Case
A 34-year-old with a recent diagnosis of COVID-19 with mild symptoms (fever, cough, mild dyspnea on exertion), presented to an outside hospital with severe headaches and nausea. Other than COVID-19, her only other notable history was the use of oral contraceptives. Her initial non-contrast CT scan was reportedly normal. She was discharged home with anti-emetics and medications for pain control. Her symptoms persisted, and she presented to our emergency department for repeat evaluation.
Her neurologic exam was normal, except for mild drowsiness and papilledema. A repeat CT and CT venogram was performed, which showed extensive dural sinus thrombosis (DST) involving the superior sagittal sinus, both transverse sinuses, torcular herophili, and jugular bulbs (Figure 1). She was started on anticoagulation with heparin for 24 hours, without significant improvement in her clinical status. Given the poor anecdotal outcomes of 2 prior patients with COVID-19 and dural sinus thrombosis treated with anticoagulation at our institution (both progressed to hemorrhagic venous infarction and died), the decision was made for early aggressive management with intrasinus tPA.
Figure 1.
34-year-old woman with dural sinus thrombosis.
She was taken to the angiography suite where, via a transfemoral venous approach, a microcatheter was advanced into the superior sagittal sinus. An angiographic run was performed, which showed complete occlusion of the dural sinuses (Figure 2). Intrasinus tPA was administered for a total of 48 hours at a rate of 1 mg per hour. Serum fibrinogen levels were obtained every 6 hours, and the rate of tPA infusion adjusted accordingly (infusion rate decreased to 0.5 mg if fibrinogen levels decreased below 150, or infusion stopped for 6 hours if fibrinogen levels decreased below 100). A repeat cerebral venogram performed 48 hours later showed complete recanalization of the superior sagittal sinus, with antegrade flow into the jugular bulb via an occipital sinus (Figure 3). Her headaches substantially improved, her papilledema resolved, and she was discharged home on anticoagulation. At her 3-month follow-up visit, she was neurologically intact, and a follow-up CTV showed continued patency of the superior sagittal sinus (Figure 4).
Figure 2.
34-year-old woman with dural sinus thrombosis.
Figure 3.
34-year-old woman with dural sinus thrombosis, 48 hours after intrasinus infusion of tPA.
Figure 4.
34-year-old woman with dural sinus thrombosis. 3-month follow-up CTV.
Over a year since the start of the COVID-19 outbreak, multiple reports have shown an increased risk of arterial and venous thrombosis in infected patients.1,2 While cases of acute ischemic strokes from arterial thrombosis predominate in the literature, a few reports have documented the course of dural sinus thrombosis in patients with COVID-19.3-5 Chougar et al. reported on a 72-year-old man with COVID-19 and deep cerebral venous thrombosis, who had rapidly progressive hemorrhagic venous infarction, eventually succumbing to his disease.3 Pouillon et al. reported on 2 patients with COVID-19 and dural sinus thrombosis, both of whom had large hemorrhagic venous infarcts.4 Tu et al reported a series of 14 patients with dural sinus thrombosis and COVID-19, in which the mortality rate was high at 45%.5 Our own institutional experience corroborates this. Several months prior to the case presented here, 2 patients with COVID-19 and dural sinus thrombosis presented to our institution, and both patients progressed to hemorrhagic venous infarction despite anticoagulation. The apparent high morbidity and mortality of dural sinus thrombosis in COVID-19 patients and our own institutional experience prompted early consideration for neurointerventional treatment in this young otherwise healthy patient, with good results. Direct instillation of tPA into a thrombosed dural sinus has been used by other authors to good effect, but a few caveats remain.6 Continuous infusion of tPA contraindicated in patients with intracranial hemorrhage, as it can cause rapid hematoma expansion and death. Recent surgery at a noncompressible site, or recent large myocardial infarction would also be a contraindication, particularly since other non-thrombolytic treatment modalities exist for dural sinus thrombosis.
The first image in Figure 1 is an axial contrast-enhanced T1-weighted MRI showing thrombus occluding the superior sagittal sinus (arrow). The second image is a coronal reconstruction of a CT venogram performed several hours later showing thrombus in the superior sagittal sinus (arrow).
Figure 2 is a lateral projection digital subtraction angiogram (DSA) performed via injection of contrast through a microcatheter navigated into the superior sagittal sinus. There are irregular fillings defects with the sinus, with essentially non-opacification/thrombosis of the entire superior sagittal sinus (arrows). There is extracranial venous drainage into the scalp veins, but no antegrade venous drainage into the proximal superior sagittal sinus, transverse sinus, or internal jugular veins.
Figure 3 is a lateral projection digital subtraction angiogram (DSA) performed via injection of contrast through a microcatheter navigated into the superior sagittal sinus. There has been interval recanalization of the superior sagittal sinus, now with antegrade flow of contrast into the proximal superior sagittal sinus and into the neck via the right internal jugular vein (arrows).
Figure 4 is a coronal reconstruction of a CT venogram, performed at a 3-month follow-up visit after patient was discharged on anticoagulation. There is persistent patency of the superior sagittal sinus without thrombosis (arrow).
Abbreviations
- COVID-19
Coronavirus disease 2019
- CT
computed tomography
- MRI
magnetic resonance imaging.
Footnotes
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethics Statement: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Mougnyan Cox, MD 
https://orcid.org/0000-0002-5113-2228
Informed Consent: Informed consent was obtained from all individual participants included in the study.
References
- 1.Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089–1098. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kremer S, Lersy F, Anheim M, et al. Neurologic and neuroimaging findings in patients with COVID-19: a retrospective multicenter study. Neurology. 2020;95(13):e1868–e1882. [DOI] [PubMed] [Google Scholar]
- 3.Chougar L, Mathon B, Weiss N, Degos V, Shor N. Atypical deep cerebral vein thrombosis with hemorrhagic venous infarction in a patient positive for COVID-19. AJNR Am J Neuroradiol. 2020;41(8):1377–1379. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Poillon G, Obadia M, Perrin M, Savatovsky J, Lecler A. Cerebral venous thrombosis associated with COVID-19 infection: causality or coincidence? J Neuroradiol. 2020;S0150–9861(20)30167–X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tu TM, Goh C, Tan YK, et al. Cerebral venous thrombosis in patients with COVID-19 infection: a case series and systematic review. J Stroke Cerebrovasc Dis. 2020;29(12):105379. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Karanam LS, Baddam SR, Pamidimukkala V, Vemuri R, Byrapaneni S, Polavarapu R. Local intrasinus thrombolysis for cerebral venous sinus thrombosis. J Vasc Interv Neurol. 2016;9(2):49–54. [PMC free article] [PubMed] [Google Scholar]