Developmental venous anomaly thrombosis in a patient with coronavirus disease 2019-associated hypercoagulability: illustrative case

Abstract

BACKGROUND Spontaneous thrombosis of a developmental venous abnormality (DVA) is a rare complication associated with hypercoagulability. The objective of this case report is to describe an association between DVA thrombosis and mild coronavirus disease 2019 (COVID-19) infection in a vaccinated patient. OBSERVATIONS A 28-year-old male with hypertension presented with severe headache and left-sided hemiparesis. Five weeks prior to presentation, the patient experienced mild respiratory symptoms and tested positive for COVID-19. Admission brain computed tomography (CT) showed a large right parieto-occipital intracerebral hemorrhage with surrounding edema. CT venography and catheter angiography showed a thrombosed DVA with associated venous infarction as the hemorrhage etiology. He was treated with decompressive hemicraniectomy, external ventricular drain placement, and systemic anticoagulation. The patient was functionally independent (modified Rankin Scale score, 2) at 4-month follow-up. Hypercoagulability work-up was unremarkable. LESSONS Delayed DVA thrombosis after the COVID-19 infectious period may represent an association between the infection and a protracted systemic viral-induced hypercoagulable state. The severity of COVID-19 symptomatology does not appear to correlate with risk of DVA thrombosis. Young patients with a recent history of COVID-19 infection who present with venous infarction should be evaluated for an underlying thrombosed DVA.

Assigning developmental venous anomaly thrombosis to SARS-CoV-2 only when the causal connection has been proven

“…The patient underwent emergent decompressive hemicraniectomy with external ventricular drain placement and received intravenous heparin. 1 His modified Rankin scale score at the 2-month follow-up was 2. 1 The study is excellent but has limitations that are cause for concern and should be discussed.…”

“…The assumed causal relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and DVA thrombosis with secondary lobar bleeding has not been proven. 1 The index patient had a mild respiratory infection 4 weeks before the cerebral hemorrhage and tested positive for SARS-CoV-2 using a home antigen test. 1 In a study of 316 paired samples, only 33 samples were positive for antigen testing and reverse transcriptase–polymerase chain reaction (RT-PCR) by both methods.…”

“… 1 The index patient had a mild respiratory infection 4 weeks before the cerebral hemorrhage and tested positive for SARS-CoV-2 using a home antigen test. 1 In a study of 316 paired samples, only 33 samples were positive for antigen testing and reverse transcriptase–polymerase chain reaction (RT-PCR) by both methods. 2 The sensitivity of the antigen test was calculated to be only 84.6%.…”

“…Surprisingly, the workup for hypercoagulability was noninformative. 1 Because venous thrombosis is usually accompanied by increased D-dimer, we should know if this parameter was actually normal or if it was not determined before craniotomy.…”

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Assigning developmental venous anomaly thrombosis to SARS-CoV-2 only when the causal connection has been provenTO THE EDITOR: I read with interest the article by Ironside et al 1 on a 28-year-old male with right-sided parieto-occipital intracerebral bleeding due to thrombosis of a right occipital developmental venous anomaly (DVA) (Ironside N, Petrosian D, Abbas S, et al Developmental venous anomaly thrombosis in a patient with coronavirus disease 2019-associated hypercoagulability: illustrative case. J Neurosurg Case Lessons.

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