Extensive Cerebral Venous Sinus Thrombosis Associated with COVID‐19 and Mastoiditis

Introduction/Purpose Cerebral venous sinus thrombosis (CVST) is the presence of thrombosis in the dural venous sinuses or the cerebral veins. CVST most commonly involves the superior sagittal sinuses, followed by the transverse sinuses, and the straight sinus. Here, we present a rare case of extensive CVST affecting nearly all intra‐cranial dural venous sinuses, including the deep and superficial venous sinuses, in a patient with concurrent COVID‐19 infection and mastoiditis, who re‐thrombosed post‐thrombectomy but improved with anticoagulation. Materials/Methods N/A Results A 58‐year‐old female with hypertension and hyperlipidemia presented with acute onset vertigo, nausea, vomiting, and headache. She tested positive for COVID‐19, and a brain magnetic resonance imaging (MRI) showed left‐sided mastoiditis. During hospitalization, the patient developed acute encephalopathy, somnolence, expressive aphasia, and right‐sided weakness. Magnetic resonance venography (MRV) revealed extensive intracranial venous thrombosis involving the superior sagittal sinus, vein of Galen, straight sinus, bilateral transverse sinuses, and left sigmoid sinus, with partial thrombosis of the right transverse sinus, extending into the proximal left internal jugular vein. She was started on therapeutic heparin anticoagulation, but developed subdural and subarachnoid hemorrhage, suggesting compromised venous outflow and congestion. She underwent endovascular venous thrombectomy, achieving near‐complete recanalization. Anticoagulation was eventually transitioned to Eliquis. A computed tomography venogram (CTV) of the brain the following day showed complete re‐thrombosis of all dural venous sinuses. Patient was started on Warfarin and remained stable with improvement in headache. Conclusion This case underscores the complexity and severity of extensive CVST involving nearly all dural venous sinuses in the context of COVID‐19 and mastoiditis. Despite aggressive therapeutic anticoagulation and endovascular thrombectomy, re‐thrombosis occurred, underscoring management challenges. This emphasizes the need for ongoing research into more effective treatments for CVST in patients with concurrent COVID‐19 and mastoiditis. image image Figures 1 and 2 : CTV sagittal and coronal views showing extensive venous sinus thrombosis.