Cerebral venous sinus thrombosis associated with COVID-19: a case series and literature review

Abstract

Background: Since the emergence of COVID-19 pandemic, several cases of cerebral venous sinus thrombosis (CVST) have been reported in SARS-CoV-2 infected individuals.

Methods: Consecutive patients with documented SARS-CoV-2 infection, as well as clinical and radiological characteristics of CVST, were reported from three teaching hospitals in the South West, North West, and the center of Iran between June and July 2020. We also searched the abstract archives until the end of August 2020 and gathered 28 reported cases. The diagnostic criteria for SARS-CoV-2 infection were determined according to SARS-CoV-2 detection in oropharyngeal or nasopharyngeal samples in clinically suspected patients. Demographics, prominent COVID-19 symptoms, confirmatory tests for SARS-CoV-2 infection diagnosis, the interval between the diagnosis of SARS-CoV-2 infection and CVST, clinical and radiological features of CVST, therapeutic strategies, CVST outcomes, rate of hemorrhagic transformation, and mortality rate were investigated.

Results: Six patients (31-62 years-old) with confirmed CVST and SARS-CoV-2 infection were admitted to our centers. Four patients had no respiratory symptoms of SARS-CoV-2 infection. Five patients developed the clinical manifestations of CVST and SARS-CoV-2 infection simultaneously. Three patients had known predisposing factors for CVST. Despite receiving CVST and SARS-CoV-2 infection treatments, four patients died. SARS-COV-2 associated CVST patients were older (49.26 vs. 37.77 years-old), had lower female/male ratio (1.42 vs. 2.19), and higher mortality rate (35.29% vs. 6.07%) than CVST not associated with COVID-19.

Conclusions: The role of SARS-CoV-2 as a "cause" versus an "additive contributor" remains to be elucidated. Practitioners should be aware of the possibility of CVST in SARS-CoV-2 infection.

Keywords: COVID-19; Coronavirus; Intracranial; SARS-CoV-2; Sinus thrombosis; Stroke.

Fig. 1

a Axial non-enhanced spiral brain computed tomography (CT) scan shows a large hematoma with surrounding edema in the right parieto-occipital lobe (black thin arrows); Note the dense clot sign in the posterior part of the superior sagittal sinus, characteristic of thrombosis (white thick arrow). b Axial T2-weighted magnetic resonance (MR) image shows a large heterogeneous lesion with surrounding edema in the right parieto-occipital lobe (white thin arrows) associated with loss of signal void in the posterior region of the superior sagittal sinus (white thick arrow) suggestive of the venous sinus thrombosis with hemorrhagic venous infarction. c Axial contrast-enhanced T1-weighted MR image shows a filling defect in the posterior part of the superior sagittal sinus suggestive of thrombosis (white thick arrow). d Brain MR venography shows extensive thrombosis in the superior sagittal, right transverse, and sigmoid sinuses as well as the right internal jugular vein (white thin arrows)