Cerebral Venous Sinus Thrombosis in COVID-19 Infection: A Case Series and Review of The Literature

Abstract

SARS-CoV-2, the virus responsible for novel Coronavirus (COVID-19) infection, has recently been associated with a myriad of hematologic derangements; in particular, an unusually high incidence of venous thromboembolism has been reported in patients with COVID-19 infection. It is postulated that either the cytokine storm induced by the viral infection or endothelial damage caused by viral binding to the ACE-2 receptor may activate a cascade leading to a hypercoaguable state. Although pulmonary embolism and deep venous thrombosis have been well described in patients with COVID-19 infection, there is a paucity of literature on cerebral venous sinus thrombosis (cVST) associated with COVID-19 infection. cVST is an uncommon etiology of stroke and has a higher occurrence in women and young people. We report a series of three patients at our institution with confirmed COVID-19 infection and venous sinus thrombosis, two of whom were male and one female. These cases fall outside the typical demographic of patients with cVST, potentially attributable to COVID-19 induced hypercoaguability. This illustrates the importance of maintaining a high index of suspicion for cVST in patients with COVID-19 infection, particularly those with unexplained cerebral hemorrhage, or infarcts with an atypical pattern for arterial occlusive disease.

Keywords: COVID-19; Coronavirus; Hypercoaguability; Stroke; Venous sinus thrombosis; Venous thromboembolism.

Fig. 1

(A) Magnetic resonance venography (MRV) demonstrates occlusion of the left transverse sinus (red arrow) and no opacification of the sigmoid sinus and jugular vein as well as occlusion of a segment of the right transverse sinus (green arrow). (B) Demonstrates occlusion of the straight sinus (green arrow). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

CT angiogram with delayed phase shows filling defect in the right sigmoid sinus and jugular bulb (green arrow). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

(A) Noncontrast CT brain demonstrates the right parasagittal hemorrhage; (B) diagnostic cerebral angiography, right internal carotid injection, coronal view, venous phase showing filling defect in the right junction of Trolard with superior sagittal sinus (black arrow).