Case reports of cerebral sinus venous thrombosis in COVID-19 patients

Abstract

Background Coronavirus disease 2019 (COVID-19) pandemic has started in December 2019 and still ongoing. The disease has been expanding rapidly with a high variety of phenotypes from asymptomatic, mild respiratory tract infection, multiple organ system dysfunction, and death. Neurological manifestations also appear in patients with COVID-19, such as headache, seizures, a decrease of consciousness, and paralysis. The hypercoagulable state in patients with COVID-19 is associated with the thromboembolic incident including ischemic strokes, venous thromboembolism, pulmonary artery embolism, and many further. Cerebral sinus venous thrombosis (CSVT) is a rare neurovascular emergency that is often found in critically ill patients. We report two cases of CSVT with different onsets, neurologic manifestations, and prognoses. Case presentation Two cases of cerebral sinus venous thrombosis in COVID-19 patients were reported, following respiratory, hematology, and coagulation disarrangements, which was triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The first patient, which was presented with a seizure, had hypertension and diabetes mellitus as comorbidities. The latter case had no comorbidity but showed more severe presentations of COVID-19 such as brain and lung thrombosis, although already had several days of intravenous anticoagulant administrations. These two cases also have a different course of disease and outcomes, which were interesting topics to study. Conclusions CSVT is one of the neurological complications of the COVID-19 when the brainstem venous drainage is involved. Despite successful alteration to the negative result of SARS-CoV-2 through the rt-PCR test, thrombogenesis and coagulation cascade continuing. Therefore, a high level of neutrophil to lymphocyte ratio (NLR), D-dimer, fibrinogen, and C-reactive protein (CRP) are paramount indicators of poor prognosis.

Sinus venous thrombosis as a complication of COVID-19-associated hypercoagulability

“…We do not agree with the statement that hypercoagulability is a complication of COVID-19 only if there is concomitant arterial hypertension or diabetes [ 1 ]. Hypercoagulability is a common complication not only of severe, but also of mild or moderate COVID-19 [ 2 ] and explained by (1) direct activation of platelets, enhancing coagulation; (2) direct infection and indirect activation of endothelial cells by the cytokine storm, shifting endothelium from an anti-thrombotic to a pro-thrombotic state, and (3) direct activation of complement pathways, promoting thrombin generation [ 3 ].…”

“…The statement of the conclusions “upon monitoring the neutrophil/lymphocyte ratio, it became apparent that D-dimer, fibrinogen, and C-reactive protein (CRP) are bad prognosis indicators, why the use of heparin or low molecular weight heparin (LMWH) decreases the D-dimer and not by any means increase the symptoms” [ 1 ] is inconclusive. Do the authors mean that LMWH decreases the D-dimer levels but not the symptoms, or do they mean that low D-dimer is associated with reduction of symptoms?…”

“…With interest we read the article by Sittanggang and colleagues about two patients (58-year-old female (patient-1), 72-year-old male (patient-2)) experiencing sinus venous thrombosis (SVT) during a SARS-CoV-2 infection [ 1 ]. Latency between the onset of COVID-19 and the onset of SVT was 7 and 17 days in patient-1/patient-2, respectively [ 1 ]. The onset manifestations were seizure and hemiparesis (patient-1) and impaired consciousness (patient-2), respectively [ 1 ].…”

“…Latency between the onset of COVID-19 and the onset of SVT was 7 and 17 days in patient-1/patient-2, respectively [ 1 ]. The onset manifestations were seizure and hemiparesis (patient-1) and impaired consciousness (patient-2), respectively [ 1 ]. It was concluded that COVID-19 can be complicated by SVT, that the prognosis of SVT is poor if drainage of the brainstem is compromised, that hypercoagulability is a complication of COVID-19 if arterial hypertension and diabetes are present, and that coagulation cascades are prolonged despite normal D-dimer [ 1 ].…”

Bilateral Cerebral Venous Thrombosis with a Rare Presentation in a COVID-19 Patient: A Case Report

“…The disease may also cause neurological manifestations such as decreased level of consciousness and myopathy. 1 2…”