Case Of Cerebral Venous Sinus Thrombosis Research Articles

Cerebral venous sinus thrombosis: changing trends in the incidence, age and gender (findings from the CMC Vellore CVT registry)

BackgroundMultiple cerebral venous sinus thrombosis (CVT) registries from various geographical regions indicate that female gender, the use of contraceptive pills, pregnancy and puerperium are important risk factors. In this study,...

Characteristics of Cerebral Venous Sinus Thrombosis Due to Autoimmune Diseases: A Single-Center Retrospective Observational Study.

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular disease characterized by thrombosis of the cerebral venous or dural sinuses. Autoimmune diseases (AD) are important causes of CVST. This study aims to reveal the differences between CVST associated with autoimmune diseases compared with other causes (OCs) and Behcet's syndrome (BS) compared with other ADs. This is a single-center retrospective study in which the medical records of 187 patients we followed with a diagnosis of CVST between 2008 and 2023 were collected retrospectively. Four neurologists collected data on initial symptoms, neurological examinations, and laboratory findings. Findings on magnetic resonance imaging and magnetic resonance venography performed on all patients (thrombosis localizations, hemorrhagic or ischemic complications, and collateralization) were re-evaluated by 2 radiologists. The results were compared with AD, other ADs, and OCs groups. There were 28 cases of CVST associated with AD. Of these, 18 were BS, and 10 were other AD. Subacute-chronic onset, headache, and transverse sinus involvement were more common in AD-related patients than in OCs. However, collateralization, venous infarction, hemorrhagic transformation, and bleeding were less common. BS-related patients had earlier age, more frequent transverse sinus, less frequent cortical vein thrombosis, and better collateralization than other ADs. CVST is one of the rare complications in autoimmune diseases. It has a more subacute-chronic onset. Since headaches are more common, it is essential to make a differential diagnosis of CVST in autoimmune diseases with chronic headaches. Transverse sinus thrombosis is more common. Collateralization, venous infarction, and hemorrhagic transformation are less.

Mechanical Thrombectomy for Aseptic, Atraumatic, Medically Refractory Cerebral Venous Sinus Thrombosis: aSystematic Review.

Cerebral venous sinus thrombosis (CVST) follows asevere clinical course in 13.5% of cases. Practice guidelines recommend endovascular therapy (EVT); no randomised control trials (RCTs) exist comparing EVTs. To determine whether specific EVTs are superior to alternatives. CENTRAL, Medline, Embase, five other databases and four clinical trials registers. Grey literature searches, reference checking, citation searching, and author contact. All CVST cases treated with mechanical thrombectomy (MT) were includible. Paediatric, and trauma-related or infection-related thromboses were excluded. Standard Cochrane review procedures. Primary outcome measures; clinical efficacy (modified Rankin Score, mRS), technical efficacy (recanalisation), and clinical safety (procedure-related complications and death). Subgroup analyses were performed, comparing outcome measures between demographic groups, clinico-radiological severity, interventional strategies, and degrees of recanalisation. In this study 124 papers were included (n = 486). All patients underwent MT, with 69.5% of patients receiving concomitant chemolysis. New/expanding intracerebral haemorrhage (ICH) occurred in 5.1%; non-haemorrhagic complications in 1.4%; 10.7% died. Predictors of poor efficacy included age ≥ 55years, altered mental status (AMS), Glasgow Coma Scale (GCS) < 8. Predictive of poor safety outcomes included pre-existing ICH, deep system thrombosis, and AMS. Complete recanalisation was associated with improved clinical efficacy and safety outcomes. The review is based on case reports/series, increasing bias-risk. Myriad of potentially includible studies were necessarily excluded due to lack of requisite details. Predictors of poor outcomes with medical therapy predict poor outcomes with MT; these measures should not dictate candidacy. Complete recanalisation predicts favorable clinical and safety outcomes. Local chemolysis is safe, improves recanalisation, and should be recommended, provided there is no contraindication. Clot maceration strategies and stent-retriever thrombectomy are associated with superior clinical efficacy and safety endpoints, as compared with balloon angioplasty and rheolysis.

Cerebral Venous Sinus Thrombosis Following Scrub Typhus Meningoencephalitis in a Pregnant Woman

Background Scrub typhus, a mite-borne zoonosis caused by Orientia tsutsugamushi, is prevalent in the Asia Pacific region and presents with various neurological manifestations, including meningoencephalitis, polyneuropathy, and, rarely, cerebral venous sinus thrombosis (CVST). Case Report We report a unique case of CVST following scrub typhus meningoencephalitis in an 18-year-old pregnant woman from West Bengal, India. Her condition was complicated by fever, headache, neck stiffness, and altered sensorium. Laboratory tests revealed leukopenia and thrombocytopenia, while serologies for other infectious diseases were negative. Cerebrospinal fluid analysis was significant for lymphocytic pleocytosis and elevated protein, with a positive O tsutsugamushi-IgM assay. Treatment with azithromycin resulted in initial improvement; however, persistent headaches led to the discovery of CVST. The patient responded well to anticoagulation therapy with low molecular weight heparin and was discharged asymptomatic, with subsequent uneventful pregnancy and delivery. Discussion Cerebral venous sinus thrombosis should be ruled out in pregnant women with refractory scrub typhus meningoencephalitis despite antibiotic therapy. Because scrub typhus is treatable with intravenous doxycycline and azithromycin, it should be considered in the workup of febrile patients with acute onset neurological disorders in the tropics or subtropics or travelers coming back from endemic areas, despite the absence of eschar and unremarkable neuroimaging findings.

Cerebral venous sinus thrombosis cases detected in on-call CT venographies in Sweden, 2019-2022.

No well-established criteria exist for assessing the risk of cerebral venous sinus thrombosis (CVST). Here, we sought to gain an understanding of CVST cases and associated risk factors, based on the rates of emergency CT venographies (CTVs) performed after hours. Furthermore, we aimed to assess possible correlations between CVST rates and COVID-19, including at the start of the COVID-19 vaccination campaign. We collected reports of emergency CTVs performed after hours at 56 Swedish hospitals between 1/1/2019 and 12/31/2022, and divided them into five groups: (I) from 1/1/2019 to 1/31/2020, before the emergence of COVID-19 cases in Sweden; (II) from 2/1/2020 to 12/26/2020, after the emergence of COVID-19 but before vaccination rollout; (III) from 12/27/2020 to 7/28/2021, from the start of the COVID-19 vaccination campaign until 50% of the adult population in Sweden had been vaccinated; (IV) from 7/29/2021 to 2/1/2022, from when 50% of the adult population was vaccinated until restrictions were lifted; and (V) from 2/2/2022 to 12/31/2022, after restriction measures were suspended. For all included patients, we collected information on demographics and clinical history, including pregnancy, recent partum, and use of oral contraceptives or post-menopausal hormone replacement therapy. In total, we collected 430 reports (92% female, 8% male). The CVST positivity rate was 22.2% in men vs. 2.3% in women. None of the pregnant (n = 49) or postpartum (n = 12) women had CVST positivity. The frequency of CTV examinations was lowest in group 2; during this period, the average time between patients being imaged was 7days. The frequency of CTV examinations was highest in group IV; during this period, a patient underwent this type of scan every 1.5days, on average. The frequency of CVST-positive scans was lowest in group II; during this period, a positive case was found every 66days, on average. The frequency of CVST-positive scans was highest in group IV; during this period, a positive case was found every 62days, on average, and no statistical difference with respect to group II was observed. Pregnancy and recent partum were not significant risk factors for CVST. The elevated CVST positivity rate observed during the height of the COVID-19 pandemic suggested that patients with less likelihood for positive CVST had fewer emergency visits. The positivity rate did not increase with the start of the COVID-19 pandemic or the rollout of COVID-19 vaccination.

Rare Causes of Cerebral Venus Sinus Thrombosis: A Systematic Review.

Background: Cerebral venous sinus thrombosis (CVST) is a rare manifestation of thrombosis commonly caused by thrombophilia, hormonal-related factors, non-cerebral malignancy, and hematologic diseases. The aim of this review was to identify and summarize rare CVST cases. Methods: A literature search of the Medline database was performed in November 2022. CVST cases of a common cause were excluded. Demographic and clinical data were extracted. Eligible cases were categorized into inflammatory, primary CNS tumors, post-operative/traumatic, and idiopathic groups to allow statistical group comparisons. Results: 76 cases were analyzed. Idiopathic CVST was most frequently reported followed by inflammatory, post-traumatic/operative and primary CNS tumor causes. The intracranial hemorrhage rate was 23.7% and it was found to increase in the inflammatory group (45.8%). Anticoagulation was used in the majority of cases and it was significantly related to better outcomes. A low rate of anticoagulation use (43.8%) was found among CVST cases in the post-operative/traumatic group. The overall mortality rate was 9.8%. 82.4% of patients showed significant early improvement. Conclusions: Most rare CVST cases were either of idiopathic or inflammatory origin. Interestingly, hemorrhage occurred often he idiopathic CVST cases. A low rate of anticoagulation use in neurosurgical CVST cases after trauma or head surgery was observed.

Cerebral Venous Sinus Thrombosis Following an mRNA COVID-19 Vaccination and Recent Oral Contraceptive Use

Rising concerns of cerebral venous sinus thrombosis (CVST) and other forms of venous thromboembolism have been associated with the SARS-CoV-2 vaccinations. Adverse effects with vector-based vaccines are well documented in the literature, while less is known about the mRNA vaccines. This report documents a case of CVST in a 32-year-old female patient who received her second Pfizer mRNA COVID-19 vaccination 16 days prior to hospital admission and had started oral combined contraceptives approximately 4 months beforehand. Clinicians should be cognizant of the possibility that mRNA vaccines, when combined with other risk factors like oral contraceptive pill use, may enhance one's hypercoagulable status.

Abstract TMP11: Cerebral Venous Sinus Thrombosis After Covid-19 Vaccination In Korea: A Nationwide Cohort Study

Introduction: Covid-19 vaccination is reported to relate with cerebral venous sinus thrombosis (CVST). This study aims to evaluate the association between CVST and Covid-19 vaccination in Korea. Methods: Hospitalized patients with incident CVST during January 2021 to January 2022 were extracted from nationwide health insurance claim data, and the history of vaccination was investigated. We used modified self-controlled case series (SCCS) analysis comparing the occurrence of CVST between risk period (within 28 days of covid-19 inoculation) and control period (excluding the risk period) and calculated the incidence rate ratio (IRR) for CVST in risk period compared to control period. Sensitivity analysis with extended risk period up to 5 weeks was also performed. Results: A total of 373 CVST cases were recruited in this SCCS study. The IRR for CVST in risk period was 1·41 (95% CI 1·01-1.95) compare with a control period. Subgroup analysis according to demographic profile revealed IRR of 1.86(1.01-3.42) and 2.53(1.40-4.58) in the age of 30-49 and 50-64 respectively, and also significantly higher IRR of 1.84(1.14-26.96) in women. CVST without thrombocytopenia group showed similar IRR of 1.45 (1.04-2.01). In the sensitivity analysis with risk period extended to 5 weeks, the IRR was 1.55 (1.13-2.13), which was not significantly different to 4 weeks risk period. Conclusions: A significant increase in the risk of cerebral venous thrombosis after COVID-19 vaccination is suggested from this study. The risk was higher in the old age and women. Because our data is health insurance claim data, the risk might be overestimated, and the validation of diagnostic accuracy is scheduled. Also nationwide registry of confirmed CVST cases will be presented and compared. Despite these limitation, this study heralds that CVST could follow after Covid-19 vaccination. Funding: This study was funded by research grant from Korean Center for Disease Conttrol, National Academy of Medicine in Korea, and Korean Stroke Society.

A Model of High-Speed Endovascular Sonothrombolysis with Vortex Ultrasound-Induced Shear Stress to Treat Cerebral Venous Sinus Thrombosis

This research aims to demonstrate a novel vortex ultrasound enabled endovascular thrombolysis method designed for treating cerebral venous sinus thrombosis (CVST). This is a topic of substantial importance since current treatment modalities for CVST still fail in as many as 20% to 40% of the cases, and the incidence of CVST has increased since the outbreak of the coronavirus disease 2019 pandemic. Compared with conventional anticoagulant or thrombolytic drugs, sonothrombolysis has the potential to remarkably shorten the required treatment time owing to the direct clot targeting with acoustic waves. However, previously reported strategies for sonothrombolysis have not demonstrated clinically meaningful outcomes (e.g., recanalization within 30 min) in treating large, completely occluded veins or arteries. Here, we demonstrated a new vortex ultrasound technique for endovascular sonothrombolysis utilizing wave-matter interaction-induced shear stress to enhance the lytic rate substantially. Our in vitro experiment showed that the lytic rate was increased by at least 64.3% compared with the nonvortex endovascular ultrasound treatment. A 3.1-g, 7.5-cm-long, completely occluded in vitro 3-dimensional model of acute CVST was fully recanalized within 8 min with a record-high lytic rate of 237.5 mg/min for acute bovine clot in vitro. Furthermore, we confirmed that the vortex ultrasound causes no vessel wall damage over ex vivo canine veins. This vortex ultrasound thrombolysis technique potentially presents a new life-saving tool for severe CVST cases that cannot be efficaciously treated using existing therapies.

Cerebral venous sinus thrombosis in a patient with Klebsiella pneumoniae primary liver abscess: a case report

BackgroundLiver abscess is a common emergency in the emergency department. However, cerebral venous sinus thrombosis (CVST) is a rare and serious cerebrovascular disease. Cases of CVST in patients with Klebsiella pneumoniae primary liver abscess (KLA) have not been described in the literature. We report a case of CVST in patients with KLA.Case presentationA 54-year-old male patient came to our department with a fever for 2 days and altered mental status for 1 day. Abdominal computed tomography (CT) and liver magnetic resonance imaging (MRI) revealed multiple liver abscesses. The blood culture was identified as Klebsiella pneumoniae sepsis. Head contrast-enhanced MRI and magnetic resonance venography (MRV) imaging showed multiple thrombus formation in the right transverse sinus and sigmoid sinus. The patient's infection and thrombosis were controlled within one week of multidisciplinary comprehensive treatment such as antibiotic and antithrombotic therapy, and a good clinical recovery during the 1-month follow-up.ConclusionCVST after liver abscess is rare, clinicians should be aware of this complication and vigilant for the possibility of bacterial meningitis. The underlying mechanisms need to be further studied.

Abstract P131: Cerebral Venous Sinus Thrombosis Risk Factors, Treatments, And Sequelae: 2011-2019

Introduction: Cerebral venous sinus thrombosis (CVST) is a rare but potentially debilitating thrombosis affecting 3-4 cases per million adults in the United States. Risk factors are thought similar to venous thrombosis, but there is little epidemiologic data corroborating this assertion. Concern about a possible association between the Janssen (Johnson and Johnson) and Oxford-AztraZenaca COVID-19 vaccines and cases of CVST resulted in increased global attention to this condition. Thus, large epidemiological assessment of the risk factors, treatment and outcomes of CVST are needed. Objective: Estimate the distributions of risk factors antecedent to CVST diagnosis, report CVST treatments in clinical practice, and potential sequelae of CVST in a large retrospective cohort of adults with CVST in the United States. Methods: MarketScan Commercial and Medicare Supplemental administrative databases were employed to assess CVST diagnosed between 2011 and 2019 in the U.S. Validated International Classification of Disease (ICD) codes and receipt of an outpatient anticoagulant (either oral or subcutaneous anticoagulant) prescription within 30 days of the ICD code identified incident CVST. Antecedent clinical characteristics, treatments, and sequelae of CVST were identified using inpatient, outpatient, and prescription data. For outcomes, proportions and incidence with 95% confidence intervals (CIs) were calculated, stratified by sex. Results: We identified 1,869 CVST patients. Of these 1,314 (70%) were female, with 200 (10%) events identified as a pregnancy-related CVST. The average age was 41 years for females and 48 years for men. Among women, 24.7% were on hormonal therapy (oral contraceptive, estrogen, and progestin) prior to diagnosis. Men had a higher prevalence of comorbidities, such as diabetes (15% men vs. 9% women) and cancer (19% men vs. 10% women). Oral anticoagulant (OAC) use was the most common treatment for CVST in both men (88%) and women (85%) and did not vary by sex. Use of procedures to treat CVST, optic nerve fenestration and catheter directed thrombolysis, were 0.5% and 4.1%, respectively. The most common sequela after CVST was incidence of intracranial hypertension (Incidence: 4.2 per 100 person-years; 95% CI: 3.3, 5.1) and palliedema was rare. Conclusions: Overall, a majority of CVST patients were women of reproductive age. Our findings suggest a potential association with both endogenous (pregnancy) and exogenous (oral contraceptives, HRT) hormones which needs further study. In our sample, CVST was managed with oral anticoagulants, regardless of sex, and intracranial hypertension was elevated following CVST. This large claims-based analysis is a descriptive insight into the risk factors and management of CVST, a rare and debilitating condition.

First dose ChAdOx1 and BNT162b2 COVID-19 vaccinations and cerebral venous sinus thrombosis: A pooled self-controlled case series study of 11.6 million individuals in England, Scotland, and Wales.

Several countries restricted the administration of ChAdOx1 to older age groups in 2021 over safety concerns following case reports and observed versus expected analyses suggesting a possible association with cerebral venous sinus thrombosis (CVST). Large datasets are required to precisely estimate the association between Coronavirus Disease 2019 (COVID-19) vaccination and CVST due to the extreme rarity of this event. We aimed to accomplish this by combining national data from England, Scotland, and Wales. We created data platforms consisting of linked primary care, secondary care, mortality, and virological testing data in each of England, Scotland, and Wales, with a combined cohort of 11,637,157 people and 6,808,293 person years of follow-up. The cohort start date was December 8, 2020, and the end date was June 30, 2021. The outcome measure we examined was incident CVST events recorded in either primary or secondary care records. We carried out a self-controlled case series (SCCS) analysis of this outcome following first dose vaccination with ChAdOx1 and BNT162b2. The observation period consisted of an initial 90-day reference period, followed by a 2-week prerisk period directly prior to vaccination, and a 4-week risk period following vaccination. Counts of CVST cases from each country were tallied, then expanded into a full dataset with 1 row for each individual and observation time period. There was a combined total of 201 incident CVST events in the cohorts (29.5 per million person years). There were 81 CVST events in the observation period among those who a received first dose of ChAdOx1 (approximately 16.34 per million doses) and 40 for those who received a first dose of BNT162b2 (approximately 12.60 per million doses). We fitted conditional Poisson models to estimate incidence rate ratios (IRRs). Vaccination with ChAdOx1 was associated with an elevated risk of incident CVST events in the 28 days following vaccination, IRR = 1.93 (95% confidence interval (CI) 1.20 to 3.11). We did not find an association between BNT162b2 and CVST in the 28 days following vaccination, IRR = 0.78 (95% CI 0.34 to 1.77). Our study had some limitations. The SCCS study design implicitly controls for variables that are constant over the observation period, but also assumes that outcome events are independent of exposure. This assumption may not be satisfied in the case of CVST, firstly because it is a serious adverse event, and secondly because the vaccination programme in the United Kingdom prioritised the clinically extremely vulnerable and those with underlying health conditions, which may have caused a selection effect for individuals more prone to CVST. Although we pooled data from several large datasets, there was still a low number of events, which may have caused imprecision in our estimates. In this study, we observed a small elevated risk of CVST events following vaccination with ChAdOx1, but not BNT162b2. Our analysis pooled information from large datasets from England, Scotland, and Wales. This evidence may be useful in risk-benefit analyses of vaccine policies and in providing quantification of risks associated with vaccination to the general public.

Epidemiology of cerebral venous sinus thrombosis and cerebral venous sinus thrombosis with thrombocytopenia in the United States, 2018 and 2019

BackgroundPopulation‐based data about cerebral venous sinus thrombosis (CVST) are limited. ObjectivesTo investigate the epidemiology of CVST in the United States. Patients/MethodsThree administrative data systems were analyzed: the 2018 Healthcare Cost and Utilization Project National Inpatient Sample (NIS) the 2019 IBM MarketScan Commercial and Medicare Supplemental Claims Database, and the 2019 IBM MarketScan Multi‐state Medicaid Database. CVST, thrombocytopenia, and numerous comorbidities were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Incidence rates of CVST and CVST with thrombocytopenia were estimated (per 100,000 total US population [NIS] and per 100,000 population aged 0 to 64 years covered by relevant contributing health plans [MarketScan samples]). Comorbidity prevalence was estimated among CVST cases versus total inpatients in the NIS sample. Recent pregnancy prevalence was estimated for the Commercial sample. ResultsIncidence rates of CVST in NIS, Commercial, and Medicaid samples were 2.85, 2.45, and 3.16, respectively. Incidence rates of CVST with thrombocytopenia were 0.21, 0.22, and 0.16, respectively. In all samples, CVST incidence increased with age; however, peak incidence was reached at younger ages in females than males. Compared with the general inpatient population, persons with CVST had higher prevalences of hemorrhagic stroke, ischemic stroke, other venous thromboembolism (VTE), central nervous system infection, head or neck infection, prior VTE, thrombophilia, malignancy, head injury, hemorrhagic disorder, and connective tissue disorders. Women aged 18 to 49 years with CVST had a higher pregnancy prevalence than the same‐aged general population. ConclusionsOur findings provide recent and comprehensive data on the epidemiology of CVST and CVST with thrombocytopenia.

Diagnostic value of whole-brain computed tomographic perfusion imaging for suspected large artery occlusion stroke patients in emergency department.

To evaluate the diagnostic value of whole-brain computed tomographic perfusion (WB-CTP) in emergency department for suspected large artery occlusion stroke. Suspected large artery occlusion (LAO) stroke patients had initial WB-CTP in the neurological emergency department from August 2016 to August 2018 were retrospectively reviewed for analysis. The sensitivity and specificity of non-contrast computed tomographic scan (NCCT) or WB-CTP for diagnosis of cerebral infarction was compared between the anterior circulation and posterior circulation. The imaging characteristics of WB-CTP in patients with stroke-mimics were described. Among the 300 included patients, 259 patients (86.3%) were finally diagnosed as cerebral infarction, 16 (5.3%) were transient ischemic attack, 10 (3.3%) were epileptic seizure and 3 (1%) were cerebral venous sinus thrombosis (CVST). For patients with final diagnosis of cerebral infarction, WB-CTP found abnormality in 206 cases (79.5%). NCCT had poor sensitivity (4.6%) but high specificity (100%) for cerebral infarction. The CTP imaging had a sensitivity of 81.2% in anterior circulation and 59.6% in posterior circulation stroke, both with good specificity (57.1% and 92.6%, respectively). 60% (6/10) of epileptic patients showed abnormal perfusion in CTP maps, which was inconsistent with cerebral arterial supply territories. Hypoperfusion manifestations were discovered in areas adjacent to occlusion sinus of all 3 CVST cases. This retrospective study indicates WB-CTP can be useful in identifying acute ischemic stroke in emergency department, especially for patients with acute LAO stroke. Moreover, WB-CTP may have a value in differentiating stroke mimics such as epilepsy and CVST.

Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review.

Introduction:COVID-19 vaccines became available after being carefully monitored in clinical trials with safety and efficacy on the human body. However, a few recipients developed unusual side effects, including cerebral venous sinus thrombosis (CVST). We aim to systematically review the baseline features, clinical characteristics, treatment, and outcomes in patients developing CVST post-COVID-19 vaccination.Methods:This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) 2020 guideline. Investigators independently searched PubMed, Embase, and Google Scholar for English language articles published from inception up until September 10, 2021, reporting the incidence of CVST post-COVID-19 vaccines. We analyzed CVST patients’ baseline data, type of vaccines, clinical findings, treatment, and outcomes. Our systematic review process yielded patient-level data.Result:The final analysis included 25 studies that identified 80 patients who developed CVST after the COVID-19 vaccination. Of the 80 CVST cases, 31 (39.24%) patients died. There was no significant relationship between mortality and age (P = .733), sex (P = .095), vaccine type (P = .798), platelet count (P = .93), and comorbidities such as hypertension (P = .734) and diabetes mellitus (P = .758). However, mortality was associated with the duration of onset of CVST symptoms after vaccination (P = .022). Patients with CVST post-COVID-19 vaccination were more likely to survive if treated with an anticoagulant (P = .039). Patients who developed intracranial hemorrhage (P = .012) or thrombosis in the cortical vein (P = .021) were more likely to die.Conclusion:COVID-19 vaccine-associated CVST is associated with high mortality rate. Timely diagnosis and management can be lifesaving for patients.

Chemotherapy-Related Cerebral Venous Sinus Thrombosis in a Colon Cancer Patient Receiving Adjuvant Chemotherapy: Case Report and Literature Review

Oxaliplatin-combination treatment has been adopted as a standard adjuvant treatment for high-risk stage II and stage III colorectal cancer. Cerebral venous sinus thrombosis (CVST) is a serious adverse event related to this combination treatment. The benefits of this combination treatment outweigh the risks, yet some physicians are reluctant to resume the treatment after the clot has resolved. The authors reported a case of CVST, and the success in resolving this situation with the use of a secondary prophylaxis, a low-molecular weight heparin. Keywords: Oxaliplatin; Central venous sinus thrombosis; Chemotherapy-induced VTE

The Effects of Temperature and Prothrombotic Conditions on Cerebral Venous Sinus Thrombosis Frequency: An Institutional Experience.

Objectives:The pathogenesis of cerebral venous sinus thrombosis (CVST) is complex and involves the interplay of underlying provocative factors. Upon observing a higher frequency of CVST cases presenting to our hospital in summer, we hypothesized that CVST may be influenced by variations in climate.Materials and Methods:A retrospective review of all patients who were diagnosed with CVST at a tertiary care hospital in Pakistan between January 2010 and December 2019 was conducted. After dividing patients into groups based on the type of risk, the frequency of CVST in these groups between four seasons (spring, summer, fall, and winter) was compared.Results:A total of 256 patients diagnosed with CVST were included, of which 129 were female and 127 were male. The mean age was 41.7 ± 15.2 years. Of the total patients, 91.4% had some sort of risk factor, either systemic (162 patients) or local (72 patients), while 22 patients did not have any identifiable risk factor. The number of patients with more than one known risk factor was 93 (36.3%). Of the total number of patients, 96 (37.5%) patients had hyperhomocysteinemia, followed by 85 patients (33.2%) with a prothrombotic risk factor other than hyperhomocysteinemia and 44 (17.2%) patients with central nervous system infections. The most commonly affected sinuses were a combination of the transverse sinus and sigmoid sinus (21%), There was a statistically significant seasonal variation in CVST cases among all patients (P = 0.03) and in the systemic risk factor group (P = 0.05), with the highest number of cases occurring in the summer season.Conclusions:CVST may be influenced by seasonal changes in atmospheric temperatures and humidity, especially in patients with underlying prothrombotic risk factors.

Abstract 1122‐000170: Stent Retrievers Utilization in Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Introduction : Patients with Cerebral Venous Sinus Thrombosis (CVT) are candidates for Endovascular Mechanical Thrombectomy (EMT) in cases of coma on presentation or clinical deterioration despite anticoagulation. We present two cases of CVT successfully treated with mechanical thrombectomy using Medtronic’s Solitaire Stent retriever. Methods : A retrospective review at a single center university hospital was performed for all cerebral venous sinus thrombosis case log from December 2018 to November 2020. Cases resistant to conventional medical therapy that underwent intrasinus stent retriever endovascular thrombectomy were noted. Results : Case 1: 26 year‐old male with a history of hypertension presented with 2 weeks of headaches, left sided numbness and blurriness of vision. Imaging revealed superior sagittal (SSS) and bilateral transverse sinus thrombosis. Patient was treated with heparin infusion and discharged home on oral apixaban. The following day he presented with new onset expressive aphasia. Imaging was unchanged. Due to worsening symptoms despite anticoagulation, Patient underwent mechanical thrombectomy using a stent retriever. Solitaire 6 × 40 mm stent was advanced and deployed through the microcatheter and retracted in the upper segment of posterior one third of SSS followed by alteplase infusion at 1 mg/hr (25 ml/hr) via Berenstein catheter for the next 36 hours. Intravenous heparin infusion was also started with aPTT goal 60–80. Cerebral angiogram was repeated two days later revealing successful recanalization of previously thrombosed SSS and bilateral transverse sinuses with significantly improved cerebral venous drainage. Patient was transitioned again to oral apixaban. Repeat CTA in 3 months showed significantly improved patency and recanalization. Case 2: A 42 year‐old male with history of ulcerative colitis presented with sudden onset right‐sided hemiparesis and hemisensory loss along with one month of headaches. Presenting NIHSS 14. Imaging revealed SSS thrombosis with thrombosis of the left transverse sinus complicated by left frontal intraparenchymal hemorrhage and subarachnoid hemorrhage. Patient underwent mechanical thrombectomy of SSS using Solitaire 6 × 40mm stent retriever with distal aspiration resulting in improved flow. Clinical course was complicated by seizures and acute respiratory distress syndrome requiring intubation followed by tracheostomy and G‐tube placement which were eventually removed during recovery. Patient was treated with high intensity heparin during his hospitalization and eventually transitioned to apixaban. Work up revealed protein S deficiency. Serial CT angiograms at 6 and 11 months revealed resolution of CVT. NIHSS improved to 1 with mRS of 2. Conclusions : These cases imply that intra‐cerebrovenous sinus mechanical thrombectomy with stent retrievers may be considered in patients with continuing worsening despite optimal medical management.

Post-traumatic cerebral venous sinus thrombosis – Institutional study and literature review

BackgroundPost-traumatic cerebral venous sinus thrombosis (CVST) – incidence is rising during the last two decades, partly due to advanced imaging technologiesand partly due to accidents caused by high-velocity vehicles. Case seriesDuring a period from January 2020 to September 2020, we had 264 cases of head injury patients. On average, we receive 30 head injury cases per month, among which 50% would be severe head injury cases. We documented ten CVST cases among them. Diagnosis and managementIn severe head injuries with suspicion, CT brain with contrast done immediately to diagnose CVST. After 48 h of admission, worsening of GCS, increased severity of headache despite adequate management, worsening of CT findings as an increase in edema, and hemorrhagic transformation are all indications for repeat CTbrain with contrast. Management of CVST patients done with enoxaparin 40 mg twice a day/1.5 mg per kg in a day, for a duration of ten to fourteen days. Anticoagulants started only after 48 h of trauma. ConclusionEarly diagnosis of CVST in severe head injury patients and treatment started early (after 48 h of trauma) will help to prevent morbidity and mortality.

Cerebral Coagulation Complications Following COVID-19 Adenoviral Vector Vaccines: A Systematic Review

Emergence of the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak identified in late 2019 in Wuhan, China, was declared a pandemic in March 2020. High fatality rate in afflicted patients prompted scientists and physicians to develop various vaccines against the virus. While administration of millions of doses of the adenoviral vector vaccines (e.g., Oxford-AstraZeneca (ChAdOx1 nCoV-19) and Janssen/Johnson & Johnson (Ad26.COV2. S)) has helped control the disease, numerous cases of cerebral venous sinus thrombosis (CVST) with thrombocytopenia have been reported in vaccinated individuals. In this article, we aim to review the cases reported thus far and further discuss the association between the vaccine administration and subsequent cerebral thromboembolic events. Our study was performed and reported based on the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, Google Scholar and Norris Medical Library databases were searched using the following terms: coronavirus disease 2019 (COVID-19) vaccines (“AstraZeneca” or “AZD1222 COVID vaccine” or “ChAdOx1 nCoV-19 COVID-19 vaccine” or “Janssen” or “Johnson & Johnson COVID vaccine” or “Ad26.COV2 COVID vaccine”), coagulopathy (“cerebral venous sinus thrombosis (CVST)” and “vaccine-induced immune thrombotic thrombocytopenia (VITT)” or “cerebral venous thrombosis (CVT)”) and thrombocytopenia. All the relevant studies within the English literature up to August 1, 2021, were included. Fourteen most recent articles reporting on 66 patients with CVST and VITT after adenoviral vector vaccination were reviewed by two independent authors. Age of the patients ranged from 18 to 60 years. The majority of cases were women (43 females versus 14 males). Platelet count was between 5 and 127 × 10 9 /L. Above-normal D-dimer was found in 86% of the patients. A total of 68% of the patients had positive platelet factor 4 IgG assay in the absence of prior exposure to heparin. Among CVST cases following COVID vaccination, 44% succumbed to death. Early diagnosis and treatment of CVST plays a fundamental role in decreasing morbidity and mortality. Health care professional should be familiar with this rare complication post vaccination against COVID-19. Given the rarity of CVST after the COVID-19 vaccine, the benefit of vaccination outweighs the potential harm. J Neurol Res. 2021;11(5):69-76 doi: https://doi.org/10.14740/jnr700