Cerebrovascular events are severe COVID-19 side effects, and 2-6% of hospitalised patients experience a cerebral stroke. According to data from Europe, Australia, Iran, and Hong Kong, cerebral vein thrombosis is a rare illness with an annual incidence of 0.2-1.75 per 100,000 people. Female sex, infections, hypercoagulability, and pregnancy are some of its known risk factors. COVID-19 causes endothelial damage, inflammation, platelet activation, and stasis, all of which predispose individuals to thromboembolic events. Additionally, there have been a few incidences of CVT, also known as vaccine-induced thrombocytopenic thrombosis, in Europe following COVID-19 inoculation. However, it is unclear whether COVID-19 induces CVT directly or through the activation of a coagulation cascade.
Case Report
This case is of CVT, which is caused by COVID in a 21-year-old mother of twins.
A 21-year-old Iranian woman with dichorionic-diamniotic spontaneous twin pregnancy arrived at the ER with a severe headache. Moreover, she was in her eighth week of pregnancy and had previously had an uncomplicated term pregnancy. In addition to that, she has had an early first-trimester abortion.
Her BMI was 21.4 kg/m2, and she had been experiencing unilateral right-sided pulsatile and throbbing occipital headache radiating to her ipsilateral half of the face for a week prior to her referral. Her headache had become more intense since it began, and simple analgesics had proven ineffective. Furthermore, she had no history of headaches prior to pregnancy, and her only complaint during pregnancy was mild-to-moderate nausea and infrequent vomiting.
The patient had seen her obstetrician two days prior to arriving at the emergency department. The obstetrician got a nasopharyngeal COVID-19 polymerase chain reaction (PCR) test, despite the absence of other common signs and symptoms just to be sure because the pandemic was on the rise. However, the PCR was negative. The Iranian woman was afebrile, in stable hemodynamic condition, and completely conscious when she arrived.
Examination
A neurological examination revealed no abnormal findings. The patient underwent an MRI and an MRV of the brain due to suspected cerebrovascular events. The doctors saw a large parenchymal hematoma in the right temporal lobe on brain MRI, in addition to peripheral white matter oedema and a 2 mm midline shift. Moreover, the MRV result was consistent with cerebral vein thrombosis.
Thrombosis was also seen in the right inferior anastomotic vein. Moreover, doctors also observed small patchy areas of filling defects in the left transverse and sigmoid sinuses had also been seen in favour of partial thrombosis. The deep cerebral veins appeared to be unharmed. The straight sinus, on the other hand, was partially obliterated.
Treatment
Full anticoagulation was initiated with enoxaparin 1 mg/kg, and levetiracetam 500 mg twice daily was added for seizure prevention. In addition, acetaminophen 500 mg was given every 6 hours to control pain. Her headache severity was obviously reduced the next day. Moreover, no new-onset focal neurological deficit was discovered, but she did have a sore throat and flu-like symptoms. The doctors repeated the nasopharyngeal PCR test because she had recently been in contact with a COVID-19-infected person, despite her first negative test result.
Her PCR test result was unexpectedly positive. Hence, The doctors started with 200 mg of remdesivir intravenously, then 100 mg daily, plus dexamethasone 8 mg intravenously twice daily. To confirm COVID-related CVT, all inherited and acquired thrombophilia were examined, and no abnormalities were discovered. Moreover, there was a gradual decrease in the WBCs count during the first four days. However, the peripheral blood smear showed no abnormalities. All other tests, including hepatitis and Coombs test, were also negative.
The doctors discontinued levetiracetam. Since then, the WBC and Plt count started to rise. However, the patient never complained of dyspnea, and her O2 saturation was always greater than 98% on peripheral blood pulse oximetry. The doctors discharged her after six days and there were no complications; both fetuses had normal fetal cardiac activity. Other than that, no retroplacental hematoma was visible on ultrasonography.
During the first and second trimesters, the patient had biweekly prenatal and monthly neurological visits, followed by weekly visits in the third trimester. She had an uncomplicated caesarean section at 38 weeks of pregnancy due to a cephalic-breech presentation twin pregnancy, and both healthy newborns and the mother were discharged 72 hours later.
