Management and Outcomes of COVID - 19 Associated Cerebral Venous Sinus Thrombosis

Angel Miraclin T; Dr Sanjith Aaron; Ajith Sivadasan; Kenneth Benjamin; Vanjare Harshad; Shalini Nair; Kpp Abhilash; Prabhakar At; Vivek Mathew

doi:10.1016/j.jstrokecerebrovasdis.2022.106306

Management and Outcomes of COVID - 19 Associated Cerebral Venous Sinus Thrombosis

J Stroke Cerebrovasc Dis. 2022 Apr;31(4):106306. doi: 10.1016/j.jstrokecerebrovasdis.2022.106306. Epub 2022 Jan 10.

Authors

Angel Miraclin T¹, Dr Sanjith Aaron², Ajith Sivadasan¹, Kenneth Benjamin¹, Vanjare Harshad³, Shalini Nair⁴, Kpp Abhilash⁵, Prabhakar At¹, Vivek Mathew¹

Affiliations

¹ Professor and Head, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu 632004, India.
² Professor and Head, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu 632004, India. Electronic address: sanjith@cmcvellore.ac.in.
³ Department of Radio diagnosis, Christian Medical College, Vellore, Tamil Nadu, India.
⁴ Department of Neurocritical care, Christian Medical College, Vellore, Tamil Nadu, India.
⁵ Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India.

PMID: 35091267
PMCID: PMC8743463
DOI: 10.1016/j.jstrokecerebrovasdis.2022.106306

Abstract

Background: Systemic hyper-coagulabilty leading to micro and macro thrombosis is a known complication of Coronavirus disease - 2019(COVID -19). The postulated mechanism appears to be the viral activation of endothelium, triggering the coagulation pathways. Thrombosis of the cerebral veins and sinuses (CVT), a potentially serious condition, has been increasingly reported with COVID - 19 infection. In this clinical study we attempt to describe the clinical profile, investigations and outcomes of patients with COVID- 19 associated CVT.

Methods: This is a single center prospective observational study from South India. The study included patients (aged >18 years) with concomitant COVID infection and CVT. The clinical, laboratory, imaging characteristics, management and outcomes were described and compared with COVID negative CVT patients.

Results: Out of 97 cases of CVT treated at our center during the first and second waves of the COVID pandemic 11/97 (11%) were COVID related CVT. Among these 11 patients, 9 (81%) had presented with only CVT related symptoms and signs and were tested positive for COVID - 19 infection during the pre-hospitalization screening. Respiratory symptoms were absent in 90% of the patients. Headache (100%) and seizures (90%) were the common presenting symptoms. The median time to diagnosis was 6 hours, from presentation to the emergency department. Transverse sinus was involved 10/11 (90%) and majority of them (9/11) had Haemorrhagic Venous Infarction (HVI). Acute inflammatory markers were elevated in comparison with non COVID CVT patients, with the mean serum D-dimer being 2462.75 ng/ml and the C-reactive protein was 64.5 mg/dl. Three patients (30%) underwent decompressive hemicraniectomy (DHC) because of large hemispheric HVI. All patients survived in the COVID CVT group while the mortality in the non COVID group was 4%. At 6 months follow up excellent outcome (modified Rankin Scale (mRS) score of 0-2) was noted equally in both groups.

Conclusions: Symptoms and signs of CVT may be the only presentation of COVID-19 infection. Prompt recognition and aggressive medical management including DHC offers excellent outcomes.

Keywords: COVID-19; Cerebral venous thrombosis; Decompressive hemicraniectomy.

Publication types

Observational Study

MeSH terms

Adolescent
COVID-19* / complications
COVID-19* / therapy
Cerebral Veins*
Humans
Intracranial Thrombosis* / diagnosis
Sinus Thrombosis, Intracranial* / complications
Sinus Thrombosis, Intracranial* / diagnostic imaging
Sinus Thrombosis, Intracranial* / therapy
Venous Thrombosis* / etiology