Cerebral Venous Thrombosis Associated with COVID-19

Abstract

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.

Fig 1.

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).

Fig 2.

Images acquired during the intervention in case 1. A, A 12F Flexor Shuttle Guiding Sheath (Cook) was brought to the internal jugular vein. An 8F Indigo Aspiration Catheter (Penumbra) is seen in the right transverse-sigmoid junction after thrombectomy of the right sigmoid sinus. B, Multiple control angiograms and venograms were obtained during the venous thrombectomy; it is possible to see a significant amount of thrombus partially occluding the torcula and the distal two-thirds of the right transverse sinus. Partial recanalization of the posterior third of the superior sagittal sinus is also seen. C, Venography, cranial view, anterior-posterior projection, shows complete recanalization of the torcula, and most of the posterior third of the superior sagittal sinus. D, Venography, cranial view, right anterior oblique projection reveals full recanalization of the superior sagittal sinus. A microcatheter was left in its anterior third to maintain continuous tPA infusion.

Fig 3.

Subacute onset of isolated deep cerebral venous thrombosis in a patient with COVID-19. A, Noncontrast head CT, axial view, reveals an infarct of the left basal ganglia and thalamus, with hemorrhagic transformation and intraventricular hemorrhage with obstructive hydrocephalus. B, Noncontrast head CT, sagittal reconstruction, reveals hyperdensity in the topography of the vein of Galen (short arrow) and left internal cerebral vein (long arrow), corresponding to deep venous thrombosis. C, CT of the chest, axial view, demonstrates patchy multifocal airspace opacities combining ground-glass and consolidation in different lobes, suggestive of pneumonia/pneumonitis. D, CT venogram, MPR sagittal reconstruction, shows a filling defect in the vein of Galen (short arrow), internal cerebral veins (long arrow), and the anterior aspect of the inferior sagittal sinus, confirming deep venous thrombosis.

Fig 4.

A 28-year-old man presenting with a decreased level of consciousness. Imaging included CT of the head (A), and MR imaging with DWI (B), ADC maps (C), T2WI (D), T1WI without contrast (E) and 2D T2* gradient recalled-echo (F). Confluent areas of low density are present in the bilateral cerebral hemispheres in A, corresponding to nonenhancing, pathologically reduced diffusion on B and C. T2- and T2*-weighted images reveal generalized low intensity of the white matter in excess of that explained by subtle foci of petechial hemorrhage in F and consistent with slow or impaired outflow of the deep medullary venous system.