Long-Delayed Manifestation of COVID-19 Coagulopathy Presenting with Severe Cerebral Venous Thrombosis Causes Massive Brain Hemorrhage

Abstract

COVID-19 infection causes coagulopathy, which may lead to cerebral venous thrombotic (CVT) event. It usually occurs in patients with higher severity level of infection and manifests mostly within a month after the infection. However, in rare cases, the CVT may happen long after the infection and unrelated to the degree of the infection severity. We present the case of a previously healthy 62-year-old male patient with very mild COVID-19 symptoms that resolved in 3 weeks of home isolation treatment. Immediately after the infection, he developed hypercoagulability and was treated routinely with a novel oral anti-coagulant drug. Four months after the infection, he developed a worsening headache which, in several days, deteriorated to cause reduction in his consciousness level. Imaging showed a right temporoparietooccipital massive brain hemorrhage with right transverse and sigmoid sinus thrombosis. Emergency decompressive craniectomy was performed and the patient recovery was excellent. In patients with a hypercoagulable state after COVID-19 infection, the possibility of CVT event should be observed. It may not be related to the severity of the infection, and it may happen long after the infection.

COVID and Vaccine-related Cerebral Venous Thrombosis

“…16 The median time duration from COVID infection to CVT diagnosis reported is seven days (range 1–120 days). 9, 35–39 The largest multicentric observational study published consisting of 20 patients also reported a male predominance (70%) and a mean age of 42.4 years at the time of presentation. 9 Traditionally, non-COVID-CVT is more common in young females (59%–75%), mostly in their second and third decades of life.…”

“…CVT in COVID sufferers usually manifests within one month of infection but the case has also been reported as a late sequala. 36, 39 Table 1 includes a summary of the published studies of CVT in COVID patients.…”

“…Among the published case reports, the majority of COVID-CVT cases are middle-aged to elderly males. Traditional CVT-related risk factors were absent 17,[28][29][30][31][32][33][34][35][36] except for two cases having OCPs 16,37 with one also being obese. 16 The median time duration from COVID infection to CVT diagnosis reported is seven days (range 1-120 days).…”

“…CVT in COVID sufferers usually manifests within one month of infection but the case has also been reported as a late sequala. 36,39 Headache is the most common neurological feature in COVID-CVT patients, followed by seizures, altered mentation, and hemiparesis. This is similar to the non-COVID-CVT patients.…”