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Cerebral venous thrombosis simulating cerebral arterial thrombosis: Late complication of COVID-19?

Context: Brain venous thrombosis (BVT) is uncommon and usually has a different clinic and treatment from cerebral arterial thrombosis. In this context, COVID-19 correlates with thrombogenesis with varied clinical repercussions. This report describes an unusual BVT case as a possible late complication of COVID-19. Case report: Male, 68 years old, athlete and healthy. April/2020: COVID-19 mild symptoms. February/2021: in road-running, he fell due to sudden left hemiparesis. Upon hospital admission: contacting, persistent headache. A week after, low level of consciousness and coma, when underwent right hemicraniectomy. Remains hospitalized. On examination: weak gestural communication, tracheostomy, enteral tube feeding, voluntary blinking. Maintains neutral cervical posture, masticatory automatisms, photoreactive isocoria, generalized rigidity, decorticated right hemiparesis, left hemiplegia. On imaging: hemorrhagic infarction on the right and mass effect due to obstruction of the Basal Rosenthal and Labbé veins and transverse sinus on the right, with venous blood flow in the rest of the hemisphere diverted to the ipsilateral internal jugular vein, by anastomotic veins of the occipital foramen and suboccipital venous plexus. Obstructed left internal jugular vein, with venous collateral flow from the left hemisphere via posterior intercavernous sinus and basilar plexus to the right internal jugular vein. Conclusions: To diagnose the venous etiology that resembled segmental occlusion of the right middle cerebral artery, CT angiography was required. Late evolution of COVID-19 has been identified by the persistence of symptoms for months. Although physical activity and possible dehydration may have contributed to BVT, a prothrombotic state correlated to COVID-19 cannot be discarded.