COVID-19 Associated Coagulopathy Resulting in Cerebral Venous Thrombosis and Pulmonary Embolism

Abstract

Venous stroke is an infrequent complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease. Coronavirus disease 2019 (COVID-19) acts as a causative factor for thromboembolic events such as pulmonary embolism (PE), deep vein thrombosis (DVT), stroke (ischemic or hemorrhagic), and myocardial infarction. We report a case of cerebral venous thrombosis (CVT) following severe COVID-19 infection, with co-incidence of pulmonary thromboembolism. A 39-year-old English lady presented with fever and cough; subsequently, she was diagnosed with COVID-19 and was managed in the high dependency unit (HDU) due to the severity of symptoms; she received dexamethasone and tocilizumab. Her condition improved and she was discharged, but presented again after 15 days due to headache and left-sided weakness. Her neurological examination confirmed nystagmus, past pointing, and dysdiadochokinesia positive on the left side. Initial blood investigations showed D-dimer being raised at 1875 ng/ml. Head CT venogram reported evidence of thrombus in the superior sagittal sinus, left transverse sinus, and inferior sagittal sinus consistent with venous sinus thrombosis. She also underwent CT pulmonary angiogram (CTPA) which revealed lingular acute segmental PE and patchy ground-glass shadowing throughout both lung fields, confirming recent infective COVID-19 changes. She was started on a therapeutic dose of dalteparin (low-molecular-weight heparin). Luckily she made a good recovery from her neurological symptoms. Like this case and many other reported cases, COVID-19 acts as an independent risk factor for increased coagulopathy. Clinicians should maintain a high index of suspicion for CVT to aid in timely diagnosis and prompt treatment to save lives.

Neurological Manifestations of SARS-CoV-2 Infection: Protocol for a Sub-analysis of the COVID-19 Critical Care Consortium Observational Study

“…Putative mechanisms include viral neurotropism, a hyperinflammatory and hypercoagulable state, or pathological brain-lung crosstalk (6). Endothelial dysregulation (7)(8)(9) and pro-thrombotic state (10)(11)(12) have been widely suspected to be the possible main contributors of the increased risk of Abbreviations: APELSO, Asia-Pacific extracorporeal life support organization; BMI, body mass index; CNS, central nervous system; COVID-19, Coronavirus disease 2019; CT, computed tomography; ECMO, extracorporeal membrane oxygenation; ECMOCARD, ExtraCorporeal Membrane Oxygenation for 2019 novel Coronavirus Acute Respiratory Disease; eCRF, electronic case report form; ICU, intensive care unit; IRB, institutional review board; ISARIC, International Severe Acute Respiratory and emerging Infection Consortium; MRI, magnetic resonance images; mRS, modified Rankin scale; NSE, neuron specific enolase; PNS, peripheral nervous system. neurologic events.…”

Causal associations of COVID‐19 on neurosurgical diseases risk: a Mendelian randomization study

“…Although COVID-19 mainly affects the lungs, many studies have reported various direct or indirect associations between COVID-19 and the occurrence of cerebral infarction. COVID-19 can lead to coagulation dysfunction and inflammation in various patients, promote the disorder of blood clotting function, and thus cause venous thromboembolism and lead to brain infarction [ 31 , 32 ]. Some studies have found that cerebral artery occlusion and infarction occurred in infants with critically ill COVID-19 due to D-dimer elevation and coagulation dysfunction [ 33 ].…”

Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers

“…A retrospective multicenter cohort study that involved 13,500 patients with COVID‐19 reported an incidence of venous stroke of 8.8 per 10,000 over 3 months 199 . Symptoms of COVID‐19 infection are often observed in patients with concomitant SARS‐CoV‐2 infection and venous stroke 200 . In a New York metropolitan cohort study, 13,500 patients with COVID‐19 were enrolled, and 12 patients had venous stroke, with headache being the most common neurological symptom in 85% of patients, focal symptoms such as seizures and hemiparesis were present in 42% of patients, and cortical signs such as aphasia, neglect, or hemianopia were present in 25% of patients 199 .…”