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

Sitanggang P.A., Tini K., Susilawathi N.M., Wijayanti I.A.S., Dewi P.U., Samatra D.P.G.P.

Departement of Neurology, Udayana University, Sanglah General Hospital, Jalan Kesehatan No.1, Denpasar, Bali, Indonesia; Department of Neurology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Hospital, Jalan Rumah Sakit Universitas Udayana No.1, Jimbaran, South Kuta, Badung, Bali, Indonesia; Department of Radiology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Hospital, Jalan Rumah Sakit Universitas Udayana No.1, Jimbaran, South Kuta, Badung, Bali, Indonesia


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. © 2021, The Author(s).

Coagulation cascade; COVID 19; CSVT; Thrombogenesis


Egyptian Journal of Neurology, Psychiatry and Neurosurgery

Publisher: Springer Science and Business Media Deutschland GmbH

Volume 57, Issue 1, Art No 83, Page – , Page Count

Journal Link:

doi: 10.1186/s41983-021-00335-y

Issn: 11101083

Type: All Open Access, Gold, Green


Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J., Zhao, X., Tan, W., A novel coronavirus from patients with pneumonia in China, 2019 (2020) N Engl J Med., 382 (8), pp. 727-733; Chen, N., Zhou, M., Dong, X., Qu, J., Gong, F., Han, Y., Qiu, Y., Zhang, L., Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study (2020) Lancet., 395 (10223), pp. 507-513; Wang, D., Hu, B., Hu, C., Zhu, F., Liu, X., Zhang, J., Wang, B., Peng, Z., Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China (2020) JAMA, 323 (11), pp. 1061-1069; Liu, K., Fang, Y.Y., Deng, Y., Liu, W., Wang, M.F., Ma, J.P., Xiao, W., Liu, H.G., Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province (2020) Chin Med J (Engl)., 133 (9), pp. 1025-1031; Mao, L., Jin, H., Wang, M., Hu, Y., Chen, S., He, Q., Chang, J., Hu, B., Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China (2020) JAMA Neurol, 77 (6), pp. 683-690; Katz, J.M., Libman, R.B., Wang, J.J., Sanelli, P., Filippi, C.G., Gribko, M., Pacia, S.V., Azhar, S., Cerebrovascular complications of COVID-19 (2020) Stroke., 51 (9), pp. e227-e231; Cavalcanti, D.D., Raz, E., Shapiro, M., Dehkharghani, S., Yaghi, S., Lillemoe, K., Nossek, E., Nelson, P.K., Cerebral venous thrombosis associated with COVID-19 (2020) AJNR Am J Neuroradiol., 41 (8), pp. 1370-1376; Garaci, F., Di Giuliano, F., Picchi, E., Da Ros, V., Floris, R., Venous cerebral thrombosis in COVID-19 patient (2020) J Neurol Sci., 414, p. 116871; Klein, D.E., Libman, R., Kirsch, C., Arora, R., Cerebral venous thrombosis: a typical presentation of COVID-19 in the young (2020) J Stroke Cerebrovasc Dis., 29 (8), p. 104989; Hamming, I., Timens, W., Bulthuis, M.L., Lely, A.T., Navis, G., van Goor, H., Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis (2004) J Pathol., 203 (2), pp. 631-637; Zhou, F., Yu, T., Du, R., Fan, G., Liu, Y., Liu, Z., Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study (2020) Lancet., 395 (10229), pp. 1054-1062; Spiezia, L., Boscolo, A., Poletto, F., Cerruti, L., Tiberio, I., Campello, E., Navalesi, P., Simioni, P., COVID-19-related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure (2020) Thromb Haemost., 120 (6), pp. 998-1000; Devasagayam, S., Wyatt, B., Leyden, J., Kleinig, T., Cerebral venous sinus thrombosis incidence is higher than previously thought: a retrospective population-based study (2016) Stroke., 47 (9), pp. 2180-2182; Coutinho, J.M., Zuurbier, S.M., Aramideh, M., Stam, J., The incidence of cerebral venous thrombosis: a cross-sectional study (2012) Stroke., 43 (12), pp. 3375-3377; Saposnik, G., Barinagarrementeria, F., Brown, R.D., Jr., Bushnell, C.D., Cucchiara, B., Cushman, M., Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association (2011) Stroke., 42 (4), pp. 1158-1192; Dmytriw, A.A., Song, J.S.A., Yu, E., Poon, C.S., Cerebral venous thrombosis: state of the art diagnosis and management (2018) Neuroradiology., 60 (7), pp. 669-685; Hui, K.P.Y., Cheung, M.C., Perera, R.A.P.M., Ng, K.C., Bui, C.H.T., Ho, J.C.W., Ng, M.M.T., Chan, M.C.W., Tropism, replication competence, and innate immune responses of the coronavirus SARS-CoV-2 in human respiratory tract and conjunctiva: an analysis in ex-vivo and in-vitro cultures (2020) Lancet Respir Med., 8 (7), pp. 687-695; Wan, Y., Shang, J., Graham, R., Baric, R.S., Li, F., Receptor recognition by the novel coronavirus from Wuhan: an analysis based on decade-long structural studies of SARS coronavirus (2020) J Virol., 94 (7), pp. e00127-e00120; Guan, W.J., Ni, Z.Y., Hu, Y., Liang, W.H., Ou, C.Q., He, J.X., Liu, L., Zhong, N.S., Clinical characteristics of coronavirus disease 2019 in China (2020) N Engl J Med., 382 (18), pp. 1708-1720; Pung, R., Chiew, C.J., Young, B.E., Chin, S., Chen, M.I., Clapham, H.E., Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures (2020) Lancet., 395 (10229), pp. 1039-1046; Guan, W.J., Liang, W.H., Zhao, Y., Liang, H.R., Chen, Z.S., Li, Y.M., Liu, X.Q., He, J.X., Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis (2020) Eur Respir J., 55 (5), p. 2000547; Catanzaro, M., Fagiani, F., Racchi, M., Corsini, E., Govoni, S., Lanni, C., Immune response in COVID-19: addressing a pharmacological challenge by targeting pathways triggered by SARS-CoV-2 (2020) Signal Transduct Target Ther., 5 (1), p. 84; Wong, C.K., Lam, C.W., Wu, A.K., Ip, W.K., Lee, N.L., Chan, I.H., Plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome (2004) Clin Exp Immunol., 136 (1), pp. 95-103; Rao, V.U.S., Arakeri, G., Subash, A., Rao, J., Jadhav, S., Suhail Sayeed, M., Rao, G., Brennan, P.A., COVID-19: Loss of bridging between innate and adaptive immunity? (2020) Med Hypotheses., 144, p. 109861; Mehta, P., McAuley, D.F., Brown, M., Sanchez, E., Tattersall, R.S., Manson, J.J., COVID-19: consider cytokine storm syndromes and immunosuppression (2020) Lancet., 395 (10229), pp. 1033-1034; Chen, G., Wu, D., Guo, W., Cao, Y., Huang, D., Wang, H., Wang, T., Ning, Q., Clinical and immunological features of severe and moderate coronavirus disease 2019 (2020) J Clin Invest., 130 (5), pp. 2620-2629; Rodriguez-Morales, A.J., Cardona-Ospina, J.A., Gutiérrez-Ocampo, E., Villamizar-Peña, R., Holguin-Rivera, Y., Escalera-Antezana, J.P., Alvarado-Arnez, L.E., Sah, R., Clinical, laboratory and imaging features of COVID-19: a systematic review and meta-analysis (2020) Travel Med Infect Dis., 34, p. 101623; Yang, A.P., Liu, J.P., Tao, W.Q., Li, H.M., The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients (2020) Int Immunopharmacol., 84, p. 106504; Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., Zhang, L., Cao, B., Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China (2020) Lancet, 395 (10223), pp. 497-506; Arachchillage, D.R.J., Laffan, M., Pathogenesis and management of thrombotic disease in myeloproliferative neoplasms (2019) Semin Thromb Hemost., 45 (6), pp. 604-611; Okamoto, K., Tamura, T., Sawatsubashi, Y., Sepsis and disseminated intravascular coagulation (2016) J Intensive Care., 4 (1), p. 23; Levi, M., van der Poll, T., Inflammation and coagulation (2010) Crit Care Med., 38, pp. S26-S34; Levi, M., van der Poll, T., ten Cate, H., van Deventer, S.J., The cytokine-mediated imbalance between coagulant and anticoagulant mechanisms in sepsis and endotoxaemia (1997) Eur J Clin Invest., 27 (1), pp. 3-9; Levi, M., van der Poll, T., Coagulation and sepsis (2017) Thromb Res., 149, pp. 38-44; Leach, J.L., Fortuna, R.B., Jones, B.V., Gaskill-Shipley, M.F., Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls (2006) Radiographics., 26, pp. S19-S43; Klok, F.A., Kruip, M.J.H.A., van der Meer, N.J.M., Arbous, M.S., Gommers, D.A.M.P.J., Kant, K.M., Kaptein, F.H.J., Endeman, H., Incidence of thrombotic complications in critically ill ICU patients with COVID-19 (2020) Thromb Res., 191, pp. 145-147; Abou-Ismail, M.Y., Diamond, A., Kapoor, S., Arafah, Y., Nayak, L., The hypercoagulable state in COVID-19: incidence, pathophysiology, and management (2020) Thromb Res., 194, pp. 101-115; Zhang, Y., Xiao, M., Zhang, S., Xia, P., Cao, W., Jiang, W., Chen, H., Zhang, S., Coagulopathy and antiphospholipid antibodies in patients with COVID-19 (2020) N Engl J Med., 382 (17); Lippi, G., Favaloro, E.J., D-dimer is associated with severity of coronavirus disease 2019: a pooled analysis (2020) Thromb Haemost., 120 (5), pp. 876-878; Tal, S., Spectre, G., Kornowski, R., Perl, L., Venous thromboembolism complicated with COVID-19: what do we know so far? (2020) Acta Haematol., 143 (5), pp. 417-424; Poterucha, T.J., Libby, P., Goldhaber, S.Z., More than an anticoagulant: do heparins have direct anti-inflammatory effects? (2017) Thromb Haemost., 117 (3), pp. 437-444; Barrett, C.D., Moore, H.B., Moore, E.E., McIntyre, R.C., Moore, P.K., Burke, J., Fibrinolytic therapy for refractory COVID-19 acute respiratory distress syndrome: scientific rationale and review (2020) Res Pract Thromb Haemost., 4 (4), pp. 524-531

Indexed by Scopus

Leave a Comment