key: cord-0706142-8ta4v1vq authors: Roy-Gash, Fabian; Marine, De Mesmay; Jean-Michel, Devys; Herve, Vespignani; Raphael, Blanc; Nicolas, Engrand title: COVID-19-associated acute cerebral venous thrombosis: clinical, CT, MRI and EEG features date: 2020-07-11 journal: Crit Care DOI: 10.1186/s13054-020-03131-x sha: 7dc014340b8826df530af14b9a3eba7e23828f5a doc_id: 706142 cord_uid: 8ta4v1vq nan Many recent COVID-19 series have reported arterial or venous thrombosis (stroke, pulmonary embolism, etc.) [1, 2] . Here, we report a case of COVID-19 associated cerebral venous thrombosis (CVT) with dramatic evolution. On April 3, 2020, a 63-year-old female presented to the emergency department because of aphasia and right hemiplegia. She had a 12-day history of fever, cough, and anosmia. Her husband was hospitalized in intensive care for confirmed COVID-19 acute respiratory distress syndrome (ARDS). Brain MRI showed a large left temporal brain hemorrhage and a suspicion of CVT confirmed on a venous brain CT scan and chest CT showed typical COVID-19 patchy ground-glass opacities in both lungs (Fig. 1) . The patient suddenly suffered a clinical status epilepticus and was administered i.v. lacosamide. Laboratory results showed hyperfibrinogenemia (7.2 g/L) and high ferritin levels (1427 μg/L). The nasopharyngeal and bronchial samples were negative for SARS-CoV-2. Most common causes of genetic thrombotic disorders and antiphospholipid antibody syndrome were excluded. The patient was started on an intravenous curative dose of heparin anticoagulation. Electroencephalograpy (EEG) showed background theta activity unreactive to nociceptive stimulus, with pseudo-periodic activity of a short period composed of slow di-phasic waves irradiating towards the anterior regions (Fig. 2) . Although subtle status epilepticus could not be excluded, the aspect was not typical and other successive EEG traces would confirm this non-epileptic paroxystic pseudo-periodic pattern. The patient eventually underwent surgical intracranial hematoma evacuation followed by decompressive craniectomy. On April 17th, brain CT scan revealed a new intracranial contralateral bleeding most likely following contralateral venous thrombosis despite being properly treated with intravenous heparin. Venous angiography showed persistent left thrombosis (Fig. 1) . On April 25th, the patient was tested positive for SARS-CoV-2 plasmatic IgG and IgM (ELISA test). On April 29th, the patient died following therapeutic limitation after ethical consultation group expertise. Although both samples were negative for SARS-CoV-2, we considered the patient infected by it, given the initial symptomatology, the confirmed infection in one relative, the specific aspect of the thoracic CT scan [3] , and the positive serology. Furthermore, in this case, the thrombotic event occurred 12 days after the first influenza-like symptoms, which corresponds to the most inflammatory period of COVID-19 [4, 5] . In addition to the left lesion temporal focus observed on the EEG, the background activity and paroxysmal activity describes atypical patterns, which can be mistaken with persistent epileptic activity. However, we believe it is compatible with newly described patterns of specific COVID-19 encephalopathy [6] . Overall, this case suggests that practitioners should be aware of the possibility of a CVT in this novel COVID-19 context, especially during the post-viral period. Abbreviations ARDS: Acute respiratory distress syndrome; COVID-19: Coronavirus disease 19; CVT: Cerebral venous thrombosis; EEG: Electroencephalography Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China Neurologic manifestations of hospitalized patients with coronavirus disease Sensitivity of chest CT for COVID-19: comparison to RT-PCR COVID-19 illness in native and immunosuppressed states: a clinical-therapeutic staging proposal Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia Report of EEG Finding on Critically Ill Patients with COVID-19 Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations The authors would like to thank Dr. Clementine Cholet, Dr. Vera Dinkelacker, and Dr. Basma Abdi for their precious help in retrieving data for this case report. Received: 28 May 2020 Accepted: 1 July 2020 All the authors listed meet the authorship criteria. FRG and NE wrote the manuscript. MDM helped in obtaining important data. RB helped in obtaining relevant CT and MRI pictures. HV helped in understanding the EEG pattern. JMD and HV reviewed and edited the manuscript. The authors read and approved the final manuscript.Authors' information None. None. All data analyzed in this report is available by simple request to the corresponding author. This study is only a retrospective report; therefore, no ethics approval was needed. Patient's family gave their written consent for publication.Competing interests H. Vespignani interprets electroencephalography patterns for his private firm Serenity Medical Service-Neurophy. All the other authors declare they have no competing interests.