Diagnosis and Treatment of Cerebral Venous Thrombosis.

OBJECTIVE: Cerebral venous thrombosis (CVT), thrombosis of the dural sinus, cerebral veins, or both, is a rare cerebrovascular disease. Although mortality rates after CVT have declined over time, this condition can result in devastating neurologic outcomes. This article reviews the latest literature regarding CVT epidemiology, details new factors associated with the development of CVT, and describes advances in CVT treatment. It also contains a discussion of future directions in the field, including novel diagnostic imaging modalities, and potential strategies to reduce the risks associated with CVT. LATEST DEVELOPMENTS: The incidence of CVT may be as high as 2 per 100,000 adults per year. It remains a difficult condition to diagnose given its variable clinical manifestations and the necessity of neuroimaging for confirmation. The COVID-19 pandemic has revealed a novel CVT trigger, vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as an association between COVID-19 infection and CVT. Although VITT is a very rare event, timely diagnosis and treatment of CVT due to VITT likely improves patient outcomes. Direct oral anticoagulants are currently being used to treat CVT and emerging data suggest that these agents are as safe and effective as vitamin K antagonists. The role of endovascular therapy to treat CVT, despite a recent clinical trial, remains unproven. ESSENTIAL POINTS: The incidence of CVT has increased, outcomes have improved, and the use of direct oral anticoagulants to treat CVT represents an important advance in the clinical care of these patients. Rates of CVT as a complication of COVID-19 vaccines using adenoviral vectors are very low (<5 per million vaccine doses administered), with the benefits of COVID-19 vaccination far outweighing the risks.

Readmission After COVID-19 for Late Acute Venous Thrombosis; CASE SERIES and Systematic Review of the Literature.

OBJECTIVE: Assess heterogeneity within patients with resolved COVID-19 to broaden the vision about post-discharge thrombotic cases and postulate possible related mechanisms in search of better anticoagulation guidelines. This study details patients' characteristics, medical history, treatment, and outcomes of readmitted patients with late acute thrombosis through a systematic review of the literature and patients from our academic center database. METHODS: We extracted the records of patients readmitted for venous thrombosis complications after discharge from the database of the first 2000 patients admitted with COVID-19 in our academic center; we also performed a systematic review of the literature using the Medical Subject Headings terms "late thrombosis," "COVID-19," + "venous thrombosis" in PubMed and Google Scholar according to PRISMA guideline. RESULTS: The literature review found 20 patients suitable for review matching the inclusion criteria. These patients were added to those in our database, summing up a total of 26 patients. The median age was 50 years old, 76.9% were male, and most were overweight or had grade 1 obesity (n = 11, 42.3%). None had a previous thrombotic history, but 50% had an underlying comorbidity. Thrombotic events presented on a median of 20 days (range: 4-150 days) from discharge. Pulmonary embolisms occurred in 23 patients (88.46%), deep vein thrombosis in 4, mesenteric thrombosis, and cerebral venous thrombosis in 1, respectively. CONCLUSION: This study found that most patients readmitted for thrombotic events after COVID-19 discharge were middle-aged men with Venous Thrombo Embolism events.

Cerebral venous thrombosis.

Cerebral venous sinus thrombosis (CVT) consists of partial or complete occlusion of a sinus or a cerebral vein. CVT represents 0.5-1% of all strokes and is more frequent in young women. This review discusses particular aspects of CVT diagnosis and management: decompressive craniectomy (DC), anticoagulation with direct oral anticoagulants (DOACs), CVT after coronavirus-disease 19 (COVID-19) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT).

[Surgical complications in patients with COVID-19]. / Khirurgicheskie oslozhneniya u bol'nykh COVID-19.

OBJECTIVE: To analyze in-hospital perioperative complications in COVID-19 patients. MATERIAL AND METHODS: We analyzed medical records of 1.250 patients with COVID-19 for the period from April 2020 to December 2021. Mean age of patients was 62.8±2.1 years, length of hospital-stay - 44.3±3.7 days. All patients received therapy in accordance with the national guidelines on prevention, diagnosis and treatment of new coronavirus infection (COVID-19)¼ (versions 1-12). Visualization of hematomas, arterial and venous thrombosis was performed using ultrasound, CT and CT angiography. RESULTS: Mortality rate was 1.5%. Surgical complications included various hematomas, arterial and venous thrombosis of great vessels. Hematomas were detected in 15 (1.2%) patients, 2 of them died. There were hematomas of extremities in 5 cases, retroperitoneal space - 4, soft tissues of the body - 4, internal organs (spleen) -2 patients. The volume of hematoma was up to 100 ml in 6 patients, 100-500 ml in 5 patients, 500-1000 ml in 3 patietns, more than 1000 ml in 1 patient. Hematomas occurred in 23.1±1.1 days after laboratory verification of COVID-19. Four (26.7%) patients underwent emergency surgery. Conservative therapy was followed by lysis of hematoma after 25.1±2.7 days. Venous thrombosis without signs of flotation occurred in 20 (1.6%) patients, arterial thrombosis - in 3 (0.24%) patients (2 ones required surgery). CONCLUSION: Management of COVID-19 patients with various hematomas should be as conservative as possible. Arterial thrombosis and extensive spleen hematomas requiring surgical treatment are features of COVID-19.

Cerebral Venous Thrombosis.

Cerebral venous thrombosis (CVT) is a rare form of stroke that often affects younger age groups, especially reproductive age group females. CVT is a potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. Headache is the most common presenting symptom. However, a wide range of symptoms can be present and the symptom onset can be acute, subacute, or chronic. Neuroimaging is mandatory in cases where CVT is suspected. Both magnetic resonance venography and computed tomography venography can confirm a diagnosis of CVT. Anticoagulation with low-molecular-weight heparin is the mainstay of treatment. Intracranial hemorrhage is not considered a contraindication to the use of anticoagulants in CVT. Endovascular intervention is still controversial but can be a treatment option for patients with neurological deterioration or thrombus progression, despite the use of anticoagulation or with development of new or worsening intracerebral hemorrhage. Patients with CVT have an increased risk of recurrence of CVT and other types of venous thromboembolism. This review provides an overview of the epidemiology, diagnosis, and treatment of CVT in adults. Commentary about increased presentation of CVT in patients with coronavirus disease 2019 (COVID-19), or after immunization against COVID-19, is also provided.

Splanchnic venous thrombosis in a nephrotic patient following COVID-19 infection: a case report.

BACKGROUND: As the COVID-19 pandemic spread worldwide, case reports and small series identified its association with an increasing number of medical conditions including a propensity for thrombotic complications. And since the nephrotic syndrome is also a thrombophilic state, its co-occurrence with the SARS-CoV-2 infection is likely to be associated with an even higher risk of thrombosis, particularly in the presence of known or unknown additional risk factors. Lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) are the most common manifestations of COVID-19-associated hypercoagulable state with other venous or arterial sites being much less frequently involved. Although splanchnic vein thrombosis (SVT) has been reported to be 25 times less common than usual site venous thromboembolism (VTE) and rarely occurs in nephrotic patients, it can have catastrophic consequences. A small number of SVT cases have been reported in COVID-19 infected patients in spite of their number exceeding 180 million worldwide. CASE PRESENTATION: An unvaccinated young adult male with steroid-dependent nephrotic syndrome (SDNS) who was in a complete nephrotic remission relapsed following contracting SARS-CoV-2 infection and developed abdominal pain and diarrhea. Abdominal US revealed portal vein thrombosis. The patient was anticoagulated, yet the SVT rapidly propagated to involve the spleno-mesenteric, intrahepatic and the right hepatic veins. In spite of mechanical thrombectomy, thrombolytics and anticoagulation, he developed mesenteric ischemia which progressed to gangrene leading to bowel resection and a complicated hospital course. CONCLUSION: Our case highlights the potential for a catastrophic outcome when COVID-19 infection occurs in those with a concomitant hypercoagulable state and reminds us of the need for a careful assessment of abdominal symptoms in SARS-CoV-2 infected patients.

Extensive deep vein thrombosis and pulmonary embolism as a unique clinical manifestation of COVID-19 in a young healthy patient.

BACKGROUND/OBJECTIVE: Deep vein thrombosis and pulmonary embolism have been described as complications in previously diagnosed COVID-19 patients, especially in those admitted in critical ill units, but, to our knowledge, there is no report of venous thromboembolism in an otherwise asymptomatic COVID-19 patient. METHODS: We report the case of a 22-year-old female, healthy patient with pulmonary embolism (Pulmonary Embolism Severity Index Score 22 points, low risk) and extensive proximal deep vein thrombosis as a unique clinical manifestation of the new coronavirus disease. RESULTS: The patient had no risk factors and no familial history of venous thromboembolism. All thrombophilia markers were negative. The patient was treated as first by an independent vascular team, performing vena cava filter placement and open thrombectomy. Her symptoms worsened, and after 3 weeks, she underwent US-enhanced thrombolysis and mechanical thrombectomy. She was isolated for 10 days and did not develop any other clinical manifestation of COVID-19 disease. During follow-up, she remained asymptomatic and complete patency of the venous system was achieved. Full oral anticoagulation was conducted for 6 months. CONCLUSION: COVID-19 appears to be a multi-symptomatic disease, and venous thromboembolism without any other previous described COVID-19 symptom could be considered one of its diverse clinical presentations and RT-PCR for SARS-CoV-2 tests emerge to be mandatory in patients with otherwise unexpected venous thrombosis.

A simple prognostic score for COVID-19 hospitalized patients developing deep vein thrombosis.

OBJECTIVE: The aim of our study was to analyze the specificity, accuracy and sensitivity of a simple, easy to calculate, prognostic score for hospitalized COVID19 patients developing deep vein thrombosis. METHODS: From March 1st to April 28th, 942 COVID-19 patients with severe symptoms were admitted to the hospital San Matteo of Pavia-Italy. Thirty two patients (3.4%) developed deep vein thrombosis during hospitalization. In all patients hemostatic and inflammatory parameters were abnormal. A simple prognostic score was developed based on the presence of specific co morbidities and D-dimers levels (quick San Matthew Score-quick SMS). RESULTS: Nine patients died in a condition of multiple organ failure, 23 patients (71.9%) survived and left the hospital in good general conditions. The developed score was based simply on two parameters: 1) presence of four specific co morbidities and 2)systemic levels of D-Dimers. The quick San Matthew Score resulted in a sensitivity, specificity and overall accuracy of more than 90% (94%, 92%,93% respectively) and compared favorably with other scores. The score was prospectively validated in 100 COVID19 patients who developed deep vein thrombosis collected from the literature and prospectively confirmed in our hospital. CONCLUSIONS: The findings of our study underline the importance of an immediate aggressive therapeutic approach for moderate and high-risk patients with COVID19 infection. The quick SMS score may help to identify patients at high risk for mortality and to follow the clinical outcome of the patient. A simple, easy to calculate prognostic score may also facilitate communication among health workers.

Clinical review of cerebral venous thrombosis in the context of COVID-19 vaccinations: Evaluation, management, and scientific questions.

BACKGROUND: Vaccine induced immune mediated thrombocytopenia or VITT, is a recent and rare phenomenon of thrombosis with thrombocytopenia, frequently including cerebral venous thromboses (CVT), that has been described following vaccination with adenovirus vaccines ChAdOx1 nCOV-19 (AstraZeneca) and Ad26.COV2·S Johnson and Johnson (Janssen/J&J). The evaluation and management of suspected cases of CVT post COVID-19 vaccination are critical skills for a broad range of healthcare providers. METHODS: A collaborative comprehensive review of literature was conducted among a global group of expert neurologists and hematologists. FINDINGS: Strategies for rapid evaluation and treatment of the CVT in the context of possible VITT exist, including inflammatory marker measurements, PF4 assays, and non-heparin anticoagulation.

Pulmonary Vein Thrombosis in COVID-19.

Research on COVID-19, the cause of a rapidly worsening pandemic, has led to the observation of laboratory derangements such as a propensity towards a hypercoagulable state. However, there are currently no reports on the incidence of pulmonary venous thrombosis in the setting of COVID-19. We report a case in which follow-up chest CT scans revealed an expansile filling defect in a branch of the right inferior pulmonary vein, which is consistent with pulmonary venous thrombosis. Our objective was to provide insight into an uncommon sequela of COVID-19 and consequently garner increased clinical suspicion for pulmonary VTE during hospitalization.

Recurrence of Upper Extremity Deep Vein Thrombosis Secondary to COVID-19.

Infection with SARS-CoV-2 leading to COVID-19 induces hyperinflammatory and hypercoagulable states, resulting in arterial and venous thromboembolic events. Deep vein thrombosis (DVT) has been well reported in COVID-19 patients. While most DVTs occur in a lower extremity, involvement of the upper extremity is uncommon. In this report, we describe the first reported patient with an upper extremity DVT recurrence secondary to COVID-19 infection.

Ovarian vein thrombosis after coronavirus disease (COVID-19) mimicking acute abdomen: two case reports.

Coronavirus is a source of deep venous thrombosis (DVT) due to complications such as over-coagulation, blood stasis, and endothelial damage. Ovarian vein thrombosis (OVT) is a very serious and rare disease. In this study, we report tow rare case of women with coronavirus who were hospitalized with a right ovarian vein thrombosis mimicking acute abdomen who progressed well on anticoagulation. Our report adds further document in Side effects and rare localisation of obstruction of veins and arteries in patient with corona virus.

Pulmonary embolism confounded with COVID-19 suspicion in a catatonic patient presenting to anesthesia for ECT: a case report.

Catatonic patients may develop deep vein thrombosis (DVT) and pulmonary embolism (PE) due to prolonged periods of immobility. These life-threatening conditions demand prompt recognition and management. We describe the case of a patient with catatonia who presented to anesthesia for electroconvulsive therapy (ECT) at the outset of the current coronavirus disease 2019 pandemic. She complained of breathing difficulty and was suspected to have COVID-19 infection. On further evaluation, she was found to have DVT and PE and required oxygen therapy and intensive care management. The diagnostic delay in our patient would have probably not occurred, had it not been for the existing pandemic situation.

A systematic review and meta-analysis of incidence, prognosis, and laboratory indicators of venous thromboembolism in hospitalized patients with coronavirus disease 2019.

OBJECTIVE: We have summarized the incidence, anticoagulation panels, laboratory characteristics, and mortality of venous thromboembolism (VTE) in hospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: After systematically searching PubMed, Embase, the Cochrane Library, MedRxiv, and BioRxiv, a systematic review and meta-analysis of 18 retrospective, 6 prospective observational, and 2 cross-sectional studies was performed according to the guidelines of the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement. RESULTS: Overall, 4382 hospitalized patients with COVID-19 were included. Men accounted for significantly more patients than did women (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.02; P < .001). The total incidence of VTE among the patients with COVID-19 was 28.3% (95% CI, 21.6%-35.4%), with an incidence of 38.0% (95% CI, 29.1%-47.4%) and 17.2% (95% CI, 11.4%-23.8%) among those with severe and general COVID-19, respectively. The total incidence of deep vein thrombosis (DVT) of the lower extremities was 18.3% (95% CI, 10.8%-27.2%). The incidence of DVT was 22.1% (95% CI, 11.0%-35.5%) and 12.8% (95% CI, 5.0%-23.3%) in those with severe and general COVID-19, respectively. The total incidence of pulmonary embolism was 17.6% (95% CI, 12.3%-23.5%), with a rate of 21.7% (95% CI, 14.8%-29.3%) in severe cases and 12.5% (95% CI, 6.1%-23.5%) in general cases. When COVID-19 severity was unclassified, the mortality for the patients with VTE was not significantly greater (25.2%; 95% CI, 12.2%-40.5%) than that for those without VTE (10.2%; 95% CI, 3.4%-19.5%; OR, 1.88; 95% CI, 0.46-7.64; P = .377). However, among the patients with severe COVID-19, those who had developed VTE had significantly greater mortality compared with those without VTE (OR, 2.02; 95% CI, 1.15-3.53; P = .014). The patients with COVID-19 and VTE had significantly higher D-dimer levels than did similar patients without VTE in multiple studies. CONCLUSIONS: The occurrence of VTE, DVT, and pulmonary embolism has been substantial among hospitalized patients with COVID-19, especially among those with severe COVID-19. Patients with severe COVID-19 and VTE had significantly greater mortality compared with similar patients without VTE. An increased D-dimer level might be an indicator of the occurrence of VTE in patients with COVID-19.