top of page

Q) What do we know about cerebral venous thrombosis (CVT) in COVID-19 patients?

A) There are a few points that we would like to share here.

1. Although venous thrombosis is very common in patients with severe COVID infection (approximately 30%), prothrombotic state from this virus can occur in milder infection.

2. There are 21 individual case reports (as of October 25th, 2020) of CVT associated with COVID-19 infection. Interestingly, deep CVT was common (40%) in COVID-19 patients. Generally, deep CVT was found in less than 10% of all CVT before the pandemic.

3. Most patients were diagnosed with CVT approximately 2 weeks after a COVID-19 diagnosis. However, some patients presented with CVT after receiving a negative COVID status or as their first manifestations of the disease.

4. CVT presentations are not specific and usually patients have risk factors for it. However, COVID-19 is a possible risk factor for CVT. CVT should be ruled out when patients present with headache, altered mental status, seizure or acute focal neurological deficits or intubated patients who are not waking up and have increasing D-dimers level.

5. All three CVT cases who had lumbar puncture done, had elevated WBC (10-40 cells/mm3) and high protein (616 & 1104 mg/dl) which imply that even though CSF profile is consistent with encephalitis profile, it does not exclude CVT.

6. How do we explain the mechanisms of venous thrombosis in COVID-19? COVID-19 can cause endothelial injury, cytokine storm which leads to COVID-19 associated coagulopathy and hemodynamic instability and ACE2 depletion (Please see figure) and elevated antiphospholipid antibodies.

7. All patients (15 patients) had elevated D-Dimers (median: 2876 ng/ml and mean: 6397; normal range < 500 ng/ml)

8. The mortality rate of CVT in COVID-19 patients is 52% (9/17) in contrast to the general population (5%).

9. Low-molecular-weight heparin (LMWH) is preferred instead of unfractionated heparin (UFH). Current evidence reveals that using LMWH decreased mortality, new associated hemorrhage, and improved thrombus regression and recovery of symptoms. Moreover, the concerns of time to achieve therapeutic aPTT and increased health care worker exposure for frequent blood draws when using UFH should be kept in mind.

10. White et al. shows heparin resistance (LMWH & UFH) was observed in 80% of COVID patients in ICU. Therefore, anti-Xa level monitoring for patients on LMWH is reasonable


1) Cavalcanti DD, Raz E, Shapiro M, Dehkharghani S, Yaghi S, Lillemoe K, Nossek E, Torres J, Jain R, Riina HA, Radmanesh A, Nelson PK. Cerebral Venous Thrombosis Associated with COVID-19. AJNR Am J Neuroradiol. 2020 Aug;41(8):1370-1376.

2) Klein DE, Libman R, Kirsch C, Arora R. Cerebral venous thrombosis: A typical presentation of COVID-19 in the young. J Stroke Cerebrovasc Dis. 2020 Aug;29(8):104989.

3) Hughes C, Nichols T, Pike M, Subbe C, Elghenzai S. Cerebral Venous Sinus Thrombosis as a Presentation of COVID-19. Eur J Case Rep Intern Med. 2020 Apr 29;7(5):001691.

4) Roy-Gash F, De Mesmay M, Devys JM, Vespignani H, Blanc R, Engrand N. COVID-19-associated acute cerebral venous thrombosis: clinical, CT, MRI and EEG features. Crit Care. 2020 Jul 11;24(1):419.

5) Hoelscher C, Sweid A, Ghosh R, Al Saiegh F, Keppetipola KM, Farrell CJ, Jallo J, Jabbour P, Tjoumakaris S, Gooch MR, Rosenwasser RH, Shah SO. Cerebral deep venous thrombosis and COVID-19: case report. J Neurosurg. 2020 Sep 4:1-4.

6) Garaci F, Di Giuliano F, Picchi E, Da Ros V, Floris R. Venous cerebral thrombosis in COVID-19 patient. J Neurol Sci. 2020 Jul 15;414:116871.

7) Hemasian H, Ansari B. First case of Covid-19 presented with cerebral venous thrombosis: A rare and dreaded case. Rev Neurol (Paris). 2020 Jun;176(6):521-523.

8) Malentacchi M, Gned D, Angelino V, Demichelis S, Perboni A, Veltri A, Bertolotto A, Capobianco M. Concomitant brain arterial and venous thrombosis in a COVID-19 patient. Eur J Neurol. 2020 Jun 5:10.1111/ene.14380.

9) Sugiyama Y, Tsuchiya T, Tanaka R, Ouchi A, Motoyama A, Takamoto T, Hara N, Yanagawa Y. Cerebral venous thrombosis in COVID-19-associated coagulopathy: A case report. J Clin Neurosci. 2020 Sep;79:30-32.

10) Chow LC, Chew LP, Leong TS, Mohamad Tazuddin EE, Chua HH. Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera. A Case Report. SN Compr Clin Med. 2020 Oct 4:1-5.

11) Poillon G, Obadia M, Perrin M, Savatovsky J, Lecler A. Cerebral venous thrombosis associated with COVID-19 infection: Causality or coincidence? J Neuroradiol. 2020 May 11:S0150-9861(20)30167-X.

12) Kananeh MF, Thomas T, Sharma K, Herpich F, Urtecho J, Athar MK, Jabbour P, Shah SO. Arterial and venous strokes in the setting of COVID-19. J Clin Neurosci. 2020 Sep;79:60-66.

13) Baudar C, Duprez T, Kassab A, Miller N, Rutgers MP. COVID-19 as triggering co-factor for cortical cerebral venous thrombosis? J Neuroradiol. 2020 Jun 27:S0150-9861(20)30205-4.

14) Rigamonti A, Mantero V, Piamarta F, Spena G, Salmaggi A. Cerebral venous thrombosis associated with coronavirus infection: an underestimated entity? Neurol Sci. 2020 Jun 29:1–2. doi: 10.1007/s10072-020-04539-7. Epub ahead of print.

15) Chougar L, Mathon B, Weiss N, Degos V, Shor N. Atypical Deep Cerebral Vein Thrombosis with Hemorrhagic Venous Infarction in a Patient Positive for COVID-19. AJNR Am J Neuroradiol. 2020 Aug;41(8):1377-1379.

16) Klein DE, Libman R, Kirsch C, Arora R. Author's response to Letter to the Editor: Anticoagulant approach in COVID-19 patients with cerebral venous thrombosis. J Stroke Cerebrovasc Dis. 2020 Jul 31:105227.

17) Keaney K, Mumtaz T. Cerebral venous thrombosis in patients with severe COVID-19 infection in intensive care. Br J Hosp Med (Lond). 2020 Sep 2;81(9):1-4.

18) Hussain S, Vattoth S, Haroon KH, Muhammad A. A Case of Coronavirus Disease 2019 Presenting with Seizures Secondary to Cerebral Venous Sinus Thrombosis. Case Rep Neurol. 2020 Aug 4;12(2):260-265.

bottom of page