Fulminant Extra- And Intracranial Arteriovenous Thrombosis And Non-aneurysmal Subarachnoid Hemorrhage Following COVID-19 Infection.

PURPOSE: Coronavirus disease of 2019 (COVID-19) is associated with increased risk of stroke and intracranial hemorrhage. This first report of fulminant panvascular arteriovenous thrombosis with subarachnoid hemorrhage (SAH) in a post-COVID-19 infection is attributed to extensive arteriovenous inflammation leading to arterial rupture following vasculitis. CASE REPORT: We report a rare case of extensive extra- and intra-cranial cerebral arteriovenous thrombosis following COVID-19 infection, presenting as fatal non-aneurysmal subarachnoid hemorrhage. The clinical course, biochemical and radiological evaluation is discussed. The other possible etiological differentials which were analysed and ruled out during case management are also detailed. CONCLUSION: A high degree of suspicion for COVID-19 induced coagulopathy leading to extensive non- aneurysmal, non-hemispheric SAH and malignant intracranial hypertension should be entertained. Our experience and previous reports on non-aneurysmal SAH in such patients show a poor prognosis.

An epidural brain abscess and thrombus in the superior sagittal sinus in a 12 year-old with sinusitis.

BACKGROUND: Upper respiratory infections can be complicated by acute bacterial sinusitis in pediatric patients, and usually resolve with antibiotic therapy (DeMuri and Wald, 2011). However, intracranial complications such as: epidural abscess, meningitis and more rarely cerebral sinus venous thrombosis (CSVT) can occur (Germiller et al., 2006). We report an unusual case of sinusitis complicated by an epidural abscess and later a CSVT in a young previously healthy patient. CASE DESCRIPTION: A 12-year-old female presented to the emergency department with a 9-day history of headaches and a 3-day history of fevers, rigors, nasal congestion and nonproductive cough. She later tested positive for Covid-19. CT and MRI showed extensive paranasal sinus disease and a right frontal epidural collection. MRV showed no sinovenous thrombosis. Washout and burr hole drainage alongside endoscopic sinus surgery was completed and post-op imaging showed evacuation of the epidural abscess with a small residual collection. Six days after the procedure, she experienced worsening headaches and MRV showed a nonocclusive thrombus in the superior sagittal sinus, which was treated with anticoagulation therapy. Upon follow-up, the patient showed improvement of the sinusitis, abscess and thrombus. CONCLUSION: This specific case encourages clinicians to be aware of complications, though rare, and to diagnose and treat sinusitis cases quickly. It is also important to be aware of any risk factors for thrombus formation, including an inflammatory and hypercoagulable state. In the patient's case, it was perceived that the CSVT was provoked due to the patient's Covid-19 infection, abscess, and sinus disease.

Cerebral venous thrombosis secondary to ulcerative colitis: A case report with a literature review.

Ulcerative colitis is an idiopathic inflammatory bowel condition that may be worsened by thromboembolic events such deep vein thrombosis, cerebral venous thrombosis, and pulmonary embolism. Cerebral venous thrombosis is a rare but critical consequence of ulcerative colitis characterized by high mortality and morbidity rate. It is thought to be caused by the hypercoagulable state that occurs during ulcerative colitis relapse. Cerebral venous thrombosis is a reversible condition with good outcomes when detected early and treated properly. In this study, we describe the case of a young woman who presented with cerebral venous thrombosis secondary to ulcerative colitis complicated by venous infarction with petechial cerebral hemorrhage.

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

Factors related to longterm anticoagulation in cvt patients from a tertiary hospital

Background and aims: Anticoagulation on CVT is followed until 6 to 12 months according to guidelines. Longer periods of treatment are used in patients with high thrombotic risk. We describe the duration of treatment with OAC and what risk factors are related to longer treatment. Methods: We conducted a retrospective single centre study in a tertiary hospital in México City. Electronic medical files of consecutive patients with CVT were reviewed from January 2018 to June 2020. Clinical, radiological and laboratory variables were obtained. Patients were allocated according to the time of use of OAC (less or more than a year). Results: We collected data from 20 patients. 14 (70%) were female, with a mean age of 33.5 (26-50). 40% (n=8) were smokers, 20% (n=4) used hormonal contraceptives, 15% (n=3) were pregnant or in puerperium and 10% (n=2) referred vaccination for SARS-CoV-2. superior sagittal sinus was the most frequently affected (65%). The median time of AOC treatment was 13 months (6.7-16.7). In the bivariate analysis, the existence of a chronic cause (OR 14;IC95%, 1.25-156;p= 0.028), and prolonged hospitalization (OR 15.7;IC95% 1.7-141.4 p= 0.22) were associated with AOC treatment over a year. Initial NIHSS, mRS at discharge, D-dimer values or seizures al presentation showed no correlation. Conclusion: Use of OAC in a tertiary centre is related to chronic conditions with high thrombotic risk and with long hospital stay, according to the guideline's recommendations.

LONG TERM USE OF ANTICOAGULATION IN CVT IN A TERTIARY HOSPITAL

Background and aims: Anticoagulation use on CVT is followed until 6 to 12 months according to guidelines. Longer periods of treatment are used in patients with high thrombotic risk. We describe the duration of treatment with OAC and what risk factors are related to longer treatment. Methods: We conducted a retrospective single centre study in a tertiary hospital in México City. Electronic medical files of consecutive patients with CVT were reviewed from January 2018 to June 2020. Clinical, radiological and laboratory variables were obtained. Patients were allocated according to the time of use of OAC (less or more than a year). Results: We collected data from 20 patients. 14 (70%) were female, with a mean age of 33.5 (26-50). 40% (n=8) were smokers, 20% (n=4) used hormonal contraceptives, 15% (n=3) were pregnant or in puerperium and 10% (n=2) referred vaccination for SARS-CoV-2. Superior sagittal sinus was the most frequently affected (65%). The median time of AOC treatment was 13 months (6.7-16.7). In the bivariate analysis, the existence of a chronic cause (OR 14;IC95%, 1.25 - 156;p= 0.028), and prolonged hospitalization (OR 15.7;IC95% 1.7 - 141.4 p= 0.22) were associated with AOC treatment over a year. Initial NIHSS, mRS at discharge, D-dimer values, or seizures at presentation showed no correlation. Conclusions: Use of OAC in a tertiary centre is related to chronic conditions with high thrombotic risk and with long hospital stay, according to the guideline's recommendations. (Table Presented).

Immune thrombocytopenia secondary to COVID-19 vaccine: a rare case

Background: SARS-CoV-2 associated COVID-19 was declared as pandemic in March'20.It led to accelerated scientific development leading to production of several vaccines.In India,first vaccine used was ChAdOx1 nCoV-19.Reports of pro-thrombotic and hemorrhagic complications with it are there but isolated immune thrombocytopenia is rare.We are reporting secondary immune thrombocytopenia (ITP) possibly attributed to COVID-19 vaccine. Aims: A 21-years female came to General Medicine with complaints of weakness,rashes all over body,bleeding from gums, menorrhagia and reddish discoloration of urine.She had history of COVID-19 vaccination 2 days back.On examination, she was mildly febrile, showed multiple pin-point petechial haemorrhages over face,abdomen,both limbs and sub-conjunctival haemorrhage with no complaints of headache/visual disturbances/pain abdomen/respiratory distress.Systemic examination showed no significant findings.She had no previous history of bleeding/drug intake/no family history of bleeding or any other significant conditions. Methods: Lab investigations showed Hb:8.6gm%,TLC:14,400/cmm, platelet counts:10,000/cmm.Peripheral blood smear showed normocytic normochromic RBC with leucocytosis and marked thrombocytopenia with absent hemoparasites.Urine examination showed numerous RBCs with no pus cells.S. electrolytes were normal, SGOT/ SGPT were mildly increased, total proteins were normal.S. bilirubin,urea,creatinine were normal.HIV,HCV,HBsAg,CMV IgM were negative.To rule out connective tissue disorders,ANA and dsDNA were performed which came negative.Her USG abdomen and CTchest were normal.COVID-19 RT-PCR was negative.ITP secondary to COVID-19 vaccination was suspected. Results: She was started with i.v. methylprednisolone pulse therapy for 3 days and IVIG for 2 days and also received trenexamic acid for menorrhagia.She received 6 units of random donor platelets which improved platelet count.After haematology consultation,oral prednisolone for 7 days with alternate day platelet count monitoring was started.She improved symptomatically with no new bleeding.She was discharged after 10 days with an advice to follow up. Summary/Conclusions: ITP is autoimmune disorder with autoantibodies against platelets,more common in females.It is usually idiopathic,but occasionally secondary to viral infections/vaccinations. Incidence of vaccine associated ITP is <1%.Previously reported with various vaccines like influenza,measles,mumps,rubella,etc.Vaccine induced thrombotic thrombocytopenia (VITT) with COVID-19 vaccine has been well documented,but ITP is rare.VITT is usually characterized by major thrombotic episodes at unusual locations like sagittal sinus,splanchnic circulation,etc. with visual, neurological and abdominal features.No such findings seen in our case.Although she had low platelet count,yet mild symptoms which improved with conservative management with steroid and IVIG.Although we could not establish a temporal link;yet based on findings,ITP secondary to COVID-19 vaccine could not be ruled out.It is important to be aware of this complication as although rare,it could lead to significant morbidity and fatal bleed if not managed promptly. Steroids and IVIG is highly effective in ITP irrespective of cause.However,more investigations need to be done to establish a temporal relationship with COVID-19 vaccine. Nevertheless,occurrence of ITP should not be a deterrent in vaccination,though caution should be exerted in history of thrombocytopenia.

A Rare Effect of Covid-19: Cerebral Venous Sinus Thrombosis Case Presentation

Introduction: Many studies have shown that coagulation disorders and increased risk of thrombosis may occur during coronavirus disease 2019 (COVID-19) infection. Although cardiac or pulmonary vascular pathologies has been detected in most cases, cerebral sinus thrombosis are rare. During COVID-19 infection patients rarely present with neurological symptoms. Case Report: A 19-year-old man was admitted to our emergency department with neurological symptoms. Cerebral venous sinus thrombosis (CVST) was detected in Brain Computerized Tomography and Magnetic Resonance Imaging examinations. Our patient was hospitalized in the neurology department of our hospital for medical treatment and was discharged after clinical recovery. Discussion: In this case report we wanted to draw attention to cerebral venous sinus thrombosis which is a rare but treatable complication of COVID-19 infection in a young patient. We examined our patient in the light of literature. Conclusion: Clinicians should keep in mind the diagnosis of CVST that may occur due to infection associated thrombosis in COVID-19 patients presenting with neurological symptoms and consider adding anticoagulants to the treatment if necessary.