key: cord-0872279-wo62cnj2
authors: Cioana, Milena; Ranalli, Paul J.; Micieli, Jonathan A.
title: Transient Visual Obscurations as the Presenting Symptom of Papilledema from COVID-19-Related Cerebral Venous Sinus Thrombosis
date: 2022-03-17
journal: Case Rep Ophthalmol
DOI: 10.1159/000522637
sha: be46f7014eb439b13b4671a5db023d4b04303688
doc_id: 872279
cord_uid: wo62cnj2

Coronavirus disease-19 (COVID-19) patients are at an increased risk of cerebral venous sinus thrombosis (CVST). Rapid diagnosis and treatment are vital to ensure a favorable outcome for CVST, so clinicians need to be aware of all its potential presentations. We describe a unique case where transient visual obscurations (TVOs) from papilledema were the presenting symptoms of COVID-19-related CVST. A 43-year-old woman, who had tested positive for severe acute respiratory syndrome coronavirus-2 1 month earlier, developed holocephalic headache, TVOs, and bilateral disc edema. She did not seek medical attention until she developed TVOs. Visual acuity was 20/20 and Humphrey visual field testing showed enlarged blind spots in both eyes. She was diagnosed with papilledema and underwent magnetic resonance imaging and magnetic resonance venography of the brain, which revealed right transverse sinus thrombosis. Lumbar puncture was performed, showing elevated opening pressure and normal cerebrospinal fluid contents. Her optic disc edema resolved and visual function remained normal 6 weeks following warfarin and topiramate therapy. Recanalization of the right transverse sinus occurred after 3 months. Although rare, TVOs are important presenting symptoms of COVID-19-related CVST. Ophthalmologists, who may be the first physicians to assess patients with this presentation, should be aware of TVOs as potential presenting symptoms of CVST, so diagnoses can be made in a timely manner.

Neurological complications, including stroke, have been frequently described in coronavirus diseae-19 (COVID-19) patients [1] . Cerebral venous sinus thrombosis (CVST) is a rare form of stroke due to obstruction of dural venous sinuses that occurs in the general population at rates of 5-20 per million per year [2, 3] . Reports estimate that CVST prevalence is higher in patients with COVID-19, with rates reaching 0.02%-1% in hospitalized COVID-19 patients [2] . CVST is more common in young, female patients, and is related to additional risk factors such as trauma, oral contraceptive use, malignant neoplasms, dehydration, and a hypercoagulable state [3] . COVID-19 has been suggested to lead to a hypercoagulable state as the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) binds to endothelial cells, causing dysfunction and activation of a cytokine cascade, which produces a prothrombotic condition [4] . The most common presenting signs and symptoms of COVID-19-related CVST are headache, seizures, encephalopathy, and focal neurological signs [2] . Visual symptoms from COVID-19-related CVST are rare and we describe a rare case where transient visual obscurations (TVOs) prompted the patient to seek medical attention. Since early recognition and treatment are essential for a favorable outcome in CVST [3] , it is important that clinicians are aware of all possible presenting symptoms of COVID-19-related CVST.

A 43-year-old woman tested positive for SARS-CoV-2 after developing symptoms of rhinorrhea and fever. She had no known medical problems and did not take any regular medications. She was not on oral contraception and had no history of iron-deficiency anemia. One week later, she developed new onset headache that was holocephalic in nature and moderate in intensity. It improved with acetaminophen, and she did not seek medical attention for the headaches. One month later, she developed bilateral TVOs as her vision "blacked out" for seconds with position changes. There was no pulsatile tinnitus or diplopia. Due to these TVOs, she saw an optometrist and was found to have bilateral optic disc edema and referred to the emergency room. In the emergency room, she had an unenhanced CT scan of the head that was reported as normal.

She was referred to neuro-ophthalmology and found to have a visual acuity of 20/20 in both eyes, pupils were equal and reactive to light, and there was no relative afferent pupillary defect. Humphrey 24-2 SITA-Fast visual fields showed enlarged blind spots in both eyes. Dilated fundus examination showed moderate-to-severe optic disc edema in both eyes (shown in Fig. 1 ). Ocular motility was normal. Due to her new symptoms and bilateral optic disc edema with preserved visual function, she was thought to have papilledema. She underwent magnetic resonance imaging and magnetic resonance venography of the brain, and was found to have right transverse sinus thrombosis (shown in Fig. 2) . She also had a lumbar puncture in the left lateral decubitus position that showed an opening pressure of 44 cm of water with normal cerebrospinal fluid contents. In particular, angiotensin-converting enzyme levels were normal, varicella zoster virus PCR, herpes simplex virus PCR, and venereal disease research laboratory test were negative, and bacterial and fungal cultures showed no growth. Workup for a hypercoagulable state was negative. Hemoglobin and ferritin levels were normal. She was diagnosed with papilledema related to CVST and started on warfarin and acetazolamide. She did not tolerate acetazolamide, and this was changed to topiramate. Her symptoms resolved within 1 month and at the 6-week follow-up appointment, her optic disc edema resolved, and visual function remained normal. Follow-up magnetic resonance venography 3 months after diagnosis showed recanalization of the right transverse sinus. 

Our report describes a unique case of TVOs from papilledema being the presenting symptom of COVID-19-related CVST. Previous cases of COVID-19-related CVST commonly present with headache, seizures, encephalopathy, and focal neurological signs [2] . It is important that visual symptoms are recognized as potential presenting symptoms for CVST related to COVID-19, so cases are not missed.

COVID-19 is believed to lead to CVST by inducing a hypercoagulable state. Patients with COVID-19 have been shown to have higher levels of D-dimer, fibrinogen, and fibrin degradation products than healthy controls [5] . SARS-CoV-2 activates the inflammatory cascade and thrombotic pathways by binding to angiotensin-converting enzyme 2 receptors of endothelial cells [6] . This leads to hyperproduction of angiotensin II, and thus generalized endothelial damage, which induces a hypercoagulable state and promotes thromboembolic events such as CVST [7] . As many patients in the literature develop CVST weeks to months after COVID-19 diagnosis, similarly to the patient we present in this report, it has been suggested that this prothrombotic state can persist even after acute infection [8] . Except for female sex, our patient did not have any other risk factors for CVST such as trauma, oral 

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