Cerebral venous thrombosis: A typical presentation of COVID-19 in the young

Abstract

Objective: Identify clinical and radiographic features of venous infarct as a presenting feature of COVID-19 in the young.

Background: SARS-CoV-2 infection causes hypercoagulability and inflammation leading to venous thrombotic events (VTE). Although elderly patients with comorbidities are at higher risk, COVID-19 may also cause VTE in a broader patient population without these risks. Neurologic complications and manifestations of COVID-19, including neuropathies, seizures, strokes and encephalopathy usually occur in severe established cases of COVID-19 infection who primarily present with respiratory distress.

Case description: Case report of a 29-year-old woman, with no significant past medical history or comorbidities, presenting with new onset seizures. Further questioning revealed a one-week history of headaches, low-grade fever, mild cough and shortness of breath, diagnosed as COVID-19. Imaging revealed a left temporoparietal hemorrhagic venous infarction with left transverse and sigmoid sinus thrombosis treated with full dose anticoagulation and antiepileptics.

Conclusion: Although elderly patients with comorbidities are considered highest risk for COVID-19 neurologic complications, usually when systemic symptoms are severe, this case report emphasizes that young individuals are at risk for VTE with neurologic complications even when systemic symptoms are mild, likely induced by COVID-19 associated hypercoagulable state.

Keywords: COVID-19; Cerebral venous thrombosis (CVT); Stroke in young; Venous thrombotic events (VTE).

Fig. 1

Non-contrast head CT demonstrating left temporoparietal hemorrhagic venous infarct with edema and mass effect causing 5 mm rightward shift, red arrow pointing to increased attenuation and venous thrombosis in distal left transverse and sigmoid sinus

Fig. 2

3T DWI MRI, yellow arrow pointing to hyperintense DWI signal of evolving left temporoparietal hemorrhagic infarct, with mass effect and effacement of the left lateral and third ventricle with 5 mm rightward shift.

Fig. 3

2D time of flight MR venography with red arrows denoting absence of flow in the left transverse and sigmoid sinus and left internal jugular vein secondary to venous thrombosis. Light blue arrows denoting normal flow related signal in the right transvers and sigmoid sinus extending to a patent right internal jugular vein.