Case Report: Take a Second Look: Covid-19 Vaccination-Related Cerebral Venous Thrombosis and Thrombotic Thrombocytopenia Syndrome

We present two cases of ChAdOx1 nCov-19 (AstraZeneca)-associated thrombotic thrombocytopenia syndrome (TTS) and cerebral venous sinus thrombosis (CVST). At the time of emergency room presentation due to persistent headache, blood serum levels revealed reduced platelet counts. Yet, 1 or 4 days after the onset of the symptom, the first MR-angiography provided no evidence of CVST. Follow-up imaging, performed upon headache refractory to nonsteroidal pain medication verified CVST 2–10 days after initial negative MRI. Both the patients received combined treatment with intravenous immunoglobulins and parenteral anticoagulation leading to an increase of platelet concentration in both the individuals and resolution of the occluded cerebral sinus in one patient.

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Management of Idiopathic Intracranial Hypertension during the COVID19 Pandemic

Reviews on Recent Clinical Trials ◽

10.2174/1574887115666200917111413 ◽

2020 ◽

Vol 15 ◽

Author(s):

Ayman G. Elnahry ◽

Gehad A. Elnahry

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Fundus Photography ◽

Young Females ◽

Optic Nerve Sheath Fenestration ◽

Threatening Condition ◽

Coronavirus Infection

Background: In the current coronavirus disease 2019 (COVID-19) pandemic, health systems are struggling to prioritize care for affected patients, however, physicians globally are also attempting to maintain care for other lessthreatening medical conditions that may lead to permanent disabilities if untreated. Idiopathic intracranial hypertension (IIH) is a relatively common condition affecting young females that could lead to permanent blindness if not properly treated. In this article, we provide some insight and recommendations regarding the management of IIH during the pandemic. Methods: The diagnosis, follow-up, and treatment methods of IIH during the COVID-19 pandemic period are reviewed. COVID-19 as a mimic of IIH is also discussed. Results: Diagnosis and follow-up of papilledema due to IIH during the COVID-19 pandemic can be facilitated by nonmydriatic fundus photography and optical coherence tomography. COVID-19 may mimic IIH by presenting as cerebral venous sinus thrombosis, papillophlebitis, or meningoencephalitis, so a high index of suspicious is required in these cases. When surgical treatment is indicated, optic nerve sheath fenestration may be the primary procedure of choice during the pandemic period. Conclusion: IIH is a serious vision threatening condition that could lead to permanent blindness and disability at a relatively young age if left untreated. It could be the first presentation of a COVID-19 infection. Certain precautions during the diagnosis and management of this condition could be taken that may allow appropriate care to be delivered to these patients while minimizing the risk of coronavirus infection.

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Cerebral venous sinus thrombosis after ChAdOx1 nCov-19 vaccination with a misleading first cerebral MRI scan

Stroke and Vascular Neurology ◽

10.1136/svn-2021-001095 ◽

2021 ◽

pp. svn-2021-001095

Author(s):

Benno Ikenberg ◽

Antonia Franziska Demleitner ◽

Thomas Thiele ◽

Benedikt Wiestler ◽

Katharina Götze ◽

...

Keyword(s):

Sinus Thrombosis ◽

Intravenous Immunoglobulins ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Pathological Findings ◽

Mri Scan ◽

Platelet Factor ◽

Venous Sinus Thrombosis ◽

Activation Assay ◽

Cerebral Mri

Vaccine-induced immune thrombotic thrombocytopenia (VITT) and cerebral venous sinus thrombosis (CVST) have been recently described as rare complications following vaccination against SARS-CoV-2 with vector vaccines. We report a case of a young woman who presented with VITT and cerebral CVST 7 days following vaccination with ChAdOx1 nCov-19 (AstraZeneca). While the initial MRI was considered void of pathological findings, MRI 3 days later revealed extensive CVST of the transversal and sigmoidal sinus with intracerebral haemorrhage. Diagnostic tests including a platelet-factor-4-induced platelet activation assay confirmed the diagnosis of VITT. Treatment with intravenous immunoglobulins and argatroban resulted in a normalisation of platelet counts and remission of CVST.

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Safety and Validity of Mechanical Thrombectomy and Thrombolysis on Severe Cerebral Venous Sinus Thrombosis

Neurosurgery ◽

10.1227/neu.0b013e318285c1d3 ◽

2013 ◽

Vol 72 (5) ◽

pp. 730-738 ◽

Cited By ~ 36

Author(s):

Guangwen Li ◽

Xianwei Zeng ◽

Mohammed Hussain ◽

Ran Meng ◽

Yi Liu ◽

...

Keyword(s):

Magnetic Resonance ◽

Treatment Modality ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Magnetic Resonance Venography ◽

Venous Sinus ◽

Venous Sinus Thrombosis ◽

Digital Subtract Angiography

Abstract BACKGROUND: Although the majority of patients with cerebral venous sinus thrombosis (CVST) obtain an optimistic clinical outcome after heparin or warfarin treatment, there remains a subgroup of patients who do not respond to conventional anticoagulation treatment. These patients, especially younger people, as documented by hospital-based studies, have a high morbidity and mortality rate. OBJECTIVE: To verify the safety and efficacy of a dual mechanical thrombectomy with thrombolysis treatment modality option in patients with severe CVST. METHODS: Fifty-two patients diagnosed with CVST were enrolled and treated with mechanical thrombectomy combined with thrombolysis. Patients underwent urokinase 100 to 1500 × 103 IU intravenous sinus injection via a jugular catheter after confirming diagnoses of CVST by using either magnetic resonance imaging/magnetic resonance venography or digital subtract angiography. Information obtained on the patients included recanalization status of venous sinuses as evaluated by magnetic resonance venography or digital subtract angiography at admission, during operation, and at 3- and 6-month follow-up after treatment. RESULTS: The percentage of patients that showed complete and partial recanalization were 87% and 6%, respectively, after mechanical thrombectomy combined with thrombolysis treatment; 8% of the patients showed no recanalization. The modified Rankin Scale scores were 1.0 ± 0.9, 0.85 ± 0.63, and 0.37 ± 0.53 for discharge, and 3- and 6-month follow-up, respectively. A total of 6 patients died despite receiving aggressive treatment. No cases of relapse occurred after 3 to 6 months of follow-up. CONCLUSION: Thrombectomy combined with thrombolysis is a safe and valid treatment modality to use in severe CVST cases or in intractable patients that have shown no adequate response to antithrombotic drugs.

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Cerebral Venous Sinus Thrombosis: An Uncommon Presentation of Headache Mimicking Subarachnoid Hemorrhage

Journal of Medicine ◽

10.3329/jom.v10i2.2826 ◽

1970 ◽

Vol 10 (2) ◽

pp. 115-118

Author(s):

Naima Sultana ◽

Monzurul H Chowdhury ◽

Md Shahriar Mahbub ◽

Md Billal Alam

Keyword(s):

Subarachnoid Hemorrhage ◽

Oral Contraceptives ◽

Sinus Thrombosis ◽

Serum Levels ◽

Cerebral Venous Sinus Thrombosis ◽

Sudden Onset ◽

Interesting Case ◽

Venous Sinus ◽

Venous Sinus Thrombosis ◽

Uncommon Presentation

Cerebral venous sinus thrombosis is a rare disorder accounting for less than 1% of all strokes. It is more common in children and young adults. Here we report a rare and interesting case of cerebral venous l sinus thrombosis mimicking subarachnoid hemorrhage. A 40 years old women, presented with sudden onset of headache, vomiting and unconsciousness associated with convulsions. She had a history of taking oral contraceptives for the last 12 years. Clinical examinations showed ill-looking women with Glasgow Coma Scale of 12 along with neck rigidity and bilateral papilloedema. Although initially we suspected her as a case of subarachnoid hemorrhage, subsequent investigations with MRI and MRV showed to be a case of superior sagittal and transverse sinus thrombosis. Treatment with anticoagulation recovered her from headache and papilloedema. Serum levels of thrombophilic factors were within the normal physiological limits. Thus we concluded that although cerebral venous thrombosis is 100 times less than the cerebral arterial disease, a women presented with sudden onset of headache and vomiting with long term use of oral contraceptives, cerebral thrombosis should be considered as a differential. Key words: Cerebral venous sinus thrombosis , Sagittal sinus thrombosis, Subarachnoid hemorrhage , Magnetic resonance venography. doi: 10.3329/jom.v10i2.2826 J MEDICINE 2009; 10 : 115-118

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A case report of extensive cerebral venous sinus thrombosis: a sequela of COVID-19?

Acute Medicine Journal ◽

10.52964/amja.0866 ◽

2021 ◽

Vol 20 (3) ◽

pp. 219-222

Author(s):

S Sivalokanathan ◽

◽

MO Syed ◽

A Sharmila ◽

◽

...

Keyword(s):

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Low Molecular Weight ◽

Diagnostic Challenge ◽

Venous Sinus Thrombosis ◽

Refractory Headache ◽

Thrombotic Complications ◽

Medical Intensive Care ◽

Persistent Headache

Coronavirus disease 2019 (COVID-19) is an infectious respiratory disease that is often the trigger for thrombotic complications. Cerebral venous sinus thrombosis (CVST) represents a small percentage of strokes, frequently proving to be a diagnostic challenge. We report a 31-year-old lady presenting with a persistent headache, 18 weeks after a mild COVID-19 illness. On her second visit, CT venography revealed extensive CVST. She was commenced on low-molecular-weight heparin, and was monitored closely in the neuro-medical intensive care unit. She was discharged 2 weeks later, with no residual neurological deficit, and commenced on a direct oral anticoagulant in the community. CVST should be considered in patients presenting with a refractory headache, with greater suspicion if previously infected with SARS-CoV-2.

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Prognostic value of systemic immune–inflammation index in acute/subacute patients with cerebral venous sinus thrombosis

Stroke and Vascular Neurology ◽

10.1136/svn-2020-000362 ◽

2020 ◽

Vol 5 (4) ◽

pp. 368-373

Author(s):

Shen Li ◽

Kai Liu ◽

Yuan Gao ◽

Lu Zhao ◽

Rui Zhang ◽

...

Keyword(s):

Regression Analysis ◽

Cox Regression ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Cox Regression Analysis ◽

Venous Sinus Thrombosis ◽

Immune Inflammation ◽

Poor Outcomes

ObjectiveTo evaluate the prognosis values of systemic immune–inflammation index (SII) in non-chronic cerebral venous sinus thrombosis (CVST).Methodspatients with CVST, admitted to the First Affiliated Hospital of Zhengzhou University, were retrospectively identified from January 2013 to December 2018. We selected patients in acute/subacute phase from database. Functional outcomes of patients were evaluated with the modified Rankin Scale (mRS)—mRS 3–6 as poor outcomes and mRS 6 as death. The overall survival time was defined as the date of onset to the date of death or last follow-up date. Survival analysis was described by the Kaplan-Meier curve and Cox regression analysis. Multivariate logistic regression analysis assessed the relationship between SII and poor functional outcome. The area under the Receiver Operating Curve curve (AUC) was estimated to evaluate the ability of SII in prediction.ResultsA total of 270 patients were included and their duration of follow-up was 22 months (6–66 months), of whom 31 patients had poor outcomes and 24 patients dead. Cox regression analysis showed that SII (HR=1.304, 95% CI: 1.101 to 1.703, p=0.001) was a predictor of death in non-chronic CVST. Patients with higher SII presented lower survival rates (p=0.003). The AUC of SII was 0.792 (95% CI: 0.695 to 0.888, p=0.040) with a sensitivity of 69.6% and specificity of 80.1%. Subgroups analysis demonstrated that SII was an important predictor of poor outcomes in male (OR=1.303, 95% CI: 1.102 to 1.501, p=0.011) and pregnancy/puerperium female (OR=1.407, 95% CI: 1.204 to 1.703, p=0.034).ConclusionsSII was a potential predictor in the poor prognosis of patients with acute/subacute CVST, especially in male and pregnancy/puerperium female.

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Hyperthyroidism as a Precipitant Factor for Cerebral Venous Thrombosis: A Case Report

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/2324709620949309 ◽

2020 ◽

Vol 8 ◽

pp. 232470962094930

Author(s):

Ahmed Elkhalifa Elawad Elhassan ◽

Mohammed Omer Khalil Ali ◽

Amina Bougaila ◽

Mohammed Abdelhady ◽

Hassan Abuzaid

Keyword(s):

Case Report ◽

Superior Sagittal Sinus ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Laboratory Findings ◽

Sagittal Sinus ◽

History Of ◽

Sagittal Sinus Thrombosis ◽

Superior Sagittal Sinus Thrombosis

Cerebral venous sinus thrombosis (CVT) is an uncommon yet serious condition. While CVT has many known precipitants and etiologies, hyperthyroidism as a precipitant of CVT is not well understood. This study reported a case of a 41-year-old male with a 4-year history of hyperthyroidism presented with seizure. Consequently, a diagnosis of superior sagittal sinus thrombosis was confirmed by computed tomography and magnetic resonance (MR) venograms. Extensive investigations yielded no apparent underlying cause, but laboratory findings were consistent with uncontrolled hyperthyroidism. The patient improved rapidly following anticoagulation. Follow-up MR and MRV scans 2 months after treatment revealed full recanalization of the superior sagittal sinus. This case report highlighted hyperthyroidism, as a procoagulant condition, resulting specifically in superior sagittal sinus thrombosis.

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Cerebral Venous Sinus Thrombosis, a Nonenhanced CT Diagnosis?

Radiology Research and Practice ◽

10.1155/2015/581437 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

Ali Alsafi ◽

Amish Lakhani ◽

Lalani Carlton Jones ◽

Kyriakos Lobotesis

Keyword(s):

Internal Carotid ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Hounsfield Units ◽

Venous Sinus Thrombosis ◽

Institutional Review Board Approval ◽

Institutional Review ◽

Internal Carotid Arteries

Purpose. Retrospectively evaluate the density of cerebral venous sinuses in nonenhanced head CTs (NCTs) and correlate these with the presence or absence of a cerebral venous sinus thrombus (CVST).Materials and Methods.Institutional review board approval was obtained and informed consent waived prior to commencing this retrospective study. Over a two-year period, all CT venograms (CTVs) performed at our institution were retrieved and the preceding/subsequent NCTs evaluated. Hounsfield Units (HUs) of thrombus when present as well as that of normal superior sagittal and sigmoid sinuses were measured. HU of thrombus was compared to that of normal vessels with and without standardisation to the average HU of the internal carotid arteries.Results. 299 CTVs were retrieved, 26 with a thrombus. Both raw and standardised HU measurements were significantly higher in CVST (p<0.0001) compared to normal vessels. Both raw and standardised HUs are good predictors of CVST. A HU of ≥67 and a standardised measurement of ≥1.5 are associated with high probability of CVST on NCT.Conclusion.Cerebral venous sinus HU measurements may help improve sensitivity and specificity of NCT for venous sinus thrombosis and avoid potentially unnecessary follow-up examinations.

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Cerebral venous sinus thrombosis associated with oral contraceptives: the case for neurosurgery

Neurosurgical FOCUS ◽

10.3171/2009.8.focus09158 ◽

2009 ◽

Vol 27 (5) ◽

pp. E5 ◽

Cited By ~ 10

Author(s):

Marcelo Galarza ◽

Roberto Gazzeri

Keyword(s):

Genetic Analysis ◽

Oral Contraceptives ◽

Young Women ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Common Symptom ◽

Venous Sinus Thrombosis ◽

Decompressive Craniotomy ◽

Cerebral Sinus

Object The goal of this study was to provide data about neurosurgical management of cerebral venous sinus thrombosis in young women after use of oral contraceptives. Methods Between 1990 and 2007, the authors treated 15 women (age range 23–45 years) in whom neurosurgical management was used for overt thrombosis of cerebral sinus. All were healthy, with a history of use of oral contraceptives. Severe headache was the most common symptom, followed by motor focal deficits and comatose state. Deep infarcts were located in the thalamic and basal ganglia region in 11 cases. Seven women had associated intracerebral hemorrhage, and 3 had ventricular dilation. Angiographic MR imaging was done in 10 patients, and conventional angiography was done in 7. Genetic analysis of chromosomal abnormalities associated with stroke was done in 5 cases. Results The intracranial pressure (ICP) was monitored in all cases. Three patients underwent external ventricular drainage, and 1 had a decompressive craniotomy. All had absence of signal in the cerebral sinus rectus, with associated thrombosis of the transverse sinus in 7 cases. Angiograms were negative for additional vascular malformation. Medical treatment included sodium heparin and mannitol in 9 cases, and enoxaparin in the other 6 patients. Genetic analysis was positive for prothrombin mutation G20210A (factor II variant) in 2 cases. The mean follow-up duration of 53 months demonstrated no neurological deficit in 10 patients, hemiparesis in 3, and severe hemiparesis with aphasia in 1 case. One woman died 5 days after a decompressive craniotomy. Conclusions Cerebral venous sinus thrombosis secondary to oral contraception in young women, including lesions in critical and deep regions, can be treated medically with acceptable morbidity. In spite of this, a subgroup of patients needed basic neurosurgical management of the lesions, including surgical measures for controlling raised ICP.

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