Diagnosis and management of cerebral venous and sinus thrombosis in patients recovering from COVID-19

BACKGROUND: Cerebral venous thrombosis is a multifactorial and difficult-to-diagnose disease, complicated by venous stroke, intracerebral hemorrhage, progressive cerebral edema, dislocation syndrome, and even death. The broad variability of clinical symptoms and lack of pathognomonic manifestations complicate timely diagnosis of cerebral venous thrombosis.

AIM: To identify significant risk factors for cerebral venous thrombosis and to evaluate the dynamics of neuroimaging findings at 1, 3, and 6 months after cerebral venous thrombosis onset in young and middle-aged patients with a history of COVID-19, comparing outcomes between those treated with direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs).

METHODS: Young and middle-aged patients with a history of novel coronavirus infection (COVID-19) were examined and divided into two groups depending on the presence or absence of cerebral venous thrombosis. The main risk factors, structural features of the major arteries and cerebral venous sinuses, as well as the course of cerebral venous and sinus thrombosis during anticoagulant therapy (with direct oral anticoagulants and vitamin K antagonists) at 1, 3, and 6 months after the development of cerebral venous thrombosis were analyzed.

RESULTS: We examined 120 young and middle-aged patients with COVID-19 divided into 2 groups: Group I – 70 patients who developed cerebral venous thrombosis during COVID-19 – 21 (30%) men and 49 (70%) women; Group II – 50 patients who had COVID-19 without cerebral venous thrombosis development – 27 (54%) men and 23 (46%) women. The main risk factor for developing cerebral venous thrombosis among women in the first group (with cerebral venous thrombosis during COVID-19) compared to the second group (patients who had COVID-19 without developing cerebral venous thrombosis) was the use of combined oral contraceptives: 22.9% and 4.0%, respectively (р = 0.001). Among group I patients, 32 (45.7%) cases of cerebral venous thrombosis were accompanied by the development of venous stroke: ischemic in 13 (18.6%) patients, hemorrhagic in 7 (10%), mixed (ischemic stroke with hemorrhagic infiltration) in 12 (17.1%) patients. In a comparative analysis of the variants of the structure of the cerebral arteries (absence of the posterior communicating arteries, pathological tortuosity of the internal carotid artery [ICA], trifurcation of the ICA, open arterial circle of Willis) and venous sinuses (presence of hypo-/aplasia), no statistically significant difference was detected. The analysis of the course of cerebral venous thrombosis during treatment with vitamin K antagonists (warfarin) and direct oral anticoagulants in 53 patients with cerebral venous thrombosis (age 41 ± 12 years) at 1,3, and 6 months after the development of cerebral venous thrombosis onset showed that with anticoagulants, recanalization was observed in 44 (83%) patients: complete – in 21 patients (47.7%), partial – in 23 (52.3%). Recanalization was absent in 9 (17.0%) cases. No recurrent cerebral venous thrombosis cases were observed among the study patients.

CONCLUSION: Verification of cerebral venous thrombosis in the context of COVID-19 necessitates a detailed examination of risk factors, patient history, assessment of clinical manifestations, and comprehensive implementation of laboratory and instrumental, as well as neuroimaging diagnostic methods. Timely verification and immediate initiation of anticoagulant therapy ensure a relatively favorable prognosis for the disease course.