key: cord-0802717-rskszk51
authors: Neshin, Saeideh Aghayari Sheikh; Basirjafari, Sedighe; Saberi, Alia; Shahhosseini, Babak; Zarei, Mohammad
title: Liver abnormality may develop cerebral vein thrombosis in COVID-19
date: 2020-08-05
journal: J Neurol Sci
DOI: 10.1016/j.jns.2020.117076
sha: 586d6a1ebe8710d457df97ba941807a5ea41a9d9
doc_id: 802717
cord_uid: rskszk51

nan

We read with great interest the manuscript written by Garaci and colleagues 1 describing, venous cerebral thrombosis in COVID-19 patient". Here we describe markedly elevated liver enzymes by SARS-COV-2 lead to hypercoagulability that may develop CVT.

A 43-year-old previously healthy woman with headache for one day developed a single episode of GTC seizure with postictal drowsiness. She admitted to the emergency department with loss of consciousness. Her vital signs were stable and oxygen saturation was 95% on room air. She had no focal neurologic signs. Initial brain computerized tomography (CT) was suggestive of cerebral venous thrombosis (Fig1.C-D), then MRI and MRV performed and revealed thrombosis in the superior sagittal sinus, internal cerebral vein, and straight sinus, and also hyperintensities in bilateral thalami (more prominent in the left-side), bilateral basal ganglia, and left temporal lobe in favor of venous infarction The cerebrospinal fluid (CSF) analysis showed a traumatic tap with normal parameters and negative culture and gram staining, however RT-PCR for SARS-CoV-2 was unable to be performed. Predisposing factors for thrombophilia were ruled out using standard lab tests. Regarding the elevated liver tests, viral hepatitis markers were negative and liver ultrasound did not exhibit any pathology. She received levetiracetam, hydroxychloroquine, oseltamivir, and ceftriaxone in addition to low molecular weight heparin as an anticoagulant. After 8 day of hospitalization, her clinical status showed improvement and on day 15 she discharged home with good general condition while she was conscious and her lab tests including liver function became near normal.

Markedly elevated liver tests in our case were met abnormal liver function in COVID-19 patients in previous reports and linked to a higher risk of disease severity 2 . Furthermore, before developing respiratory symptoms, infection of COVID-19 can be presented as acute hepatitis 3 , and elevation of hepatic enzymes were associated with higher incidence of venous thromboembolism 4 . Although it is uncommon, but acute viral hepatitis has been related to thrombotic events. 5 It has been shown that there is a high thrombotic risk in severe COVID-19 5 . COVID-19 leads to cerebrovascular events (CVE) through different mechanisms of action, including coagulopathy 7 . Even though this patient had a history of oral contraceptive consumption, it does not exclude the possibility that her CVT attack could be precipitated by her infection. In this context, Cavalcanti et al. found that CVT associated with COVID-19 8 .

We speculate that markedly elevated liver enzymes in this patient with COVID-19 led to hypercoagulability and developed CVT. This evidence indicates the neurological manifestations in COVID-19 and highlights the increase in liver enzymes as a precipitating factor for CVT in COVID-19, which may provide better strategy for the prevention and treatment of the SARS-CoV-2 targeting central nervous system, and also suggests that acute liver abnormality to be isolated and undergo testing for COVID-19.

The authors declare no competing interests.

A-B, non-contrast lung CT scan at two cross-sections exhibit multilobar areas of groundglass opacity (GGO) in the peripheral and subpleural band (red arrowhead) in favor of COVID-19. C-D, non-contrast brain CT scans demonstrate increased density within straight sinus (red arrowhead) and superior sagittal sinus (green arrow). E, axial FLAIR image shows hyperintensity involving the bilateral thalami (most prominent in the left-side) and bilateral basal ganglia (green arrowhead). Findings were compatible with thrombosis of superior sagittal sinus, straight sinus, both internal cerebral veins and left transverse sinus (red arrowhead). F, coronal T1 weighted image shows hyperintensity at both internal cerebral veins in favor of thrombosis (red arrow). G-H, axial T1 weighted images show lack of signal void at superior sagittal sinus and after GAD injection at the same image, the thrombosis is more visible (red arrowhead). I, there is also hyperintensity at left temporal lobe in favor of venous infarction (green arrowhead), (J) MR venography demonstrates the absence of normal flow-related signal within the deep cerebral veins. 

Venous cerebral thrombosis in COVID-19 patient

Characteristics of liver tests in COVID-19 patients

COVID-19 presenting as acute hepatitis

Elevated hepatic enzymes and incidence of venous thromboembolism: a prospective study

Thrombosis Associated with Viral Hepatitis

Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in

COVID-19-Related Stroke

Cerebral Venous Thrombosis associated with COVID-19