Title : A headache that makes a grown man cry: Cerebral sinus thrombosis secondary to coronavirus disease 2019
There have been increasing reports associating coronavirus disease 2019 (COVID-19) with thromboembolic phenomenon including cerebral venous thrombosis (CVT), which is a rare neurovascular emergency often found in critically ill patients, yet its true incidence and underlying pathophysiology remains unknown. In light of the ongoing pandemic of this devastating disease, it is critical to identify, understand and manage all its clinical manifestations and associated complications. We report the case of a middle aged man who presents with complaints of acute onset intense occipital headaches and visual disturbances due to CVT after a mild form of COVID-19.
Case of a 50 years old man with known medical history of arterial hypertension, major depressive disorder and hypothyroidism who presents to the neurology outpatient clinics with complains of daily intense occipital headaches of approximately 6 months in evolution and with associated findings on clinical evaluation of a left superior quadrantanopia after recovering from a mild COVID-19 managed in an outpatient setting. Headaches were described as sudden in onset, intermittent in nature, oppressive in quality, 10/10 in intensity, non-radiating, and only mildly improved with over-the-counter or prescribed medications such as valproate and aspirin. Further evaluation with head imaging studies ruled out a traumatic etiology and the brain magnetic resonance venography (MRV) revealed areas of partial thrombosis in the proximal third of the straight sinus and vein of Galen and partial thrombosis of the posterior third of the superior sagittal sinus. Patient was admitted to the internal medicine ward in order to receive anticoagulation therapy with enoxaparin bridging therapy and warfarin initiation with a goal INR of 2-3 and an extensive workup in order to rule out possibilities of a pro-coagulation state were ordered, but a COVID-19 hypercoagulability complication was highly suspected. Antiphospholipid panel, Protein C, Protein S and Factor V Leiden were reported negative and further supported the suspicion. Afterwards, the patient's symptoms completely resolved and he was discharged home on continued warfarin therapy with follow up at the neurology and hematology/oncology clinics.
COVID-19 has been associated with a plethora of systemic effects not limited to the respiratory system including an increased propensity for systemic hypercoagulability and thromboembolism and an association with CVT has been previously reported. CVT is a relatively rare condition that is difficult to diagnose due to its multiple and various clinical manifestations. It generally has a favorable prognosis if diagnosed and treated in a timely manner, but can be lethal if not with high associated mortality rates. Therefore, it is important to identify and treat this complication promptly.
What will audience learn from your presentation?
- The audience will be able to consider cerebral venous thrombosis as a possible neurological complication of COVID-19 and, therefore, be able to identify it and treat it before further complications
- The report can create awareness of a systemic manifestation of COVID-19 that is not limited to the respiratory system
- The case report could be referenced in future studies attempting to clarify the underlying pathophysiology of COVID-19 related hypercoagulability and thromboembolism