A case of cerebral venous sinus thrombosis as initial presentation of COVID-19

Abstract

Objective: To highlight CNS thrombotic events as an initial presentation of Corona virus disease. Background: Sars COV 2 has had numerous varying clinical presentations since it first emerged in Wuhan city of China in late 2019. One of the widely proposed pathogenic mechanisms by which Covid 19 causes devastating effects is through an inflammatory cascade of events including Endothelial cell injury, immune-mediated vascular inflammation, down regulation of ACE2 and unopposed pro-inflammatory and prothrombotic effects of angiotensin II. Coagulopathy and hypercoagulable state are a known feature of this disease. Herein, we report a case of a 64 yr old woman seen in the Emergency Room with a 5 day history of new onset left temporal and left occipital headache with associated nausea and an episode of vomiting. She was afebrile. Her neurological examination including a cranial nerve examination was unremarkable.Results: Her labs revealed mild leukocytosis with lymphopenia. Her non contrast Head CT was suggestive of venous sinus thrombosis and subsequent MRV confirmed thrombosis involving posterior part of superior Sagitta sinus, straight sinus, left sigmoid sinus, extending into proximal part of left internal jugular vein. She was commenced on therapeutic dose of enoxaparin and admitted to the inpatient unit. Her COVID 19 PCR sent as part of routine Emergency Room screening returned positive. Her Headache improved over the next 10 days and she was discharged on therapeutic dose enoxaparin for 6 months and instructed to follow up in hematology and neurology outpatient clinics in 3 months. Conclusions: Clinicians should maintain a high suspicion for COVID 19 infection in patients presenting with headaches despite absence of classic pulmonary features and fever.