting a link between low stroke incidence and decreased air pollution during pandemic lock down was published from Pakistan [ 29 ].…”

“…There is a convincing data that COVID-19 may result in an increase in cerebrovascular disease in the community [ 30 , 31 ]. In stroke patients with severe infection, hypercoagulation and cardioembolic stroke are frequently evident [ 28 ]. COVID-19 virus may also play a direct role through injury to the human angiotensin converting enzyme, ACE2, expressed in epithelial cells throughout the body, including the central nervous system [ 30 ].…”