- Research Letter
- Open Access
COVID-19-associated acute cerebral venous thrombosis: clinical, CT, MRI and EEG features
Critical Care volume 24, Article number: 419 (2020)
Many recent COVID-19 series have reported arterial or venous thrombosis (stroke, pulmonary embolism, etc.) [1, 2]. Here, we report a case of COVID-19 associated cerebral venous thrombosis (CVT) with dramatic evolution.
On April 3, 2020, a 63-year-old female presented to the emergency department because of aphasia and right hemiplegia. She had a 12-day history of fever, cough, and anosmia. Her husband was hospitalized in intensive care for confirmed COVID-19 acute respiratory distress syndrome (ARDS). Brain MRI showed a large left temporal brain hemorrhage and a suspicion of CVT confirmed on a venous brain CT scan and chest CT showed typical COVID-19 patchy ground-glass opacities in both lungs (Fig. 1).
The patient suddenly suffered a clinical status epilepticus and was administered i.v. lacosamide.
Laboratory results showed hyperfibrinogenemia (7.2 g/L) and high ferritin levels (1427 μg/L).
The nasopharyngeal and bronchial samples were negative for SARS-CoV-2.
Most common causes of genetic thrombotic disorders and antiphospholipid antibody syndrome were excluded.
The patient was started on an intravenous curative dose of heparin anticoagulation.
Electroencephalograpy (EEG) showed background theta activity unreactive to nociceptive stimulus, with pseudo-periodic activity of a short period composed of slow di-phasic waves irradiating towards the anterior regions (Fig. 2). Although subtle status epilepticus could not be excluded, the aspect was not typical and other successive EEG traces would confirm this non-epileptic paroxystic pseudo-periodic pattern. The patient eventually underwent surgical intracranial hematoma evacuation followed by decompressive craniectomy.
On April 17th, brain CT scan revealed a new intracranial contralateral bleeding most likely following contralateral venous thrombosis despite being properly treated with intravenous heparin. Venous angiography showed persistent left thrombosis (Fig. 1). On April 25th, the patient was tested positive for SARS-CoV-2 plasmatic IgG and IgM (ELISA test).
On April 29th, the patient died following therapeutic limitation after ethical consultation group expertise.
Although both samples were negative for SARS-CoV-2, we considered the patient infected by it, given the initial symptomatology, the confirmed infection in one relative, the specific aspect of the thoracic CT scan , and the positive serology. Furthermore, in this case, the thrombotic event occurred 12 days after the first influenza-like symptoms, which corresponds to the most inflammatory period of COVID-19 [4, 5].
In addition to the left lesion temporal focus observed on the EEG, the background activity and paroxysmal activity describes atypical patterns, which can be mistaken with persistent epileptic activity. However, we believe it is compatible with newly described patterns of specific COVID-19 encephalopathy .
Overall, this case suggests that practitioners should be aware of the possibility of a CVT in this novel COVID-19 context, especially during the post-viral period.
Availability of data and materials
All data analyzed in this report is available by simple request to the corresponding author.
Acute respiratory distress syndrome
Coronavirus disease 19
Cerebral venous thrombosis
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The authors would like to thank Dr. Clementine Cholet, Dr. Vera Dinkelacker, and Dr. Basma Abdi for their precious help in retrieving data for this case report.
Ethics approval and consent to participate
This study is only a retrospective report; therefore, no ethics approval was needed.
Consent for publication
Patient’s family gave their written consent for publication.
H. Vespignani interprets electroencephalography patterns for his private firm Serenity Medical Service-Neurophy. All the other authors declare they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Following publication of the original article, the authors identified an error in five author names. The given name and family name were erroneously transposed.
Address for reprint: Fondation Ophtalmologique Adolphe de Rothschild, 29 Rue Manin, 75019 Paris, France.
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Cite this article
Roy-Gash, F., De Mesmay, M., Devys, JM. et al. COVID-19-associated acute cerebral venous thrombosis: clinical, CT, MRI and EEG features. Crit Care 24, 419 (2020). https://doi.org/10.1186/s13054-020-03131-x
- Cerebral venous thrombosis
- Intracerebral hematoma
- Diagnostic imaging