Abstract 232: Complex Management Of Cerebral Venous Sinus Thrombosis In A Pregnant COVID‐19 Patient: Case Report
Authors: Kendall T. , Cheon B. , Mehta B. , Kamal H. , Ajiboye N. 
Published: January 2025

Introduction
Cerebral venous sinus thrombosis (CVST) is a rare but serious condition characterized by blood clot formation in the dural venous sinuses. It can manifest with symptoms ranging from mild headaches to severe complications such as cerebral herniation and death. CVST predominantly affects women aged 20‐40, comprising about 0.5‐1% of acute ischemic events. Although systemic anticoagulation is the first‐line treatment, 10‐20% of cases require further interventions like mechanical thrombectomy and/or localized thrombolysis when medical management alone fails. This case report describes a complex instance of CVST in a 30‐year‐old pregnant woman with COVID‐19 refractory to systemic anticoagulation requiring careful further neurointervention.

Results
30‐year‐old pregnant female with COVID‐19 infection presented to the emergency department with acute progressive encephalopathy, nausea, vomiting, and aphasia. She was eight weeks pregnant at this time. Initial brain imaging revealed extensive thrombi in the superior sagittal sinus, vein of Galen, bilateral transverse sinus, sigmoid sinus, and jugular sinuses accompanied by cerebral edema. Due to severe agitation and worsening neurological status, the patient was intubated for further management. Magnetic resonance imaging (MRI) confirmed the extensive bilateral thrombosis and revealed left frontoparietal edematous changes consistent with distal venous infarcts. Given the severity of her condition, a heparin drip was started, but the thrombotic burden persisted. After consulting with neurointerventional radiology and discussing the risks with her husband and family, the team proceeded with an emergent venous thrombectomy. Thrombus retrieval was attempted with five passes using an ACE68 aspiration catheter. Despite multiple attempts, post‐thrombectomy angiography showed persistent extensive thrombosis. A follow‐up Computerized Tomography (CT) scan revealed evolving venous infarcts with signs of increased intracranial pressure including sulci effacement but no hemorrhage. Given the clot burden, further mechanical intervention was not possible, and an infusion of alteplase (tPA) was started via right internal carotid catheter. The following day, new small cortical hemorrhages were noted on CTB, leading to the cessation of thrombolytic therapy. However, repeat CT venogram showed significant reduction of clot burden.
Following days, the patient was extubated and transitioned to oral anticoagulation therapy with Lovenox, later switched to Coumadin. Hematological evaluation revealed she was a heterozygous carrier for Factor V Leiden and Factor II mutation, increasing her risk for thrombotic events. Over time, she showed gradual improvement, with mild residual left upper extremity weakness responding well to physical therapy.

Conclusion
This case highlights the challenges of managing extensive CVST in a pregnant patient with COVID‐19. It demonstrates the successful use of both neurointervention and thrombolytic therapy in a scenario where conventional anticoagulation failed. It highlights the potential for improved patient outcomes by integrating these advanced therapeutic strategies in complex, refractory cases, underscoring the importance of a multidisciplinary approach.