A Case of Dural Arteriovenous Fistula Following Cerebral Venous Sinus Thrombosis Associated with the COVID-19 Vaccine

Abstract

Objective: Cerebral venous sinus thrombosis (CVST) is one of the rare and severe complications of coronavirus disease 2019 (COVID-19) vaccines. CVST has also been reported to develop into dural arteriovenous fistula; however, there were no reports of dural arteriovenous fistula associated with COVID-19 vaccine-induced cerebral venous sinus thrombosis. Here, we describe a rare case of a transverse-sigmoid sinus dural arteriovenous fistula followed by CVST due to COVID-19 vaccination.

Case presentation: A 70-year-old patient presented with headache five days after receiving a second dose of COVID-19 vaccine. MRI showed a CVST in the superior sagittal sinus, left transverse sinus, and left sigmoid sinus. His headache improved after the administration of anticoagulant therapy. Six months later, a similar headache recurred, and cerebral angiography demonstrated a dural arteriovenous fistula in the left transverse sigmoid sinus and convexity dural arteriovenous fistulas in the left parietal cortex. The patient was treated twice with two sessions of transarterial embolization, and the shunts were completely occluded. His symptoms improved, and he was discharged with a modified Rankin Scale score of 0.

Conclusion: Dural arteriovenous fistula can develop after CVST in association with COVID-19 vaccination.

Keywords: COVID-19; cerebral venous sinus thrombosis; dural arteriovenous fistula; vaccine.

Fig. 1. MRI at diagnosis of CVST. T1-weighted image (A–C) and T2 weighted image (D–F) show the CVST in left transverse–sigmoid sinus and SSS. Time-of-flight MRA revealed no evidences of dural arteriovenous fistula (G–I). CVST: cerebral venous sinus thrombosis; SSS: superior sagittal sinus

Fig. 2. MRI at diagnosis of DAVF. T1-weighted image (A and B) and T2-weighted image (C and D) show some thromboses in some part of left transverse–sigmoid sinus. Time-of-flight MRA reveals some feeders from OA to the left transverse sigmoid sinus (E and F, white arrow). DAVF: dural arteriovenous fistula; OA: occipital artery

Fig. 3. DSA before and after transarterial embolizations. Left external carotid artery angiography demonstrates multiple arterial feeders to the transverse sinus. Arterial feeders include the OA (black arrowhead), ascending pharyngeal artery (large black arrow), and MMA (white arrowhead) (A and B). Furthermore, some feeders from MMA shunts directly to the cortical vein (B, white arrow). Right external carotid artery angiography demonstrates multiple arterial feeders from OA to the transverse sinus (C and D, black arrow). The proximal of left sigmoid sinus is occluded (E, large white arrow). The main outflow routes were through the confluence to the right transverse sinus and through the cortical vein to the SSS (F, large black arrowhead). Left external carotid artery angiography demonstrates no residual fistulas after endovascular treatments (G and H). MMA: middle meningeal artery; OA: occipital artery; SSS: superior sagittal sinus