{"id":28653,"date":"2024-06-29T14:02:15","date_gmt":"2024-06-29T11:02:15","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=28653"},"modified":"2024-06-29T16:04:51","modified_gmt":"2024-06-29T13:04:51","slug":"serebral-sinus-ven-trombozlu-covid-19-olgusu","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2024\/06\/29\/serebral-sinus-ven-trombozlu-covid-19-olgusu\/","title":{"rendered":"Serebral Sin\u00fcs Ven Trombozu Saptanan bir COVID-19 Olgusu"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

Koronavirus hastal\u0131\u011f\u0131 2019 (COVID-19) ile ili\u015fkili koag\u00fclopati SARS-CoV-2 infeksiyonunun hayat\u0131 tehdit eden bir komplikasyonudur. Koag\u00fclopatinin rol oynad\u0131\u011f\u0131 \u00fc\u00e7 ana patolojik mekanizma; vask\u00fcler endotel h\u00fccre disfonksiyonu, hiperinflamatuar imm\u00fcn yan\u0131t ve hiperkoag\u00fclobilitedir. D-dimer \u00e7apraz ba\u011fl\u0131 fibrinin y\u0131k\u0131m \u00fcr\u00fcn\u00fcd\u00fcr. Hem p\u0131ht\u0131la\u015fma sisteminin hem de fibrinolizin g\u00f6stergesi olup y\u00fcksek seviyeleri COVID-19\u2019da k\u00f6t\u00fc prognoz g\u00f6stergesidir (1). COVID-19\u2019da k\u00f6t\u00fc prognoz ile ili\u015fkili risk fakt\u00f6rleri ta\u015f\u0131yan bireylerde ve ciddi klinik seyir g\u00f6steren olgularda tromboembolik olaylar\u0131n g\u00f6r\u00fclme s\u0131kl\u0131\u011f\u0131 artmaktad\u0131r (2). Hastanede yatan t\u00fcm COVID-19 olgular\u0131nda ven\u00f6z tromboemboli (VTE) geli\u015fimini \u00f6nlemek i\u00e7in d\u00fc\u015f\u00fck molek\u00fcl a\u011f\u0131rl\u0131kl\u0131 heparin tedavisi uygulanmas\u0131 rehberlerin ortak \u00f6nerisidir (3,4).<\/p>\n

Serebral sin\u00fcs ven trombozu (SSVT) nadir g\u00f6r\u00fclen, \u00e7o\u011funlukla gen\u00e7 eri\u015fkin ya\u015f grubunda ortaya \u00e7\u0131kan ve mortalitesi y\u00fcksek olabilen bir serebrovask\u00fcler hastal\u0131kt\u0131r. En s\u0131k g\u00f6zlenen bulgular ba\u015f a\u011fr\u0131s\u0131, n\u00f6bet ve bilin\u00e7 de\u011fi\u015fikli\u011fidir. Hastal\u0131k i\u00e7in tan\u0131mlanm\u0131\u015f risk fakt\u00f6rleri aras\u0131nda en s\u0131k g\u00f6r\u00fcleni protrombin 20210 G\/A gen mutasyonunun da yer ald\u0131\u011f\u0131 konjenital trombofililerdir (5).<\/p>\n

Bu yaz\u0131da, bilinen bir komorbiditesi olmayan ve trombotik risk fakt\u00f6r\u00fc ta\u015f\u0131mamas\u0131na ra\u011fmen COVID-19 seyrinde SSVT geli\u015fen bir olgu tart\u0131\u015f\u0131ld\u0131. Olgunun ileri tetkiklerinde tromboza e\u011filimi art\u0131ran bir risk fakt\u00f6r\u00fc olan protrombin 20210 G\/A gen mutasyonu ta\u015f\u0131d\u0131\u011f\u0131 saptand\u0131. Amac\u0131m\u0131z; konuyla ilgili yay\u0131nlanm\u0131\u015f \u00e7ok az say\u0131da makale olmas\u0131 nedeniyle, komorbiditesi olmayan ve daha \u00f6nce COVID-19 ge\u00e7irmeyen ki\u015filerde, COVID-19 seyrinde geli\u015fen tromboembolik olaylarda ek patolojilerin ara\u015ft\u0131r\u0131lmas\u0131n\u0131n \u00f6nemini vurgulamakt\u0131r.<\/p>\n

OLGU<\/h2>\n

K\u0131rk \u00fc\u00e7 ya\u015f\u0131nda erkek hasta; \u015fiddetli ba\u015f a\u011fr\u0131s\u0131, ba\u015f d\u00f6nmesi, bulant\u0131 kusma ve sa\u011fa bak\u0131\u015fta \u00e7ift g\u00f6rme yak\u0131nmalar\u0131yla acil servise ba\u015fvurdu. Yedi g\u00fcn \u00f6nce ba\u015f a\u011fr\u0131s\u0131 ve bo\u011faz a\u011fr\u0131s\u0131 yak\u0131nmalar\u0131 nedeniyle al\u0131nan nasofarengeal s\u00fcr\u00fcnt\u00fc \u00f6rne\u011finde SARS-CoV-2 PCR test sonucunun pozitif \u00e7\u0131kmas\u0131 nedeniyle favipiravir 200 mg tb oral (ilk g\u00fcn 2x8tb\/g\u00fcn, ikinci g\u00fcnden itibaren 2×3 tb\/g\u00fcn olarak) ve asetil salisilik asit 100 mg tb oral kullanmakta oldu\u011fu \u00f6\u011frenildi. \u00d6ks\u00fcr\u00fck, nefes darl\u0131\u011f\u0131 \u015fik\u00e2yeti olmayan olgunun son iki g\u00fcnd\u00fcr gittik\u00e7e \u015fiddetlenen ba\u015f a\u011fr\u0131s\u0131na \u00e7ift g\u00f6rme yak\u0131nmas\u0131n\u0131n da eklendi\u011fi \u00f6\u011frenildi. Ba\u015fvurdu\u011fu d\u00f6nemde, COVID-19 i\u00e7in \u00f6ncelikli grupta olmamas\u0131 nedeniyle a\u015f\u0131lanmam\u0131\u015ft\u0131.<\/p>\n

\"\"<\/a>

\u015eekil 1.<\/strong> Beyin Manyetik Rezonans Venografis. Parasaggital ve paraaksiyal kesitlerde superior sagittal sin\u00fcs ve sa\u011f transvers sin\u00fcs i\u00e7inde d\u00fc\u015f\u00fck sinyalli tromb\u00fcs g\u00f6r\u00fcn\u00fcm\u00fc oklarla g\u00f6sterilmi\u015ftir.<\/p><\/div>\n

\"\"<\/a>

Tablo 1.<\/strong> Laboratuvar Bulgular\u0131<\/p><\/div>\n

Hastan\u0131n fizik muayenesinde sa\u011f g\u00f6z\u00fcnde i\u00e7e deviasyon, d\u0131\u015fa bak\u0131\u015fta k\u0131s\u0131tl\u0131l\u0131k saptand\u0131. Oftalmolojik muayenesinde ise sa\u011f g\u00f6zde alt\u0131nc\u0131 kranial sinir paralizisi ve papil \u00f6demi g\u00f6r\u00fcld\u00fc; n\u00f6rolojik muayenesi normal olarak de\u011ferlendirildi. Olgunun akci\u011fer bilgisayarl\u0131 tomografisi normal idi; beyin manyetik rezonans venografisi (MRV)\u2019nde (\u015eekil 1) superior saggital sin\u00fcs ve sa\u011fda transvers sin\u00fcste belirgin tromb\u00fcs, solda transvers sin\u00fcste incelme saptand\u0131. Tedavi amac\u0131yla enoksaparin sodyum 2\u00d7600 \u00dc subkutan ve diazomid 250 mg tb 3×1 oral tedavileri ba\u015fland\u0131. Olgunun a\u011f\u0131r COVID-19 geli\u015fimine yol a\u00e7abilecek komorbiditesi yoktu ve SSVT i\u00e7in bilinen bir risk fakt\u00f6r\u00fc tan\u0131mlanmam\u0131\u015ft\u0131. Ailesinde, gen\u00e7 ya\u015fta g\u00f6r\u00fclen VTE \u00f6yk\u00fcs\u00fc de yoktu. \u0130zleminde vital bulgular\u0131 stabil seyretti ve kan de\u011ferlerinde COVID-19 a\u00e7\u0131s\u0131ndan k\u00f6t\u00fc progroz g\u00f6stergelerinden yaln\u0131zca D-dimer y\u00fcksekti (Tablo 1). COVID-19 tedavisinin 10. g\u00fcn\u00fcnde tekrarlanan SARS-CoV-2 PCR test sonucu negatif saptand\u0131. Klinik ve laboratuvar bulgular\u0131nda belirgin d\u00fczelme saptanan olgu, oral varfarin tedavisi ba\u015flanarak yat\u0131\u015f\u0131n\u0131n 21. g\u00fcn\u00fcnde taburcu edildi. Taburculuk sonras\u0131 poliklinik izleminde SSVT etiyolojisine y\u00f6nelik yap\u0131lan de\u011ferlendirmesinde, kal\u0131tsal trombofili nedenlerinden biri olan protrombin 20210 G\/A heterozigot mutasyonu saptand\u0131. Olgu hastal\u0131\u011f\u0131 hakk\u0131nda bilgilendirilerek uzun s\u00fcreli oral antikoag\u00fclan tedavisi ile poliklinik izlemine al\u0131nd\u0131.<\/span><\/p>\n

\u0130RDELEME<\/h2>\n

Literat\u00fcrde, burada sunuldu\u011fu gibi COVID-19 seyrini a\u011f\u0131rla\u015ft\u0131ran bilinen bir risk fakt\u00f6r\u00fc ta\u015f\u0131mayan ve hafif COVID-19 ge\u00e7iren olgular aras\u0131nda COVID-19 ili\u015fkili \u00e7ok az say\u0131da SSVT olgusu tan\u0131mlanm\u0131\u015ft\u0131r. Elde edilen bulgular SSVT ve COVID-19 ili\u015fkili koag\u00fclopati aras\u0131nda g\u00fc\u00e7l\u00fc bir ili\u015fki oldu\u011funu \u00f6ne s\u00fcrmekle birlikte destekleyici kan\u0131tlar s\u0131n\u0131rl\u0131d\u0131r (6). Baldini ve arkada\u015flar\u0131n\u0131n (7) hastaneye yat\u0131r\u0131lan COVID-19 olgular\u0131nda SSVT s\u0131kl\u0131\u011f\u0131n\u0131 belirlemek amac\u0131yla yapt\u0131klar\u0131 meta-analizde, 28 makale taranm\u0131\u015f ve 57 olguda (ya\u015f ortalamas\u0131 53.5 y\u0131l, %19 kad\u0131n) SSVT saptand\u0131\u011f\u0131, SSVT s\u0131kl\u0131\u011f\u0131n\u0131n ise %0.08 oldu\u011fu bildirilmi\u015ftir. Ayn\u0131 \u00e7al\u0131\u015fmada, solunum sistemi semptomlar\u0131n\u0131n; olgular\u0131n %90\u2019\u0131nda bulundu\u011fu ve sadece d\u00f6rt olguda akci\u011fer tomografisinin normal saptand\u0131\u011f\u0131 belirtilmi\u015ftir. Olgular\u0131n %90\u2019\u0131nda SSVT bulgular\u0131n\u0131n SARS-CoV-2 infeksiyonu ile e\u015f zamanl\u0131 ba\u015flad\u0131\u011f\u0131 (ortalama hastal\u0131\u011f\u0131n 13. g\u00fcn\u00fc), sadece iki olgunun asemptomatik oldu\u011fu da bildirilmi\u015ftir. Serebrovask\u00fcler bulgular\u0131 olan olgular aras\u0131nda ise SSVT s\u0131kl\u0131\u011f\u0131 %4.2 oran\u0131nda saptanm\u0131\u015ft\u0131r. Olgular\u0131n %31\u2019inde SARS-CoV-2 infeksiyonu i\u00e7in tan\u0131mlanm\u0131\u015f risk fakt\u00f6rleri d\u0131\u015f\u0131nda, SSVT i\u00e7in predispozan fakt\u00f6rlerin de oldu\u011fu bildirilmi\u015ftir (oral kontraseptif kullan\u0131m\u0131, polistemia vera,\u00a0 <\/span>solid t\u00fcm\u00f6r, t\u00fcberk\u00fcloz menenjit \u00f6yk\u00fcs\u00fc, kafa travmas\u0131). Tan\u0131mlanm\u0131\u015f trombofili, ge\u00e7irilmi\u015f SSVT ya da DVT \u00f6yk\u00fcs\u00fc ise hi\u00e7bir olguda saptanmam\u0131\u015ft\u0131r. Olgular\u0131n tamam\u0131nda SSVT ile ili\u015fkili n\u00f6rolojik bulgular saptand\u0131\u011f\u0131, izole ba\u015f a\u011fr\u0131s\u0131 ile ba\u015fvuran bir olgu d\u0131\u015f\u0131ndaki di\u011fer olgularda ensefalopati, fokal n\u00f6rolojik bulgular ve n\u00f6bet oldu\u011fu bildirilmi\u015ftir. Bilin\u00e7 de\u011fi\u015fikli\u011fi olgular\u0131n %60.5\u2019\u0131nda ve epileptik n\u00f6bet ise %27.8\u2019inde g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. Yaz\u0131m\u0131zda sunulan COVID-19 olgusu, SSVT a\u00e7\u0131s\u0131ndan bilinen bir predispozan risk fakt\u00f6r\u00fc ta\u015f\u0131m\u0131yordu; akci\u011fer tutulumu olmaks\u0131z\u0131n yaln\u0131zca n\u00f6rolojik semptomlarla ba\u015fvurmu\u015ftu.<\/p>\n

Baldini ve arkada\u015flar\u0131n\u0131n (7) \u00e7al\u0131\u015fmas\u0131nda, tan\u0131 i\u00e7in en s\u0131k olarak bilgisayarl\u0131 tomografi (%69.8) ve anjiyografinin kullan\u0131ld\u0131\u011f\u0131 g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. En s\u0131k etkilenen b\u00f6lgelerin s\u0131ras\u0131yla transvers sin\u00fcs (%65), sigmoid sin\u00fcs (%47) ve superior saggital sin\u00fcs (%44) oldu\u011fu bildirilmi\u015f olup olgular\u0131n %95\u2019ine antikoag\u00fclan tedavisi verilmi\u015f, mortalite oran\u0131 ise %40 olarak saptanm\u0131\u015ft\u0131r. Olgumuzda ise MRV tetkikinde superior saggital sin\u00fcs ve transvers sin\u00fcs\u00fcn etkilendi\u011fi tespit edildi. Antikoag\u00fclan ve anti\u00f6dem tedavileri ile olgunun bulgular\u0131n\u0131n geriledi\u011fi g\u00f6r\u00fcld\u00fc.<\/p>\n

\u0130ki SSVT olgusunun sunuldu\u011fu bir di\u011fer makalede (bir olguda hipertansiyon ve diyabet olup di\u011ferinde komorbidite yoktu) yazarlar, D-dimer ve C-reaktif protein (CRP) y\u00fcksekli\u011finin ve n\u00f6trofil\/ lenfosit oran\u0131n\u0131n y\u00fcksek bulunmas\u0131n\u0131n k\u00f6t\u00fc prognoz kriteri oldu\u011funu bildirmi\u015flerdir (8). Baldini ve arkada\u015flar\u0131n\u0131n (7) meta-analizinde ise olgular\u0131n %90\u2019\u0131nda lenfopeni, %54.5\u2019inde fibrinojen d\u00fczeyinde anormallik, iki olgu hari\u00e7 di\u011fer olgularda CRP ve D-dimer d\u00fczeylerinin y\u00fcksek oldu\u011fu bildirilmi\u015ftir. Bizim olgumuzda ise CRP minimal y\u00fcksek, D-dimer d\u00fczeyi y\u00fcksek, lenfosit say\u0131s\u0131 ise normal s\u0131n\u0131rlarda saptand\u0131.<\/p>\n

Ba\u015fka bir \u00e7al\u0131\u015fmada, ailede trombotik hastal\u0131k \u00f6yk\u00fcs\u00fc olmayan ve obezite d\u0131\u015f\u0131nda bilinen bir risk fakt\u00f6r\u00fc ta\u015f\u0131mayan 17 ya\u015f\u0131ndaki erkek olgunun COVID-19 tan\u0131s\u0131 ald\u0131ktan iki hafta sonra ba\u015flayan \u015fiddetli ba\u015f a\u011fr\u0131s\u0131, bulant\u0131 ve bulan\u0131k g\u00f6rme \u015fik\u00e2yeti ile hastaneye ba\u015fvurdu\u011fu, fizik muayenede hipertansiyon ve papil \u00f6demi, beyin MRV\u2019de yayg\u0131n dural ven\u00f6z sin\u00fcs trombozu saptanm\u0131\u015ft\u0131. D-dimer y\u00fcksekli\u011fi de bulunan olgunun trombofiliye y\u00f6nelik tetkiklerinde lipoprotein A ve fakt\u00f6r VIII aktivitesinin y\u00fcksek bulundu\u011fu ve antikoag\u00fclan tedavi ile bulgular\u0131n\u0131n geriledi\u011fi belirtilmi\u015ftir (9). Baldini ve arkada\u015flar\u0131n\u0131n (7) \u00e7al\u0131\u015fmas\u0131nda ise trombofili taramas\u0131 12 olguda yap\u0131lm\u0131\u015f olup bunlardan \u00fc\u00e7\u00fcnde lupus antikoag\u00fclan\u0131 ve ikisinde antikardiolipin antikor pozitifti\u011fi saptand\u0131\u011f\u0131 bildirilmi\u015ftir. Olgumuzda da komorbidite olmamas\u0131na ve ailede kal\u0131tsal trombofilik bir hastal\u0131k \u00f6yk\u00fcs\u00fc bulunmamas\u0131na ra\u011fmen kal\u0131tsal trombofili risk fakt\u00f6rlerinden birisi olan protrombin 20210 G\/A heterozigot mutasyonu saptand\u0131. Olgumuzda geli\u015fen SSVT i\u00e7in hem yeni saptanan kal\u0131tsal trombofilik e\u011filimin hem de COVID-19\u2019un tetikledi\u011fi prokoag\u00fclan durumun katk\u0131s\u0131 olabilece\u011fi d\u00fc\u015f\u00fcn\u00fcld\u00fc.<\/p>\n

COVID-19\u2019da ba\u015f a\u011fr\u0131s\u0131 s\u0131k g\u00f6r\u00fclen bir klinik yak\u0131nmad\u0131r; ancak ba\u015f a\u011fr\u0131s\u0131na e\u015flik eden fokal n\u00f6rolojik bulgular\u0131n geli\u015fmesi halinde serebrovask\u00fcler komplikasyonlar mutlaka ara\u015ft\u0131r\u0131lmal\u0131d\u0131r.<\/p>\n

Sonu\u00e7 olarak; komorbiditesi bulunmayan, bilinen tromboembolik risk fakt\u00f6r\u00fc ta\u015f\u0131mayan ve a\u011f\u0131r COVID-19 ge\u00e7irmemesine ra\u011fmen beklenmedik tromboembolik olaylar\u0131n geli\u015fti\u011fi olgularda, COVID-19 seyrini a\u011f\u0131rla\u015ft\u0131rabilecek ve trombofiliye e\u011filimi art\u0131rabilecek ek risk fakt\u00f6rleri ara\u015ft\u0131r\u0131lmal\u0131d\u0131r. \u00c7\u00fcnk\u00fc trombofili risk fakt\u00f6r\u00fcne sahip ki\u015filerde tromboembolik olaylar\u0131n tekrarlama riski artmaktad\u0131r. Bu ki\u015filerde uzun s\u00fcreli antikoag\u00fclan tedaviyle, tekrarlayan tromboembolik olaylar \u00f6nlenerek morbidite ve mortalitenin azalmas\u0131 sa\u011flanabilir.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Koronavirus hastal\u0131\u011f\u0131 2019 (COVID-19) ile ili\u015fkili koag\u00fclopati SARS-CoV-2 infeksiyonunun hayat\u0131 tehdit eden bir komplikasyonudur. Koag\u00fclopatinin rol oynad\u0131\u011f\u0131 \u00fc\u00e7 ana patolojik mekanizma; vask\u00fcler endotel h\u00fccre disfonksiyonu, hiperinflamatuar imm\u00fcn yan\u0131t ve hiperkoag\u00fclobilitedir. D-dimer \u00e7apraz ba\u011fl\u0131 fibrinin y\u0131k\u0131m \u00fcr\u00fcn\u00fcd\u00fcr. Hem p\u0131ht\u0131la\u015fma sisteminin hem de fibrinolizin g\u00f6stergesi olup y\u00fcksek seviyeleri COVID-19\u2019da k\u00f6t\u00fc prognoz g\u00f6stergesidir (1). COVID-19\u2019da k\u00f6t\u00fc prognoz […]<\/p>\n","protected":false},"author":6,"featured_media":29042,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5131],"tags":[5174,5908,5909],"class_list":["post-28653","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-olgu-sunumu","tag-covid-19","tag-serebral-sinus-ven-trombozu","tag-trombofili"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/28653","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=28653"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/28653\/revisions"}],"predecessor-version":[{"id":28963,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/28653\/revisions\/28963"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/29042"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=28653"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=28653"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=28653"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}