SUPERIOR SAGITTAL SINUS THROMBOSIS PRESENTING AS DETERIORATING RESIDUAL WEAKNESS

SESSION TITLE: Imaging, ECMO, and other Procedures in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Superior sagittal sinus (SSS) thrombosis is a rare cause of stroke that is difficult to identify due to various clinical presentations. It is the most common form of dural sinus thrombosis, and common risk factors include hypercoagulable state, traumatic head injury, pregnancy/postpartum, and malignancy. More than 85 percent of adult patients have at least one risk factor for cerebral venous thrombosis. Some patients with SSS thrombosis do not have clearly identifiable risk factors, and this case highlights one such patient. CASE PRESENTATION: A 60-year-old Caucasian male with hypertension, hyperlipidemia, and a recent intracranial hemorrhage with residual left-sided weakness, presented to the emergency department with worsening left-sided weakness. Upon admission, his physical exam was notable for 4/5 strength in the left upper extremity and 2/5 strength in the left lower extremity. This was a reduction in strength from a baseline of 4/5 in the left upper and lower extremities. Labs on admission were normal except for high-sensitivity troponin of 86 and WBC of 14.5. UA with a small amount of blood. An initial CT brain without contrast showed no acute changes, evolutionary changes in the right frontal temporal lobe, and subtle curvilinear hyperdensity near a site of the intracranial hemorrhage identified in the prior month. This curvilinear hyperdensity was thought to reflect early parenchymal calcification. MRI brain without contrast showed new and evolving areas of abnormal signaling and an evolving hematoma with surrounding vasogenic edema, all of which are in the right lobe. There was no apparent diffusion coefficient correlate. Thus, MRI with contrast and MRV was recommended. EEG showed no evidence of epileptiform activity. Additionally, transthoracic echo demonstrated new non-ischemic cardiomyopathy with an EF of 35-40%. The diagnosis was ultimately made after the patient had a Magnetic Resonance Venography (MRV) which showed evidence of the SSS thrombosis and an indication that the previously visualized curvilinear hyperdensity is suspected to represent slowed flow within a surface vein. Heparin was started to recanalize the sinus and prevent thrombus propagation. After the appropriate treatment was started, the patient's weakness improved dramatically. DISCUSSION: Typically, patients with SSS thrombosis have identifiable risk factors like hypercoagulable states, traumatic head injuries, pregnancy/postpartum, malignancy, and more recently association with COVID-19 infection. In this case, since the patient lacked identifiable risk factors, the MRV played a key role in the diagnosis. CONCLUSIONS: Like our patient, 30-40 percent of patients present with an intracerebral hemorrhage. Differentials of SSS thrombosis should be considered in etiologies for intracerebral hemorrhage, especially when an identifiable cause is lacking, in order to avoid delays in treatment and resolution. Reference #1: Abdalkader M, Shaikh SP, Siegler JE, Cervantes-Arslanian AM, Tiu C, Radu RA, Tiu VE, Jillella DV, Mansour OY, Vera V, Chamorro Á, Blasco J, López A, Farooqui M, Thau L, Smith A, Gutierrez SO, Nguyen TN, Jovin TG. Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature. J Stroke Cerebrovasc Dis. 2021 Jun;30(6):105733. doi: 10.1016/j.jstrokecerebrovasdis.2021.105733. Epub 2021 Mar 4. PMID: 33743411;PMCID: PMC7931726. Reference #2: Rehman A, Husnain MG, Mushtaq K, Eledrisi MS. Cerebral venous sinus thrombosis precipitated by Graves’ disease. BMJ Case Rep. 2018 Jun 4;2018:bcr2017224143. doi: 10.1136/bcr-2017-224143. PMID: 29866676;PMCID: PMC5990097. Reference #3: Nakase H, Takeshima T, Sakaki T, Heimann A, Kempski O. Superior sagittal sinus thrombosis: a clinical and experimental study. Skull Base Surg. 1998;8(4):169-74. doi: 10.1055/s-2008-1058178. PMID: 17171061;PMCID: PMC1656696. DISCLOSURES: No relevant rel tionships by Ken Johnson No relevant relationships by Nina Le No relevant relationships by Riaz Mahmood No relevant relationships by Ngoc Phan

A RARE PRESENTATION OF COVID-19-ASSOCIATED CENTRAL VENOUS THROMBOSIS

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Due to a wide range of clinical presentations, central venous thrombosis (CVT) is a rare neurologic condition that can be difficult to diagnose. Since the COVID-19 pandemic, more cases of venous thromboembolic events have emerged and been found associated with COVID-19. We detail a potential case of COVID-19 associated CVT. CASE PRESENTATION: A 28-year-old female with past medical history of obesity, polycystic ovary syndrome, recurrent sinusitis, and presumed history of COVID-19 infection with anosmia, ageusia, and sinusitis symptoms three- months prior presented to the hospital with 1-month history of worsening, right-sided pain behind her ear, eye, head, posterior neck and shoulder, nausea, and photophobia, which had worsened in the last 5 days. She initially tried over-the-counter medications with no improvement. Vital signs were unremarkable. Examination was notable for frontal sinus and right postauricular tenderness to palpation. C- reactive protein was elevated at 26.2 mg/L. Non- contrasted brain computed tomography (CT) was concerning for right transverse sinus and superior sagittal sinus thrombosis. Brain magnetic resonance imaging (MRI) showed early signs of cortical edema and venous infarction and findings concerning for right mastoiditis. Intracranial venous MRI showed complete thrombosis of the right transverse and sigmoid sinus, superior sagittal sinus, and most of the superior draining cortical veins. Heparin drip was started. Initial empiric antibiotics for mastoiditis were stopped. Hyper-coagulopathy work-up with beta- 2 glycoprotein 1 antibodies and phospholipid antibodies were negative. As there were no other inciting factors for CVT found and no history of positive COVID-19 test, a COVID-19 antibody immunoassay was obtained and returned positive. The patient did not have a history of COVID vaccination. She was discharged on warfarin and enoxaparin. Anticoagulation was stopped after 6 months with repeat imaging showing resolution of clot burden. DISCUSSION: Usual risk factors associated with CVT are morbid obesity, hormone replacement therapy, oral contraceptive use, hereditary thrombophilia, and pregnancy. Literature on CVT related to COVID-19 is limited. In 41 documented cases, the average age of incidence is 50 years old and median onset of neurological symptoms from initial COVID-19 diagnosis is 7 days [0 to 21 days]. Our patient's neurological symptoms began about 3 months after her initial diagnosis, potentially making it the first known case of COVID-19 associated CVT with symptom onset past 21 days. Anticoagulation is the mainstay treatment for CVT, and duration depends on the presence of provoking factor. CONCLUSIONS: In patients with new neurologic symptoms and recent diagnosis of COVID-19, CVT should be considered in the differential diagnosis as it can initially present in a subtle manner. Early recognition could improve patient morbidity and mortality. Reference #1: Abdalkader, M., Shaikh, S. P., Siegler, J. E., Cervantes-Arslanian, A. M., Tiu, C., Radu, R. A., Tiu, V. E., Jillella, D. v., Mansour, O. Y., Vera, V., Chamorro, Á., Blasco, J., López, A., Farooqui, M., Thau, L., Smith, A., Gutierrez, S. O., Nguyen, T. N., Jovin, T. G. (2021). Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature. Journal of Stroke and Cerebrovascular Diseases. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105733 Reference #2: Idiculla, P. S., Gurala, D., Palanisamy, M., Vijayakumar, R., Dhandapani, S., Nagarajan, E. (2020). Cerebral Venous Thrombosis: A Comprehensive Review. European Neurology (Vol. 83, Issue 4). https://doi.org/10.1159/000509802 Reference #3: Ostovan VR, Foroughi R, Rostami M, et al. Cerebral venous sinus thrombosis associated with COVID-19: a case series and literature review. Journal of Neurology. 2021 Oct;268(10):3549-3560. DOI: 10.1007/s00415-021-10450-8. PMID: 33616740;PMCID: PMC7897893. DI CLOSURES: No relevant relationships by Shu Xian Lee No relevant relationships by Arif Sarwari No relevant relationships by Benita Wu