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Cerebral Venous Thrombosis in Patients with COVID-19 Infection: a Case Series and Systematic Review
Tian Ming Tu1, Claire Goh2, Ying Kiat Tan2
1Department of Neurology, National Neuroscience Institute, Singapore.
Insights
Coronavirus disease 2019 (COVID-19) is linked to cerebral venous thrombosis (CVT), a rare condition. Early anticoagulation is crucial due to the high mortality rate in COVID-19 patients with CVT.
Area of Science:
- Neurology
- Infectious Diseases
- Hematology
Background:
- Increasing reports link COVID-19 to thromboembolic events, including ischemic strokes and venous thromboembolism.
- Cerebral venous thrombosis (CVT) is a rare neurovascular emergency observed in some COVID-19 patients, with unclear pathophysiology.
Observation:
- A case series of two patients with concomitant COVID-19 and CVT from Singapore.
- A systematic literature review of 14 COVID-19 patients with CVT across nine studies.
Findings:
- The median age of affected patients was 43, with 60% having no significant past medical conditions.
- CVT diagnosis occurred a median of 7 days after COVID-19 symptom onset, commonly involving transverse and sigmoid sinuses.
- Elevated D-dimer (75%) and CRP (50%) levels were frequent; 45.5% mortality rate was observed.
Implications:
- High index of suspicion for CVT in COVID-19 patients is warranted.
- Early anticoagulation treatment is recommended for COVID-19 patients diagnosed with CVT.
- Further research into the pathophysiology of COVID-19-associated CVT is needed.
Background:
There has been increasing reports associating the coronavirus disease 2019 (COVID-19) with thromboembolic phenomenon including ischemic strokes and venous thromboembolism. Cerebral venous thrombosis (CVT) is a rare neurovascular emergency that has been observed in some COVID-19 patients, yet much remains to be learnt of its underlying pathophysiology.
Objective:
We present a case series of local patients with concomitant COVID-19 infection and CVT; and aim to perform a systematic review of known cases in the current literature.
Methods:
We describe two patients with concomitant COVID-19 infection and CVT from a nationwide registry in Singapore. We then conducted a literature search in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 11th June 2020. All studies reporting CVT in COVID-19 patients were included.
Results:
Nine studies and 14 COVID-19 patients with CVT were studied. The median age was 43 years (IQR=36-58) and majority had no significant past medical conditions (60.0%). The time taken from onset of COVID-19 symptoms to CVT diagnosis was a median of 7 days (IQR=6-14). CVT was commonly seen in the transverse (75.0%) and sigmoid sinus (50.0%); 33.3% had involvement of the deep venous sinus system. A significant proportion of patients had raised D-dimer (75.0%) and CRP levels (50.0%). Two patients reported presence of antiphospholipid antibodies. Most patients received anticoagulation (91.7%) while overall mortality rate was 45.5%.
Conclusions:
The high mortality rate of CVT in COVID-19 infection warrants a high index of suspicion from physicians, and early treatment with anticoagulation should be initiated.
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