Increased risk of cerebral venous thrombosis in COVID-19

Patients with COVID-19 are at high risk for cerebral venous thrombosis (CVT), therefore, this complication should be suspected in COVID-19 patients presenting with headache or seizures. Mortality among patients with CVT was high, but the functional neurological outcome was good among survivors. This was found in an international observational study [1].

An increased propensity for systemic hypercoagulability and thromboembolism has been reported among COVID-19 patients [2]. In one study, thrombotic complications were reported in approximately one-third of critically ill COVID-19 patients. “Although the majority had pulmonary embolism, ischaemic stroke was also observed in these patients,” said Dr Sajid Hameed (Aga Khan University, Pakistan). Furthermore, an increased incidence of cerebrovascular diseases (1–6%) has been reported among patients with COVID-19 [3]. In April 2020, the first case of CVT in a COVID-19 patient was published [4]. At the time of the present study, evidence on CVT among COVID-19 patients was limited [1].

To this end, the current multinational, prospective, observational study was performed in 4 countries: Pakistan, Egypt, Singapore, and the United Arab Emirates. All data was obtained retrospectively from COVID-19 registries and hospital medical records. The study included 20 adult patients with symptomatic CVT and a recent SARS-CoV-2 infection. “At the time of this study, this was the largest study of CVT in patients with COVID-19,” Dr Hameed explained. Non-COVID-19 CVT occurs mainly in young women. However, in COVID-19, men are more frequently affected (70%) and patients have a slightly older age (mean age 42.4 years).

Headache (85%) and seizures (65%) were the most common neurological features. Headache lasted 3–7 days in 76% of the cases. Seizures were of generalised onset in 10 cases (77%) and of focal onset in 3 cases (23%). CVT was the presenting feature in 13 (65%) COVID-19 cases; 7 (35%) patients developed CVT while being treated for COVID-19. “Interestingly, 9 (45%) cases did not have respiratory symptoms at the time of diagnosis of CVT,” Dr Hameed added. In 5 (25%) patients, CVT was the sole presentation of COVID-19, with no signs of respiratory symptoms nor fever.

Of the analysed patients, 15 (75%) were discharged with an improving condition, 4 (20%) patients died, and 1 (5%) patient was referred to another hospital for rehabilitation. “All 4 patients who died had a low Glasgow Coma Score (GCS; 8–10) at admission, hence a poor prognosis,” Dr Hameed said, “whereas the discharged cases had an average modified Rankin Scale score of 1.3, which is excellent.”

Dr Hameed speculated that the current number of CVT cases in COVID-19 patients may be an underestimation and that COVID-19 testing should be included as standard workup among all patients with CVT, including those without throat or respiratory symptoms. Conversely, all COVID-19-positive patients with headache and neurological symptoms should be evaluated for CVT.

1. Shaikh SH, et al. Cerebral venous thrombosis (CVT) associated with COVID-19 infection; A multi-center study. AL09, IHC 2021, 8–12 September.
2. Klok FA, et al. Thromb Res. 2020;191:145–7.
3. Aggarwal G, et al. Int J Stroke. 2020;15(4):385–9.
4. Hughes C, et al. Eur J Case Rep Intern Med. 2020;7:001691.

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Posted on 8 November, 202120 February, 2024