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.

Keywords: COVID-19; cerebral venous thrombosis; decompressive craniectomy; long covid.

Fig. 1

(A) CT Scan and (B) T2 Flair MRI: Cerebral imaging showing large inhomogeneous hemorrhagic lesion with malignant edema at right parietotemporooccipital region leading to subfacine and transtentorial brain herniation. (C) An axial T2 Flair imaging shows absence of abnormal flow void at right transverse and signoid sinus. (D) Coronal MIP image time-of-flight venography shows loss of signal at right transverse and sigmoid sinus.

Fig. 2

(A) Macroscopic appearance of hemorrhagic cerebral venous thrombosis on right temporoparietal area ( inside the yellow line area ). (B) Histopathological H&E staining with 100x magnification demonstrating brain parenchyma with diffuse hemorrhage and thrombosis. (C) Histopathological H&E staining with 400x magnification demonstrating diffuse brain thrombosis with neutrophil infiltration. (D) Histopathological H&E staining with 400x magnification demonstrating ischemic and degenerative neurons.