Intracranial complications of hypercoagulability and superinfection in the setting of COVID-19: illustrative cases

Abstract

BACKGROUND Hypercoagulability with thrombosis and associated inflammation has been well-documented in COVID-19, and catastrophic cerebral venous sinus thromboses (CVSTs) have been described. Another COVID-19–related complication is bacterial superinfection, including sinusitis. Here, the authors reported three cases of COVID-19–associated sinusitis, meningitis, and CVST and summarized the literature about septic intracranial thrombotic events as a cause of headache and fever in COVID-19. OBSERVATIONS The authors described three adolescent patients with no pertinent past medical history and no prior COVID-19 vaccinations who presented with subacute headaches, photosensitivity, nausea, and vomiting after testing positive for COVID-19. Imaging showed subdural collections, CVST, cerebral edema, and severe sinus disease. Two patients had decline in mental status and progression of neurological symptoms. In all three, emergency cranial and sinonasal washouts uncovered pus that grew polymicrobial cultures. After receiving broad-spectrum antimicrobials and various additional treatments, including two of three patients receiving anticoagulation, all patients eventually became neurologically intact with varying ongoing sequelae. LESSONS These cases demonstrated similar original presentations among previously healthy adolescents with COVID-19 infections, concurrent sinusitis precipitating CVST, and subdural empyemas. Better recognition and understanding of the multisystem results of severe acute respiratory syndrome coronavirus 2 and the complicated sequelae allows for proper treatment.

Spontaneous subdural effusion in a hospitalized Covid-19 patient: Case report

“…In total, 5 cases were found in our literature review, and all of them had one thing in common: the presence of bacterial rhinosinusitis concomitant with Covid-19, confirmed by imaging and/or culture tests 8 , 9 , 10 . In all 5 cases, subdural empyema turned out to be a complication of bacterial superinfection, confirmed by subdural fluid culture, which showed bacterial growth and negative PCR for Covid-19.…”

Sinusitis complicated by intracranial abscess in 3 patients with coronavirus disease 2019: illustrative cases

“…To our knowledge, there are only 7 other reported cases of sinusitis and associated intracranial abscess in the setting of COVID-19 (Table 1). [5][6][7][8] Of the known cases, only 1 occurred in a patient with a history of chronic sinusitis. Although intracranial abscesses are known to occur because of contiguous spread in the setting of chronic sinusitis, the absence of chronic sinusitis in the remaining cases suggests that SARS-CoV-2 could have contributed to the pathogenesis.…”

“…8 Neurological outcomes were largely favorable following treatment, except for one case complicated by concomitant cerebral venous sinus thrombosis (CVST). 5 It has been argued that forgoing neurosurgical operative intervention in favor of antibiotic treatment or antibiotic treatment and sinus debridement may be adequate to treat small intracranial abscesses without signs of neurological impairment or midline shift in high-risk patients. 9,15,16 However, newer studies suggest that forgoing neurosurgical operative intervention is associated with a significant increase in mortality rate and inferior neurological outcomes.…”

COVID-19 Co-Infection May Promote Development of Sinusitis Complication in Children

“…More “typical” intracranial complications in the course of SARS-CoV-2 infection, such as septic venous thrombosis, subdural empyemas, and herniation, were also described in children. The authors see hypercoagulability, immune/endothelial dysfunction, and superinfection as the cause of those complications [ 58 ].…”