Massive cerebral venous thrombosis and venous watershed infarction as late complications of COVID-19: a case report

Abstract

In this case report, a male patient who was recovered from COVID-19 with mild symptoms but has developed massive CVT accompanied by venous watershed infarcts as late complications of COVID-19 is presented. The 39-year-old male patient subject to this case report presented to the emergency service with severe headache that started 2 days ago and persisted since then. Vital signs were stable. Neurological examination was normal except for bilateral papilledema. Three months before his hospitalization due to severe headache, he had tested positive for COVID-19, based on the real-time reverse transcriptase polymerase chain reaction (RT-PCR) test performed via nasopharyngeal swab. Neither he nor his family had a history of venous thromboembolism. The computed tomography (CT) scan of his brain taken at the emergency service revealed an increase in calibration and density in bilateral transverse sinus, straight sinus, and superior sagittal sinus (Fig. 1). The results of the laboratory tests of the patient, who was considered to have CVT based on the brain CT scan, are given in Table 1. The high resolution thorax computed tomography of the patient revealed minimal imperceptible ground glass images in the bilateral lower lobes. This result was attributed to COVID-19. The patient was hospitalized, and he was started on 2 × 60 mg/day subcutaneous low molecular weight heparin, 2 × 1 g/day intravenous ceftriaxone, 4 × 125 cc intravenous mannitol, and 3 × 250 mg oral acetazolamide. Mannitol was given for 3 days, ceftriaxone for 2 weeks, and low molecular weight heparin for 3 weeks. Acetazolamide was continued until the headache was relieved and the papilledema subsided. RT-PCR test was performed again from the nasopharyngeal swab on admission, and it was negative. His immunoglobulin G (IgG) antibody level was found to be 3.34 g/L. He tested negative for prothrombin gene mutation test, which was administered in search for the etiology. He was found to have heterozygous methylene tetrahydrofolate reductase and factor V Leiden gene mutations. The results of his anti-nuclear antibody, anti-ds-DNA, antiphospholipid antibody, and anticardiolipin antibody tests came out as negative. Cranial magnetic resonance imaging (MRI) revealed venous infarct area in the right thalamus; MRI and magnetic resonance venography (MRV) revealed bilateral transverse sinus, straight sinus, superior sagittal sinus, right internal cerebral vein, and thrombus in the right thalamostriate vein; and diffusion-weighted images revealed watershed infarct areas restricting diffusion in the border regions of the deep white matter (Fig. 2). Carotid-vertebral artery Doppler ultrasonography did not reveal anything abnormal, as did electrocardiography, echocardiography, Holter monitor test, and magnetic resonance angiography. After 3 weeks of treatment, the patient’s headaches almost halved, and his C-reactive protein (CRP) levels returned to the normal. He was started on warfarin sodium, having set the related international correction rate (INR) to be in the range of 2–2.5, and was then discharged, having scheduled a follow-up visit for 1 month after the date of discharge. He was still being followed up until the time he presented to the emergency service with severe headache. It was reported in numerous studies that COVID-19 causes neurological symptoms. Neurological findings were Highlights • Cerebral venous thrombosis (CVT) is a rare complication of COVİD-19 infection. • Late neurological complications can be seen in COVID-19 infection. • Venous watershed infarcts are rare, and CVT is also rare. • CVT is more common in cases with a mild course of COVID infection.