Cerebral Venous Thrombosis Associated with COVID-19

Ocular neuroinflammatory response secondary to SARS-CoV-2 infection-a review

With the consistent occurrence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the prevalence of various ocular complications has increased over time. SARS-CoV-2 infection has been shown to have neurotropism and therefore to lead to not only peripheral inflammatory responses but also neuroinflammation. Because the receptor for SARS-CoV-2, angiotensin-converting enzyme 2 (ACE2), can be found in many intraocular tissues, coronavirus disease 2019 (COVID-19) may also contribute to persistent intraocular neuroinflammation, microcirculation dysfunction and ocular symptoms. Increased awareness of neuroinflammation and future research on interventional strategies for SARS-CoV-2 infection are important for improving long-term outcomes, reducing disease burden, and improving quality of life. Therefore, the aim of this review is to focus on SARS-CoV-2 infection and intraocular neuroinflammation and to discuss current evidence and future perspectives, especially possible connections between conditions and potential treatment strategies.

Treatment of cerebral venous thrombosis: a review

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke. COVID-19 infection and vaccination have been associated with CVT. Fibrinolysis and mechanical thrombectomy may play an emerging role in management. We conducted a literature review summarizing current evidence on use of antiplatelets, anticoagulants, thrombolysis, and mechanical thrombectomy for the management of CVT and COVID-19 related CVT. This was achieved through a review of MEDLINE, PubMed, and Cochrane Reviews databases, performed using the search terms CVT AND "antiplatelets' aspirin", "ticagrelor", "clopidogrel", "eptifibatide", "Low-molecular-weight-heparin (LMWH)", "Unfractionated heparin (UH)", "warfarin", "DOACs", "rivaroxaban", "apixaban", "dabigatran", "fibrinolysis", "intra-sinus thrombolysis", "mechanical thrombectomy", and "craniectomy". We found that LMWH and UH are safe and effective for the management of acute CVT and should be considered first line. Warfarin may be used in the sub-acute phase for secondary prevention but has weak evidence. DOACs are potentially a safe warfarin alternative, but only warfarin is currently recommended in international guidelines. Antiplatelets show little evidence for the prevention or management of CVT, but studies are currently limited. COVID-19 related CVT is treated similarly to non-COVID-19 CVT; however, vaccine-related CVT is a newly recognised disease with a different pathophysiology and is treated with a combination of non-heparin anticoagulants, immunotherapy, and steroids. Decompressive craniectomy may be used to reduce intracranial pressure in life-threatening cases. There is a small body of evidence for endovascular therapy in complex cases but should be reserved for complex cases in specialist centres. This paper is of relevance to clinical practice since the safe and effective management of CVT is important to reduce the risk of disability.

Uveitis following COVID-19 vaccination in the pediatric population: Experience at a tertiary referral hospital

OBJECTIVE

To determine the incidence and outcomes of uveitis following coronavirus (COVID-19) vaccination in the pediatric population.

METHODS

A case series of all patients under the age of 18years diagnosed with uveitis within 28days of COVID-19 vaccination.

RESULTS

Out of 33 patients under the age of 18years who presented with uveitis from July 2021 until May 2022, eight (24.2%) developed uveitis following COVID-19 vaccination within 28days. Four had a previous history of uveitis. The mean time interval from COVID-19 vaccination to uveitis diagnosis was 14.75days. The most common anatomic diagnosis was anterior uveitis in four children, followed by panuveitis in two and posterior uveitis in two. Seven children were treated with systemic steroids/immunomodulatory agents. Improved or unaffected visual acuity was noted in all children at the final follow-up.

CONCLUSION

The pediatric population may demonstrate uveitis following COVID-19 vaccination. All children were treated successfully, and good final visual acuity was achieved.

Characteristics and outcomes of cerebral venous thrombosis associated with COVID-19

INTRODUCTION

Previous reports and meta-analyses derived from small case series reported a mortality rate of up to 40% in patients with coronavirus disease 2019 associated cerebral venous thrombosis (COVID-CVT). We assessed the clinical characteristics and outcomes in an international cohort of patients with COVID-CVT.

PATIENTS AND METHODS

This was a registry study of consecutive COVID-CVT patients diagnosed between March 2020 and March 2023. Data collected by the International Cerebral Venous Thrombosis Consortium from patients with CVT diagnosed between 2017 and 2018 served as a comparison. Outcome analyses were adjusted for age and sex.

RESULTS

We included 70 patients with COVID-CVT from 23 hospitals in 15 countries and 206 controls from 14 hospitals in 13 countries. The proportion of women was smaller in the COVID-CVT group (50% vs 68%, p < 0.01). A higher proportion of COVID-CVT patients presented with altered mental state (44% vs 25%, p < 0.01), the median thrombus load was higher in COVID-CVT patients (3 [IQR 2-4] vs 2 [1-3], p < 0.01) and the length of hospital stay was longer compared to controls (11 days [IQR 7-20] vs 8 [4-15], p = 0.02). In-hospital mortality did not differ (5/67 [7%, 95% CI 3-16] vs 7/206 [3%, 2-7], aOR 2.6 [95% CI 0.7-9]), nor did the frequency of functional independence after 6 months (modified Rankin Scale 0-2; 45/58 [78%, 95% CI 65-86] vs 161/185 [87%, 81-91], aOR 0.5 [95% CI 0.2-1.02]).

CONCLUSION

In contrast to previous studies, the in-hospital mortality rate and functional outcomes during follow-up did not differ between COVID-CVT patients and the pre-COVID-19 controls.

Bibliometric Analysis of the Composition of Landmark Cerebral Venous Sinus Thrombosis Research

Background

Cerebral Venous Sinus Thrombosis (CVST) is a relatively rare type of stroke, accounting for less than 3% of all stroke cases, and is associated with significant morbidity and mortality in young females. However, when promptly diagnosed and treated, it can have favorable outcomes. Several knowledge gaps remain regarding pathophysiology, diagnosis, and management of CVST, so critical assessment of past and present research could help close these gaps or establish targeted future research goals.

Methods

We screened Elsevier Scopus database articles with CVST as the primary topic. Clinical guidelines, abstracts, letters, and editorials were excluded. The top 100 articles, ordered by number of citations, were selected, and data collection and analysis were performed using Microsoft Excel, R software, and VOS viewer.

Results

Out of 4,832 documents, the top 100 most-cited articles spanned the years of 1973 to 2021 and had a total citation frequency of 18,208. France and the United States were the top-contributing countries, and Stroke had the highest number of manuscripts published in the top 100 (n=30). Analysis of word-use trends over time showed increases in the mention of "vaccination" since 2021, "mechanical thrombectomy" since 2017, and "fibrinolytic therapy" since 2015.

Conclusions

Our study detailed the 100 most-cited articles on CVST in the past 50 years. Understanding top-contributing countries, authors, and journals may help guide the direction of future research in CVST and encourage collaboration within the field. Areas of further research may include association with other pathologies (non-infectious and infectious) and advancements in acute therapies.

COVID-19 Neuroimaging Update: Pathophysiology, Acute Findings, and Post-Acute Developments

COVID-19 has prominent effects on the nervous system with important manifestations on neuroimaging. In this review, we discuss the neuroimaging appearance of acute COVID-19 that became evident during the early stages of the pandemic. We highlight the underlying pathophysiology mediating nervous system effects and neuroimaging appearances including systemic inflammatory response such as cytokine storm, coagulopathy, and para/post-infections immune mediated phenomena. We also discuss the nervous system manifestations of COVID-19 and the role of imaging as the pandemic has evolved over time, including related to the development of vaccines and the emergence of post-acute sequalae such as long COVID.

Isolated cortical vein thrombosis with hemorrhagic infarction during the application of a transdermal estradiol patch: A case report

Isolated cortical vein thrombosis (ICVT) is a rarer subtype of cerebral venous sinus thrombosis (CVST) that involves only the cortical veins without any thrombosis in the major cerebral veins or sinuses. Among the known causes of CVST are factors, such as being a young female or the use of hormonal preparations. This study presents a case of a 35-year-old female who underwent endometrial polyp removal 5 days before symptom onset and started using a transdermal estradiol patch. After 4 days of using the transdermal estradiol patch, the patient developed recurrent seizures and sustained sensory aphasia. The head computed tomography revealed hemorrhagic infarction. Given her young age and the use of hormonal therapy, CVST was suspected. However, the initial diagnosis with magnetic resonance imaging (MRI) was inconclusive, and no venous sinus thrombosis could be identified on additional cerebral angiography. Instead, stasis of venous flow in the temporal vein was noted. It was difficult to determine whether these findings were due to hemorrhage or ICVT. Upon re-evaluation with MRI, signal changes suggestive of thrombosis in a cortical vein in the parietal region, which is different from the stasis observed in cerebral angiography, led to the diagnosis of ICVT. This is the first study to link the use of transdermal estradiol patches to ICVT. In cases where ICVT leads to cerebral hemorrhage, cerebral angiography may not be useful. Instead, a comprehensive diagnosis should be made based on imaging findings from various MRI sequences and the patient's medical history.

Emergency Presentations of Coronavirus Disease (COVID-19): A Review of the Literature and Radiologic Perspective

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the debilitating global pandemic known as Coronavirus disease (COVID-19). In this paper, we highlight the widespread manifestations and complications across disease systems. In addition, we present their relevant imaging findings to inform appropriate investigations and management in patients presenting to the Emergency Department with COVID-19 and its respective sequalae. Of note, we outline considerations for diagnosis of long COVID, an important medium to long term sequalae in patients with previous COVID-19 infections.

SARS-CoV-2 associated septic venous cavernous sinus thrombosis: A case report

Cavernous sinus thrombosis (CST) is a life-threatening condition occurring due to an active infection, coagulation abnormalities, and trauma. Thromboembolic events are known complications secondary to novel coronavirus disease-19 (COVID-19) due to dysfunction in endothelial function and clotting factor dysfunction. We report a case of cavernous sinus thrombosis and delayed ophthalmic vein thrombosis associated with a preceding COVID-19 infection confirmed with a facial computed tomography (CT) scan. Clinicians should have a broad differential in patients with hypercoagulable states, as complications secondary to COVID-19 can be life-threatening.

COVID-19 and the brain: understanding the pathogenesis and consequences of neurological damage

SARS-CoV-2 has been known remarkably since December 2019 as a strain of pathogenic coronavirus. Starting from the earlier stages of the COVID-19 pandemic until now, we have witnessed many cases of neurological damage caused by SARS-CoV-2. There are many studies and research conducted on COVID-19-positive-patients that have found brain-related abnormalities with clear neurological symptoms, ranging from simple headaches to life-threatening strokes. For treating neurological damage, knowing the actual pathway or mechanism of causing brain damage via SARS-CoV-2 is very important. For this reason, we have tried to explain the possible pathways of brain damage due to SARS-CoV-2 with mechanisms and illustrations. The SARS-CoV-2 virus enters the human body by binding to specific ACE2 receptors in the targeted cells, which are present in the glial cells and CNS neurons of the human brain. It is found that direct and indirect infections with SARS-CoV-2 in the brain result in endothelial cell death, which alters the BBB tight junctions. These probable alterations can be the reason for the excessive transmission and pathogenicity of SARS-CoV-2 in the human brain. In this precise review, we have tried to demonstrate the neurological symptoms in the case of COVID-19-positive-patients and the possible mechanisms of neurological damage, along with the treatment options for brain-related abnormalities. Knowing the transmission mechanism of SARS-CoV-2 in the human brain can assist us in generating novel treatments associated with neuroinflammation in other brain diseases.

How the immune response to the structural proteins of SARS-CoV-2 affects the retinal vascular endothelial cells: an immune thrombotic and/or endotheliopathy process with in silico modeling

Thrombotic events associated with SARS-CoV-2 at the vascular endothelium still remains unclear. The aim of the current study is to determine the relationship between cellular proteins on the (ocular) vascular endothelial surface and the immune thrombotic and/or endotheliopathy process elicited by SARS-CoV-2 using an in-silico modeling. The structural S (spike glycoprotein), N (nucleocapsid protein), M (membrane protein), and E (envelope protein) proteins, an accessory protein (ORF1ab) of SARS-CoV-2 and 158 cellular proteins associated with retinal vascular endothelial cell surface or structure were included in this study for comparison of three-dimensional (3D) structure and sequence. Sixty-nine of the retinal proteins were obtained from the Uniprot database. Remaining proteins not included in the database were included in the study after they were converted into 3D structures using the RaptorX web tool. Sequence and three-dimensional structure of SARS-COV-2 S, N, M, E, ORF1ab proteins and retinal vascular endothelial proteins were compared with mTM-align server. Proteins with significant similarity (score above 0.5) were validated with the TM-align web server. Immune and thrombosis-related protein-receptor interactions of similar proteins was checked with CABS-dock. We detected a high level of structural similarity between E protein and ACE, ACE2, LAT1, and TM9SF4 endothelial proteins. In addition, PECAM-1 was found to be structurally similar to ORF1ab and S protein. When we evaluated the likelihood/potential to stimulate an immune responses/a cytokine release, TLR-2 and TLR-3, which are highly susceptible to SARS-CoV2, showed a potential receptor-protein interaction with retinal vascular endothelial proteins. Our study demonstrates that SARS-CoV-2 proteins may have structural similarities with vascular endothelial proteins, and therefore, as immunological target sites, the counterpart proteins on the endothelial surface of many organs may also be secondarily affected by any immune response against SARS-CoV-2 structural proteins.

Neurotropism of SARS-CoV-2: A Pathological Examination of Neurosurgical Specimens

BACKGROUND AND OBJECTIVES

Neurological manifestations may occur in more than 80% of patients hospitalized with COVID-19 infection, including severe disruptions of the central nervous system (CNS), such as strokes, encephalitis, or seizures. Although the primary pathophysiological mechanism for the effects of COVID-19 in CNS remains unknown, evidence exists for both direct injury from neuroinvasion and indirect effects from disruptions in systemic inflammatory and coagulation pathways. In this study, we analyzed CNS tissue from living patients to better understand these processes.

METHODS

With institutional review board approval and patient consent, samples that would be otherwise discarded from patients with active or recent (within 6 days of surgery) COVID-19 infection undergoing neurosurgical intervention were collected and tested for the presence of SARS-CoV-2 using immunohistochemistry, in situ hybridization, electron microscopy, and reverse transcription polymerase chain reaction.

RESULTS

Five patients with perioperative mild-to-moderate COVID-19 infection met inclusion criteria (2 male, 3 female; mean age 38.8 ± 13.5 years). Neurosurgical diagnoses included a glioblastoma, a ruptured arteriovenous malformation, a ruptured posterior inferior cerebellar artery aneurysm, a middle cerebral artery occlusion, and a hemorrhagic pontine cavernous malformation. Samples analyzed included the frontal lobe cortex, olfactory nerve, arteriovenous malformation/temporal lobe parenchyma, middle cerebral artery, cerebellum, and cavernous malformation/brainstem parenchyma. Testing for the presence of SARS-CoV-2 was negative in all samples.

CONCLUSION

The CNS is likely not a significant viral reservoir during mild-to-moderate COVID-19 infection, although direct neuroinvasion is not definitively excluded. Additional testing to help elucidate the relative contributions of direct and indirect pathways for CNS injury from COVID is warranted.

Nervous system-related tropism of SARS-CoV-2 and autoimmunity in COVID-19 infection

The effects of SARS-CoV-2 in COVID-19 on the nervous system are incompletely understood. SARS-CoV-2 can infect endothelial cells, neurons, astrocytes, and oligodendrocytes with consequences for the host. There are indications that infection of these CNS-resident cells may result in long-term effects, including emergence of neurodegenerative diseases. Indirect effects of infection with SARS-CoV-2 relate to the induction of autoimmune disease involving molecular mimicry or/and bystander activation of T- and B cells and emergence of autoantibodies against various self-antigens. Data obtained in preclinical models of coronavirus-induced disease gives important clues for the understanding of nervous system-related assault of SARS-CoV-2. The pathophysiology of long-COVID syndrome and post-COVID syndrome in which autoimmunity and immune dysregulation might be the driving forces are still incompletely understood. A better understanding of nervous-system-related immunity in COVID-19 might support the development of therapeutic approaches. In this review, the current understanding of SARS-CoV-2 tropism for the nervous system, the associated immune responses, and diseases are summarized. The data indicates that there is viral tropism of SARS-CoV-2 in the nervous system resulting in various disease conditions. Prevention of SARS-CoV-2 infection by means of vaccination is currently the best strategy for the prevention of subsequent tissue damage involving the nervous system.

Sex Differences and Clinical Outcomes of Patients with Coronavirus Disease 2019 Infection and Cerebral Venous Sinus Thrombosis: A Systematic Review

Cerebral venous sinus thrombosis (CVST) is a rare neurovascular condition that has been observed in individuals with coronavirus disease 2019 (COVID-19). This systematic review aimed to explore the sex differences and characteristics of concurrent COVID-19 and CVST cases. A total of 212 CVST patients were included in the study. Women with CVST had a slightly higher mean age compared to men (47.359 years vs 46.08 years). Women were more likely to report symptoms such as fever (56.1%) and decreased sense of smell or taste (71.4%), while men more frequently experienced nausea or vomiting (55.6%), headache (62.9%), and seizures (72%). Notably, current smokers, who were predominantly men, had a higher occurrence of CVST. On the other hand, women had a higher likelihood of CVST risk factors such as oral contraceptive pill (OCP) use and autoimmune diseases. Treatment approaches also showed sex-based differences. Unfractionated heparin was administered more often to women with CVST (63.2%). The in-hospital mortality rate for CVST patients was 21.3%, with men having a significantly higher mortality rate than women (65.2% vs 34.8%, P = .027). Survival analysis revealed that factors such as smoking history, diabetes mellitus, hypertension, OCP use, COVID-19 symptoms, CVST symptoms, and the need for intubation significantly influenced survival outcomes. Understanding these sex differences in COVID-19-related CVST is crucial for accurate diagnosis and effective management, ultimately leading to improved patient outcomes. Our findings highlight the importance of considering sex as a factor in the evaluation and treatment of individuals with COVID-19 and concurrent CVST.

SARS‑CoV‑2 infection and associated risk factors for clinical cases of cerebral venous thrombosis: A case series

The present study focused on examining the association between the SARS-CoV-2 virus, responsible for the COVID-19 pandemic, and cerebral venous thrombosis (CVT), a specific form of stroke that affects the brain's vessels and sinuses. While COVID-19 is primarily recognized for its respiratory impact, it may also affect other organs, including the brain. One notable aspect of COVID-19 is its association with coagulopathy, an abnormal condition of blood clotting. Coagulopathy may result in various complications, including neurological ones such as stroke. The study analyzed data obtained from patients admitted to a neurology department who had confirmed neurological pathologies along with COVID-19. It specifically examined the cases of three patients with neurological conditions and COVID-19, discussing their risk factors and how their conditions progressed clinically. The study concluded that COVID-19 infection increases the likelihood of stroke, particularly within the initial 10 days after infection. CVT in particular is strongly linked to COVID-19 and its underlying mechanisms involve immune systemic processes, cytokine storms, increased blood thickness, thrombogenesis, hypercoagulability and inflammation. The presence of SARS-CoV-2 infection may worsen the procoagulant cascade, thereby affecting the clinical condition of patients with CVT. The study underscores the importance of recognizing this uncommon but treatable consequence of COVID-19 infection. Furthermore, it highlights the uniqueness of the study in evaluating COVID-19 infection in patients with CVT from Romania and South-East Europe. The findings support the existence of neurological disorders, including clotting complications in the brain's sinuses and vessels, in individuals infected with SARS-CoV-2. Several risk factors contribute to the development of CVT, such as infections, oral contraceptives, pregnancy, hematological disorders, trauma, autoimmune disorders and malignancies.

Neuroprotective Agents with Therapeutic Potential for COVID-19

COVID-19 patients can exhibit a wide range of clinical manifestations affecting various organs and systems. Neurological symptoms have been reported in COVID-19 patients, both during the acute phase of the illness and in cases of long-term COVID. Moderate symptoms include ageusia, anosmia, altered mental status, and cognitive impairment, and in more severe cases can manifest as ischemic cerebrovascular disease and encephalitis. In this narrative review, we delve into the reported neurological symptoms associated with COVID-19, as well as the underlying mechanisms contributing to them. These mechanisms include direct damage to neurons, inflammation, oxidative stress, and protein misfolding. We further investigate the potential of small molecules from natural products to offer neuroprotection in models of neurodegenerative diseases. Through our analysis, we discovered that flavonoids, alkaloids, terpenoids, and other natural compounds exhibit neuroprotective effects by modulating signaling pathways known to be impacted by COVID-19. Some of these compounds also directly target SARS-CoV-2 viral replication. Therefore, molecules of natural origin show promise as potential agents to prevent or mitigate nervous system damage in COVID-19 patients. Further research and the evaluation of different stages of the disease are warranted to explore their potential benefits.

Continued Infarction Growth and Penumbral Consumption After Reperfusion in Vaccine-Naive Patients With COVID-19: A Case-Control Study

BACKGROUND. Neurologic sequelae of SARS-CoV-2 include potentially malignant cerebrovascular events arising from complex hemodynamic, hematologic, and inflammatory processes occurring in concert. OBJECTIVE. This study concerns the hypothesis that despite angiographic reperfusion COVID-19 promotes continued consumption of at-risk tissue volumes after acute ischemic stroke (AIS), yielding critical insights into prognostication and monitoring paradigms in vaccine-naive patients experiencing AIS. METHODS. This retrospective study compared 100 consecutive COVID-19 patients with AIS presenting between March 2020 and April 2021 with a contemporaneous cohort of 282 AIS patients without COVID-19. Reperfusion classes were dichotomized into positive (extended thrombolysis in cerebral ischemia [eTICI] score = 2c-3) and negative (eTICI score < 2c) groups. All patients underwent endovascular therapy after initial CT perfusion imaging (CTP) to document infarction core and total hypoperfusion volumes. RESULTS. Ten COVID-positive (mean age ± SD, 67 ± 12 years; seven men, three women) and 144 COVID-negative patients (mean age, 71 ± 16 years; 76 men, 68 women) undergoing endovascular reperfusion, with antecedent CTP and follow-up imaging, comprised the final dataset. Initial infarction core and total hypoperfusion volumes (mean ± SD) were 1.5 ± 18 mL and 85 ± 100 mL in COVID-negative patients and 30.5 ± 34 mL and 117 ± 80.5 mL in COVID-positive patients, respectively. Final infarction volumes were significantly larger in patients with COVID-19, with median volumes of 77.8 mL versus 18.2 mL among control patients (p = .01), as were normalized measures of infarction growth relative to baseline infarction volume (p = .05). In adjusted logistic parametric regression models, COVID positivity emerged as a significant predictor for continued infarct growth (OR, 5.10 [95% CI, 1.00-25.95]; p = .05). CONCLUSION. These findings support the potentially aggressive clinical course of cerebrovascular events in patients with COVID-19, suggesting greater infarction growth and ongoing consumption of at-risk tissues, even after angiographic reperfusion. CLINICAL IMPACT. SARS-CoV-2 infection may promote continued infarction progression despite angiographic reperfusion in vaccine-naive patients with large-vessel occlusion AIS. The findings carry potential implications for prognostication, treatment selection, and surveillance for infarction growth among revascularized patients in future waves of infection by novel viral strains.

Severe Headache, Seizures and Supraventricular Tachycardia in a 33-year-old Filipino Male with Confirmed COVID-19: A Case Report

COVID-19 primarily presents as a pulmonary problem, ranging from mild respiratory illness to fatal acute respiratory distress syndrome. Most common manifestations are fever (89%) and cough (72%), while headache and arrhythmia are found in 28% and 17%, respectively. We aim to present a confirmed COVID-19 case presenting with both neurologic and cardiac manifestations. A 33-year-old Filipino male nurse initially consulted at the emergency room due to progressive diffuse headache, with associated localized seizures progressing to generalized tonic clonic seizure and arrhythmia. He had no coryza, cough, sore throat, and diarrhea. He was previously well and had no known co-morbidities or direct exposure to confirmed COVID-19 patients. Physical examination showed elevated blood pressure, tachycardia, and sensory and motor deficits in the left upper and lower extremities. Pertinent diagnostic test results included the detection of SARS-CoV-2 viral RNA via RT-PCR. Imaging studies demonstrated cortical venous thrombosis with hemorrhagic venous infarction in the right parietal lobe. Ground glass appearance on the middle lobe of the left lung was also evident. ECG showed supraventricular tachycardia. Prothrombin time, activated partial thromboplastin time, and D-dimer were all within the normal limits. Carotid massage was done. He was treated with anti-epileptics, anticoagulants, antiarrhythmics, antivirals, antibiotics, and supportive management. During the hospital stay, his symptoms resolved; he was discharged after 21 days. Follow-up done after 3 weeks revealed no recurrence of severe headache, seizure, or tachycardia. It is theorized that an interplay exists between ACE-2 tropism, systemic inflammation, cytokine storm, and hypoxemia in the background of COVID-19 infection. These mechanisms may lead to thrombosis and arrhythmia resulting to neurologic derangements and myocardial injury. Underlying mechanisms make the cerebro-cardiovascular systems vulnerable to the coronavirus disease 2019 infection. COVID-19 should therefore be part of the differential diagnoses in patients presenting with headache, seizures, and arrhythmias.

Coronavirus disease 2019 and acute cerebrovascular events: a comprehensive overview

Since the Corona Virus Disease 2019 (COVID-19) pandemic, there has been increasing evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with acute cerebrovascular events such as cerebral infarction, cerebral hemorrhage, and cerebral venous thrombosis. Although the mechanism of cerebrovascular complications among COVID-19 patients has not been adequately elucidated, the hypercoagulable state, excessive inflammation and ACE-2-associated alterations in the renin-angiotensin-aldosterone system after SARS-CoV-2 infection probably play an essential role. In this overview, we discuss the possible mechanisms underlying the SARS-CoV-2 infection leading to acute cerebrovascular events and review the characteristics of COVID-19-related acute cerebrovascular events cases and treatment options available worldwide.

[COVID-19: Neurological manifestations and complications during the acute phase of the disease]

The neurological manifestations and complications of the acute phase of COVID-19 are numerous. They mainly concern the central nervous system in the frequent forms of encephalopathy, encephalitis and neurovascular pathologies. Peripheral neurological manifestations mainly include acute polyneuropathies such as Guillain-Barré syndrome and intensive care neuromyopathies. Most of these manifestations were described during the first wave of the pandemic. The epidemiological, clinical, paraclinical, pathophysiological and therapeutic aspects are addressed in this general review of the literature published from 2020 to early 2023.

Coagulopathy and thromboembolic events a pathogenic mechanism of COVID-19 associated with mortality: An updated review

During 2019, the SARS-CoV-2 emerged from China, and during months, COVID-19 spread in many countries around the world. The expanding data about pathogenesis of this virus could elucidate the exact mechanism by which COVID-19 caused death in humans. One of the pathogenic mechanisms of this disease is coagulation. Coagulation disorders that affect both venous and arterial systems occur in patients with COVID-19. The possible mechanism involved in the coagulation could be excessive inflammation induced by SARS-CoV-2. However, it is not yet clear well how SARS-CoV-2 promotes coagulopathy. However, some factors, such as pulmonary endothelial cell damage and some anticoagulant system disorders, are assumed to have an important role. In this study, we assessed conducted studies about COVID-19-induced coagulopathy to obtain clearer vision of the wide range of manifestations and possible pathogenesis mechanisms.

Neuroimaging of COVID-19

We review the wide variety of common neuroimaging manifestations related to coronavirus disease 2019 (COVID-19) and COVID therapies, grouping the entities by likely pathophysiology, recognizing that the etiology of many entities remains uncertain. Direct viral invasion likely contributes to olfactory bulb abnormalities. COVID meningoencephalitis may represent direct viral infection and/or autoimmune inflammation. Para-infectious inflammation and inflammatory demyelination at the time of infection are likely primary contributors to acute necrotizing encephalopathy, cytotoxic lesion of the corpus callosum, and diffuse white matter abnormality. Later postinfectious inflammation and demyelination may manifest as acute demyelinating encephalomyelitis, Guillain-Barré syndrome, or transverse myelitis. The hallmark vascular inflammation and coagulopathy of COVID-19 may produce acute ischemic infarction, microinfarction contributing to white matter abnormality, space-occupying hemorrhage or microhemorrhage, venous thrombosis, and posterior reversible encephalopathy syndrome. Adverse effects of therapies including zinc, chloroquine/hydroxychloroquine, antivirals, and vaccines, and current evidence regarding "long COVID" is briefly reviewed. Finally, we present a case of bacterial and fungal superinfection related to immune dysregulation from COVID.

Eye damage in COVID-19. Part 2: posterior segment complications, neuro-ophthalmic manifestations, vaccination and risk factors

Posterior eye segment involvement in COVID-19 has varied manifestations: vascular, inflammatory, and neuronal. All of them are triggered by SARS-CoV-2 virus but they cannot be viewed as exclusively specific to COVID-19. According to the literature, the mean age of the patients varies from 17 to 75 with the median of 50 years. The median duration between the appearance of ophthalmic symptoms and the detection of COVID-19 was 12 days. The disease affects both men and women equally. Direct exposure to the virus, immune-mediated tissue damage, activation of the coagulation system, the prothrombotic state caused by a viral infection, concomitant diseases and medications used in the treatment contribute to the development of eye pathologies. Ophthalmologists should be aware of the possible relations of posterior eye segment pathologies, orbit and neuro-ophthalmic disorders with SARS-CoV-2, as well as the possible exacerbation of chronic forms of inflammatory eye diseases and autoimmune disorders due to anti-COVID-19 vaccination.

A Model of High-Speed Endovascular Sonothrombolysis with Vortex Ultrasound-Induced Shear Stress to Treat Cerebral Venous Sinus Thrombosis

This research aims to demonstrate a novel vortex ultrasound enabled endovascular thrombolysis method designed for treating cerebral venous sinus thrombosis (CVST). This is a topic of substantial importance since current treatment modalities for CVST still fail in as many as 20% to 40% of the cases, and the incidence of CVST has increased since the outbreak of the coronavirus disease 2019 pandemic. Compared with conventional anticoagulant or thrombolytic drugs, sonothrombolysis has the potential to remarkably shorten the required treatment time owing to the direct clot targeting with acoustic waves. However, previously reported strategies for sonothrombolysis have not demonstrated clinically meaningful outcomes (e.g., recanalization within 30 min) in treating large, completely occluded veins or arteries. Here, we demonstrated a new vortex ultrasound technique for endovascular sonothrombolysis utilizing wave-matter interaction-induced shear stress to enhance the lytic rate substantially. Our in vitro experiment showed that the lytic rate was increased by at least 64.3% compared with the nonvortex endovascular ultrasound treatment. A 3.1-g, 7.5-cm-long, completely occluded in vitro 3-dimensional model of acute CVST was fully recanalized within 8 min with a record-high lytic rate of 237.5 mg/min for acute bovine clot in vitro. Furthermore, we confirmed that the vortex ultrasound causes no vessel wall damage over ex vivo canine veins. This vortex ultrasound thrombolysis technique potentially presents a new life-saving tool for severe CVST cases that cannot be efficaciously treated using existing therapies.

Acute Neurological Complications of Coronavirus Disease

The coronavirus disease (COVID-19) pandemic has impacted many lives globally. Neurologic manifestations have been observed among individuals at various stages and severity of the disease, the most common being stroke. Prompt identification of these neurologic diagnoses can affect patient management and prognosis. This article discusses the acute neuroradiological features typical of COVID-19, including cerebrovascular disease, intracerebral hemorrhage, leukoencephalopathy, and sensory neuropathies.

Magnetic Resonance Imaging (MRI) Findings in COVID-19 Associated Encephalitis

We conducted this study to investigate the scope of the MRI neuroimaging manifestations in COVID-19-associated encephalitis. From January 2020 to September 2021, patients with clinical diagnosis of COVID-19-associated encephalitis, as well as concomitant abnormal imaging findings on brain MRI, were included. Two board-certified neuro-radiologists reviewed these selected brain MR images, and further discerned the abnormal imaging findings. 39 patients with the clinical diagnosis of encephalitis as well as abnormal MRI findings were included. Most (87%) of these patients were managed in ICU, and 79% had to be intubated-ventilated. 15 (38%) patients died from the disease, while the rest were discharged from the hospital. On MRI, FLAIR hyperintensities in the insular cortex were the most common finding, seen in 38% of the patients. Micro-hemorrhages on the SWI images were equally common, also seen in 38% patients. FLAIR hyperintensities in the medial temporal lobes were seen in 30%, while FLAIR hyperintensities in the posterior fossa were evident in 20%. FLAIR hyperintensities in basal ganglia and thalami were seen in 15%. Confluent FLAIR hyperintensities in deep and periventricular white matter, not explained by microvascular angiopathy, were detected in 7% of cases. Cortical-based FLAIR hyperintensities in 7%, and FLAIR hyperintensity in the splenium of the corpus callosum in 7% of patients. Finally, isolated FLAIR hyperintensity around the third ventricle was noted in 2% of patients.

[Cerebral venous sinus thrombosis presenting transient ischemic attack after recovery from COVID-19 with Graves' disease and IgG4-related ophthalmic disease: a case report]

A 57-year-old man presented with headache, transient right upper extremity weakness and numbness one month after recovery from coronavirus disease 2019 (COVID-19). His medical history included Graves' disease and IgG4-related ophthalmic disease. He had been administered prednisolone. His weakness and numbness were transient and not present on admission. Contrast-enhanced CT and MRI of the head showed thrombi in the superior sagittal sinus, right transverse sinus, sigmoid sinus, and the right internal jugular vein. Digital subtraction angiography showed occlusion at the same sites and mild perfusion delay in the left frontoparietal lobe. We diagnosed the patient with cerebral venous sinus thrombosis and treated him with anticoagulation. The thrombi partially regressed three months later, and perfusion delay became less noticeable. Cerebral venous sinus thrombosis is an important complication of COVID-19. Patients with predisposing factors, including Graves' disease and IgG4-related ophthalmic disease, may be at increased risk of developing cerebral venous sinus thrombosis even after recovery from COVID-19.

Subclavian Steal Syndrome Caused by Thrombosis Associated with COVID-19: a Case Report

Background

Thromboembolic complications are a frequent occurrence during COVID-19. This report presents a patient with signs of subclavian steal syndrome (SSS) caused by a thrombus in the initial part of the right subclavian artery. Pathological occlusive changes, such as thrombosis, are four times more common on the left subclavian. Thrombosis of the subclavian artery occurs in about 1% of the population, but atherosclerotic changes are common and usually asymptomatic.

Objective

The aim of this report is to present a patient with signs of subclavian steal syndrome (SSS) caused by a thrombus in the initial part of the right subclavian artery associated with symptoms of COVID-19.

Case report

A 56-year-old female patient presented with tremor, numbness and prickling in the right hand, tinnitus, blurred vision, vertigo, syncope, trismus and headaches. The formation of a thrombus caused neurological symptoms in the right hand with a stronger pronounced tremor, headache and syncopal episodes. Routine CT with angiography did not reveal significant subocclusions of the neck arteries or significant ischemic changes in the brain. The patient was treated as Parkinsonismus (disease) with syncopal and collapsing episodes. Due to worsening subjective complaints, CT angiography of the neck and head blood vessels was repeated with iterative 3D reconstruction. The examination, as mentioned above, revealed atherosclerotic changes with thrombosis and stronger subocclusion of the right subclavian artery (RSA) proximal to the origin of the arteria vertebralis. Both vertebral arteries, as well as arteria basilaris, had a normal appearance. During physical exertion of the right arm doppler examination of neck blood vessels revealed the presence of reverse blood flow in the right vertebral artery. Haematological tests and high D-dimer also confirmed the diagnosis. After anticoagulant therapy, the thrombotic mass on the mural calcified RSA plaque disappeared. With the reduced physical strain on the right hand and a lifestyle change, syncopal conditions and headaches stopped. There was a reduction in tremors and tingling in the right hand as well.

Conclusion

We reported a case of subclavian steal syndrome caused by thrombosis associated with OVID-19. Thromboembolic complications are common in the course of this disease. The diagnosis was confirmed with advanced diagnostic tools (CTA with 3D reconstruction), laboratory tests (D-dimer) and doppler ultrasound. When routine CT angiography is not completely clear, 3D reconstruction is necessary.

Investigation of Neurological Symptoms Caused by COVID-19 in Intensive Care Unit

We examined the neurological symptoms of patients treated in intensive care for COVID-19 in this study. We obtained the study data retrospectively from data records of 1,699 patients treated in the COVID-19 clinics of a training and research hospital. The study is a descriptive and cross-sectional study. Sociodemographic and Disease Information Form were used for data collection. Statistical Packed for the Social Sciences 25.0 IBM was used in Data analysis. It was observed that 37% of the COVID-19 patients were between the ages of 66-80 years and 55.6% of the COVID-19 patients were male. The most common neurological symptoms in the disease process and their rates were as follows: insomnia 74.6%, taste loss 74%, smell loss 75.6%, muscle pain 83.2%, headache 45.1%, dizziness 32.2%, weakness 20.2%, and agitation 34.7%. Assessment of neurological symptoms of patients followed up for COVID-19 is of great importance. We suggest that neurological problems should be tried to be cured with appropriate treatment protocols and therapy support before they progress further and the neurological prognosis progresses.

[German S1 Guideline Long-/Post-COVID]

The German Society of Pneumology initiated 2021 the AWMF S1 guideline Long COVID/Post-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendations describe current Long COVID/Post-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an explicit practical claim and will be developed and adapted by the author team based on the current increase in knowledge.

Prevalence of acute neurological complications and pathological neuroimaging findings in critically ill COVID-19 patients with and without VV-ECMO treatment

Acute brain injuries such as intracerebral hemorrhage (ICH) and ischemic stroke have been reported in critically ill COVID-19 patients as well as in patients treated with veno-venous (VV)-ECMO independently of their COVID-19 status. The purpose of this study was to compare critically ill COVID-19 patients with and without VV-ECMO treatment with regard to acute neurological symptoms, pathological neuroimaging findings (PNIF) and long-term deficits. The single center study was conducted in critically ill COVID-19 patients between February 1, 2020 and June 30, 2021. Demographic, clinical and laboratory parameters were extracted from the hospital's databases. Retrospective imaging modalities included head computed tomography (CT) and magnetic resonance imaging (MRI). Follow-up MRI and neurological examinations were performed on survivors > 6 months after the primary occurrence. Of the 440 patients, 67 patients received VV-ECMO treatment (15%). Sixty-four patients (24 with VV-ECMO) developed acute neurological symptoms (pathological levels of arousal/brain stem function/motor responses) during their ICU stay and underwent neuroimaging with brain CT as the primary modality. Critically ill COVID-19 patients who received VV-ECMO treatment had a significantly lower survival during their hospital stay compared to those without (p < 0.001). Among patients treated with VV-ECMO, 10% showed acute PNIF in one of the imaging modalities during their ICU stay (vs. 4% of patients in the overall COVID-19 ICU cohort). Furthermore, 9% showed primary or secondary ICH of any severity (vs. 3% overall), 6% exhibited severe ICH (vs. 1% overall) and 1.5% were found to have non-hemorrhagic cerebral infarctions (vs. < 1% overall). There was a weak, positive correlation between patients treated with VV-ECMO and the development of acute neurological symptoms. However, the association between the VV-ECMO treatment and acute PNIF was negligible. Two survivors (one with VV-ECMO-treatment/one without) showed innumerable microhemorrhages, predominantly involving the juxtacortical white matter. None of the survivors exhibited diffuse leukoencephalopathy. Every seventh COVID-19 patient developed acute neurological symptoms during their ICU stay, but only every twenty-fifth patient had PNIF which were mostly ICH. VV-ECMO was found to be a weak risk factor for neurological complications (resulting in a higher imaging rate), but not for PNIF. Although logistically complex, repeated neuroimaging should, thus, be considered in all critically ill COVID-19 patients since ICH may have an impact on the treatment decisions and outcomes.

Extensive Cerebral Venous Thrombosis as an Isolated Presentation in a COVID-19-Positive Young Adult

Due to the increase in the number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases globally, more medical case reports are being published showing the different complications of coronavirus disease 2019 (COVID-19). One of the important complications is thrombotic events that occur as a sequela of COVID-19. Here we present a case of a previously healthy male patient in his 30s who presented to the emergency unit experiencing headaches, vomiting, and weakness in his left arm. On examination, he was vitally stable, and fully oriented, but noted to have jerky movements of the left arm; therefore, he was sent for a CT brain scan. Shortly after, he developed a generalized tonic-clonic seizure. After stabilizing the patient, CT brain with cerebral venography was done, which revealed extensive thrombosis of the superior sagittal sinus and bilateral superficial cortical veins. The patient's blood test showed a high D-dimer (4.90 ug/ml), and the COVID-19 polymerase chain reaction (PCR) swab test was positive. It is commonly known that COVID-19 infection presents with fever and respiratory symptoms; however, our case illustrates the thrombotic complication of SARS-CoV-2 infection with no pneumonia or respiratory symptoms with a high level of d-dimer.

Cerebral venous sinus thrombosis in COVID 19 patients: Report of 2 cases

Background

Initially, novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) was considered primarily a respiratory pathogen. However, with time it has behaved as a virus with the potential to cause multi-system involvement, including neurological manifestations which varies from acute to subacute onset of headache, seizures, a decrease of consciousness, and paralysis.

Case description

Two cases of cerebral sinus venous thrombosis in COVID-19 patients were reported, following respiratory disorders, which was triggered by the SARS-CoV-2 infection. The first patient, presented with a decrease in level of consciousness and hemiparesis, was 23 years old female having no history of previous medical co-morbidities. The latter case, 21 years old woman showed less severe presentations of COVID-19 associated with headache, vomiting and papilledema. These two cases marvellously improved with no neurological deficit with aggressive course of anticoagulation.

Conclusion

CVST should be suspected in COVID-19 patients presenting with headache, paralysis, aphasia or seizures. The high mortality rate of CVST in COVID-19 infection warrants a high index of suspicion from physicians, and early treatment with anticoagulation should be initiated.

Cerebrovascular Complications of COVID-19 Disease in Children: A Single-Center Case Series

This work presents a case series of four children diagnosed with severe cerebrovascular disease in association with recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, yet no patient from the group met typical diagnostic criteria for multisystem inflammatory syndrome in children. Our aim was to highlight the possible vascular involvement and coagulopathies associated with SARS-CoV-2 infection in the pediatric population. Further data are needed to better understand the pathophysiological basis of this condition in children and to ensure its optimal management.

Cerebral Venous Sinus Thrombosis Associated With Coronavirus Disease 2019: Case Report and Review of the Literature

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is associated with significant risk of acute thrombosis. We present a case report of a patient with cerebral venous sinus thrombosis (CVST) associated with COVID-19 and performed a literature review of CVST associated with COVID-19 cases.

CASE REPORT

A 38-year-old woman was admitted with severe headache and acute altered mental status a week after confirmed diagnosis of COVID-19. Magnetic resonance imaging brain showed diffuse venous sinus thrombosis involving the superficial and deep veins, and diffuse edema of bilateral thalami, basal ganglia and hippocampi because of venous infarction. Her neurological exam improved with anticoagulation (AC) and was subsequently discharged home. We identified 43 patients presenting with CVST associated with COVID-19 infection. 56% were male with mean age of 51.8±18.2 years old. The mean time of CVST diagnosis was 15.6±23.7 days after onset of COVID-19 symptoms. Most patients (87%) had thrombosis of multiple dural sinuses and parenchymal changes (79%). Almost 40% had deep cerebral venous system thrombosis. Laboratory findings revealed elevated mean D-dimer level (7.14/mL±12.23 mg/L) and mean fibrinogen level (4.71±1.93 g/L). Less than half of patients had prior thrombotic risk factors. Seventeen patients (52%) had good outcomes (mRS <=2). The mortality rate was 39% (13 patients).

CONCLUSION

CVST should be in the differential diagnosis when patients present with acute neurological symptoms in this COVID pandemic. The mortality rate of CVST associated with COVID-19 can be very high, therefore, early diagnosis and prompt treatment are crucial to the outcomes of these patients.

Thrombotic Presentation of MIS-C After COVID-19 Infection in a Nine-Year-Old Boy

Introduction: SARS-CoV-2 is the cause of the recent pandemic. Although children are less affected by the virus, they can present with various presentations ranging from asymptomatic or fatigue and fever to multisystem inflammatory syndrome in children (MIS-C). Case Presentation: In this case report, we presented a case of a 9-year-old boy who presented with bilateral deep vein thromboses (DVTs) of the femoral and iliac veins as his main presentation of MIS-C, which occurred following a COVID-19 infection. A complete history was taken from the patient, and then a series of tests, including complete blood counts (CBCs), liver function tests (LFTs), and D-dimer, were performed. Bilateral doppler sonography to confirm the event and its location, as well as a decent follow-up method, were performed. Levels of anti-Xa assays followed the toxic levels of enoxaparin. The child was treated with a regimen of enoxaparin and corticosteroids, with a dosage of 1 mg/kg/12 h for both. The child was in the hospital for two weeks, after which he got better and was managed as an out-patient with a regularly scheduled appointment. Finally, once the radiologic evidence of DVTs was cleared, the patient tapered off his enoxaparin over the course of three weeks. Conclusions: Thrombotic events following COVID-19-associated MIS-C are an unlikely yet deadly event, especially in children. Prompt treatment with anticoagulants and corticosteroids alongside monitoring the patients are strongly advised.

Coronavirus disease 19 (COVID-19) and Cerebral venous sinus thrombosis (CVST): A case series and review of the literature

A large proportion of patients with coronavirus disease 19 (COVID-19) suffer from excessive coagulation activation and coagulopathy which predisposes them to a wide spectrum of thrombotic events including in situ pulmonary thrombosis, deep-vein thrombosis, and associated pulmonary embolism, as well as arterial thrombotic events. Cerebral venous sinus thrombosis (CVST) have also been reported but in a very small number of cases. This report aims to increase awareness about CVST as a potential neurological thromboembolic complication in patients with coronavirus disease. We report three COVID-19 patients presenting with CVTS. We also review all previously described cases and present an overview of their demographic, clinical, and diagnostic data. We describe three patients with concomitant coronavirus disease and CVST among 1000 hospitalized COVID-19 patients (2 males, 1female, and mean age of 37 years). One patient was previously healthy, while the two others had a history of chronic anemia and ulcerative colitis, respectively. CVST symptoms including seizure in two patients and headache in one patient occurred day to weeks after the onset of COVID-19 symptoms. Three months of anticoagulant therapy was given for all three patients with favorable outcomes. No neurological sequelae and no recurrence occurred within 6 months after hospital discharge. Our search identified 33 cases of COVID-19 complicated by CVST. The mean age was 45.3 years, there was a slight male predominance (60%), and more than half of cases were diagnosed in previously healthy individuals. All cases of CVT were clinically symptomatic and were observed in patients with a different spectrum of coronavirus disease severity. Headache was the most common complaint, reported by just less than half of patients. There was a high mortality rate (30.3%). CVT is a very rare, but potentially life-threatening complication in patients with COVID-19. It's mainly reported in relatively young individuals with no or little comorbid disease and can occur even in patients who do not display severe respiratory symptoms. Atypical clinical presentations may pose a challenge to the early diagnosis and treatment. High suspicion is necessary as early diagnosis and prompt treatment with anticoagulation in all patients with COVID-19 and CVT could contain the mortality rate and improve neurological outcomes in these patients.

A systematic review on neutrophil extracellular traps and its prognostication role in COVID-19 patients

Neutrophil extracellular traps (NETs) are extracellular webs composed of neutrophil granular and nuclear elements. Because of the potentially dangerous amplification circuit between inflammation and tissue damage, NETs are becoming one of the investigated components in the current Coronavirus Disease 2019 (COVID-19) pandemic. The purpose of this systematic review is to summarize studies on the role of NETs in determining the prognosis of COVID-19 patients. The study used six databases: PubMed, Science Direct, EBSCOHost, Europe PMC, ProQuest, and Scopus. This literature search was implemented until October 31, 2021. The search terms were determined specifically for each databases, generally included the Neutrophil Extracellular Traps, COVID-19, and prognosis. The Newcastle Ottawa Scale (NOS) was then used to assess the risk of bias. Ten studies with a total of 810 participants were chosen based on the attainment of the prerequisite. Two were of high quality, seven were of moderate quality, and the rest were of low quality. The majority of studies compared COVID-19 to healthy control. Thrombosis was observed in three studies, while four studies recorded the need for mechanical ventilation. In COVID-19 patients, the early NETs concentration or the evolving NETs degradations can predict patient mortality. Based on their interactions with inflammatory and organ dysfunction markers, it is concluded that NETs play a significant role in navigating the severity of COVID-19 patients and thus impacting their prognosis.

Epidemiology and Management of Cerebral Venous Thrombosis during the COVID-19 Pandemic

Cerebral venous thrombosis (CVT) is a rare type of stroke that may cause an intracranial hypertension syndrome as well as focal neurological deficits due to venous infarcts. MRI with venography is the method of choice for diagnosis, and treatment with anticoagulants should be promptly started. CVT incidence has increased in COVID-19-infected patients due to a hypercoagulability state and endothelial inflammation. CVT following COVID-19 vaccination could be related to vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare but severe complication that should be promptly identified because of its high mortality rate. Platelet count, D-dimer and PF4 antibodies should be dosed. Treatment with non-heparin anticoagulants and immunoglobulin could improve recuperation. Development of headache associated with seizures, impaired consciousness or focal signs should raise immediate suspicion of CVT. In patients who received a COVID-19 adenovirus-vector vaccine presenting thromboembolic events, VITT should be suspected and rapidly treated. Nevertheless, vaccination benefits clearly outweigh risks and should be continued.

Endovascular Treatment of Intracranial Vein and Venous Sinus Thrombosis—A Systematic Review

Background: Cerebral venous sinus or vein thromboses (SVT) are treated with heparin followed by oral anticoagulation. Even after receiving the best medical treatment, numerous patients experience neurological deterioration, intracerebral hemorrhage or brain edema. Debate regarding whether endovascular treatment (EVT) is beneficial in such severe cases remains ongoing. This systematic review summarizes the current evidence supporting the use of EVT for SVT on the basis of case presentations, with a focus on patient selection, treatment strategies and the effects of the COVID-19 pandemic. Methods: This systemic literature review included randomized controlled trials (RCTs) and retrospective observational data analyzing five or more patients. Follow-up information (modified Rankin scale (mRS)) was required to be provided (individual patient data). Results: 21 records (n = 405 patients; 1 RCT, 20 observational studies) were identified. EVT was found to be feasible and safe in a highly selected patient cohort but was not associated with an increase in good functional outcomes (mRS 0–2) in RCT data. In observational data, good functional outcomes were frequently observed despite an anticipated poor prognosis. Conclusion: The current evidence does not support the routine incorporation of EVT in SVT treatment. However, in a patient cohort prone to poor prognosis, EVT might be a reasonable therapeutic option. Further studies determining the patients at risk, choice of methods and devices, and timing of treatment initiation are warranted.

Brain dural arteriovenous fistulas in the COVID-19 Era: A warning and rationale for association

Objectives

Brain dural arteriovenous fistulas(bDAVFs) are anomalous connections between dural arteries and cerebral veins or sinuses. Cerebral venous thrombosis(CVT) often precedes or coincides with bDAVFs and is considered a risk factor for these vascular malformations. Recently, vaccine-induced thrombotic thrombocytopenia causing CVTs has been associated with COVID-19 vaccines. Concurrently with the start of massive vaccination in our region, we have observed a fivefold increase in the average incidence of bDAVFs. Our objective is to raise awareness of the potential involvement of COVID-19 vaccines in the pathogenesis of bDAVF.

Methods

A retrospective review of demographic, clinical, radiological, COVID-19 infection and vaccination data of patients diagnosed with bDAVFs between 2011 and 2021 was conducted. Patients were divided into two cohorts according to their belonging to pre- or post-COVID-19 vaccination times. Cohorts were compared for bDAVFs incidences and demographic and clinical features.

Results

Twenty-one bDAVFs were diagnosed between 2011 and 2021, 7 of which in 2021. The mean age was 57.7 years, and 62 % were males. All cases except one were treated; of them, 85 % exclusively managed with surgery. All treated cases were successfully occluded. The incidence in 2021 was significantly higher than that in the prevaccination period (1.72 vs 0.35/100,000/year;p = 0.036; 95 %Confidence Interval = 0.09–2.66). Cohorts were not different in age, sex, hemorrhagic presentation, dural sinus thrombosis or presence of prothrombotic or cardiovascular risk factors.

Conclusion

The significant increase in the incidence of bDAVF following general vaccination policies against COVID-19 observed in our region suggests a potential correlation between these two facts. Our findings need confirmation from larger cohorts and further pathogenic research.

The Hospitalization Rate of Cerebral Venous Sinus Thrombosis before and during COVID-19 Pandemic Era: A Single-Center Retrospective Cohort Study

OBJECTIVES

There are several reports of the association between SARS-CoV-2 infection (COVID-19) and cerebral venous sinus thrombosis (CVST). In this study, we aimed to compare the hospitalization rate of CVST before and during the COVID-19 pandemic (before vaccination program).

MATERIALS AND METHODS

In this retrospective cohort study, the hospitalization rate of adult CVST patients in Namazi hospital, a tertiary referral center in the south of Iran, was compared in two periods of time. We defined March 2018 to March 2019 as the pre-COVID-19 period and March 2020 to March 2021 as the COVID-19 period.

RESULTS

50 and 77 adult CVST patients were hospitalized in the pre-COVID-19 and COVID-19 periods, respectively. The crude CVST hospitalization rate increased from 14.33 in the pre-COVID-19 period to 21.7 per million in the COVID-19 era (P = 0.021). However, after age and sex adjustment, the incremental trend in hospitalization rate was not significant (95% CrI: -2.2, 5.14). Patients > 50-year-old were more often hospitalized in the COVID-19 period (P = 0.042). SARS-CoV-2 PCR test was done in 49.3% out of all COVID-19 period patients, which were positive in 6.5%. Modified Rankin Scale (mRS) score ≥3 at three-month follow-up was associated with age (P = 0.015) and malignancy (P = 0.014) in pre-COVID period; and was associated with age (P = 0.025), altered mental status on admission time (P<0.001), malignancy (P = 0.041) and COVID-19 infection (P = 0.008) in COVID-19 period.

CONCLUSION

Since there was a more dismal outcome in COVID-19 associated CVST, a high index of suspicion for CVST among COVID-19 positive is recommended.

Cerebral venous thrombosis in a young asymptomatic COVID-19 patient

We report an unusual case of cerebral venous thrombosis (CVT temporally associated with an otherwise asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While coronavirus disease 2019 (COVID-19) has been associated with thrombotic events at different sites, most published cases report on symptomatic SARS-CoV-2 infection. We are confident this was an otherwise asymptomatic infection as the patient reported no symptoms and molecular and serological testing was consistent with infection more than 3weeks in the past.

We believe this is an important report as it adds to the existing literature on thrombotic events in patients with COVID. It may even inform discussion of COVID vaccines and CVT since our patient, as those reported in association with vaccines, also had thrombocytopenia on admission.

Radiographic and Clinical Analysis of Cranio-Maxillofacial Complications of Cavernous Sinus Thrombosis Among 256 COVID-19 Patients

A heavy burden of cranio-maxillofacial complications may be encountered in corona virus disease-2019 patients due to the associated coagulopathy and inflammatory consequences of the disease. This study aims to describe clinical and radiographic features of these complications in 256 patients who developed 1 or more of the following complications: cavernous sinus thrombosis, osteomyelitis or necrosis of the jaws.

Long-Delayed Manifestation of COVID-19 Coagulopathy Presenting with Severe Cerebral Venous Thrombosis Causes Massive Brain Hemorrhage

COVID-19 infection causes coagulopathy, which may lead to cerebral venous thrombotic (CVT) event. It usually occurs in patients with higher severity level of infection and manifests mostly within a month after the infection. However, in rare cases, the CVT may happen long after the infection and unrelated to the degree of the infection severity. We present the case of a previously healthy 62-year-old male patient with very mild COVID-19 symptoms that resolved in 3 weeks of home isolation treatment. Immediately after the infection, he developed hypercoagulability and was treated routinely with a novel oral anti-coagulant drug. Four months after the infection, he developed a worsening headache which, in several days, deteriorated to cause reduction in his consciousness level. Imaging showed a right temporoparietooccipital massive brain hemorrhage with right transverse and sigmoid sinus thrombosis. Emergency decompressive craniectomy was performed and the patient recovery was excellent. In patients with a hypercoagulable state after COVID-19 infection, the possibility of CVT event should be observed. It may not be related to the severity of the infection, and it may happen long after the infection.

Cerebral venous thrombosis during the COVID-19 Pandemic: A multi-center experience

Objective

To describe the clinical characteristics and outcomes of CVT in patients with history of recent COVID-19 infection or vaccination.

Methods

We reviewed demographic, clinical, and radiographic characteristics of non-pyrogenic, non-traumatic CVT cases at our multi-center institution between March 2020 and December 2021. Patients were grouped according to their history of recent COVID-19 infection or vaccination into group-I (+COVID-19 association) and group-II (-COVID-19 association).

Results

Fifty-one patients with CVT were included, of which 14 (27.4%) had a positive COVID-19 association: 10 with infection and 4 with mRNA-COVID-vaccine. Nine patients in group-I had COVID-19 infection or vaccine within 30 days of CVT diagnosis, including 3 patients with active infection at the time of CVT diagnosis. Half of the patients in group-I (n = 7,50.0%) and 32.4% (n = 12) of group-II were male, and mean age was 52.6 years in group-I and 51.4 years in group-II. Fever at presentation was noted in one patient who had active COVID infection (I=1 (7.1%), II= 0 (0%)). Higher rates of comorbidities were observed in group-II: hypertension (I= 2 (14.3%), II= 13 (35.1%)), deep venous thrombosis(I=1(7.1%), II= 10 (27.0%)), pulmonary emboli (I=1(7.1%), II= 8(21.6%)), or stroke(I=0(0%), II= 6(16.4%)). Three patients had thrombocytopenia at the time of CVT diagnosis (5.4%) and most patients (n = 37, 72.5%) were treated medically with anticoagulation. Complication rate during hospitalization was 17.6% (n = 6), and no mortality was noted.

Conclusion

Twenty-seven percent of CVT patients were associated with COVID-19 infection or vaccination, and the majority presented within 30 days of infection/vaccination.