Case Of Cerebral Venous Sinus Thrombosis Research Articles

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

Declining mortality of cerebral venous sinus thrombosis with thrombocytopenia after SARS-CoV-2 vaccination.

Background and purposeHigh mortality rates have been reported in patients with cerebral venous sinus thrombosis (CVST) due to vaccine‐induced immune thrombotic thrombocytopenia (VITT) after vaccination with adenoviral vector SARS‐CoV‐2 vaccines. The aim of this study was to evaluate whether the mortality of patients with CVST‐VITT has decreased over time.MethodsThe EudraVigilance database of the European Medicines Agency was used to identify cases of CVST with concomitant thrombocytopenia occurring within 28 days of SARS‐CoV‐2 vaccination. Vaccines were grouped based on vaccine type (adenoviral or mRNA). Cases with CVST onset until 28 March were compared to cases after 28 March 2021, which was the day when the first scientific paper on VITT was published.ResultsIn total, 270 cases of CVST with thrombocytopenia were identified, of which 266 (99%) occurred after adenoviral vector SARS‐CoV‐2 vaccination (ChAdOx1 nCoV‐19, n = 243; Ad26.COV2.S, n = 23). The reported mortality amongst adenoviral cases with onset up to 28 March 2021 was 47/99 (47%, 95% confidence interval 37%–58%) compared to 36/167 (22%, 95% confidence interval 16%–29%) in cases with onset after 28 March (p < 0.001). None of the four cases of CVST with thrombocytopenia occurring after mRNA vaccination died.ConclusionThe reported mortality of CVST with thrombocytopenia after vaccination with adenoviral vector‐based SARS‐CoV‐2 vaccines has significantly decreased over time, which may indicate a beneficial effect of earlier recognition and/or improved treatment on outcome after VITT.

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 × 109/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.

Case Reports: Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Background: The causes of cerebral venous sinus thrombosis (CVST) are diverse, and headache is the only symptom in mild cases. However, in severe cases, perfusion disorders may concomitantly cause intracerebral hemorrhage, resulting in serious complications. Herein, we report two severe CVST cases in which good outcomes were obtained following endovascular treatment. Patients and Methods: Case 1. A 42-year-old man consulted an ophthalmologist with a chief complaint of decreased vision. The patient had a considerably high intraocular pressure and papilledema. However, due to unknown etiology, he was only prescribed eye drops. He subsequently developed headaches and experienced an alteration in his. An urgent surgery was performed with using the pull-back technique using a suction catheter, following which, the patient’s neurological symptoms improved. Case 2. A 50-year-old man was transferred to our hospital with a chief complaint of generalized clonic convulsions. The patient was diagnosed with venous sinus thrombosis. Attempts were made to crush the thrombus with a percutaneous transluminal angioplasty balloon and aspirate the thrombus with an aspiration catheter. However, thrombus removal and recanalization could not be achieved. Subsequently, a thrombectomy was performed using the FilterWire technique with a distal embolic protection device. Anterograde blood flow was restored, and the convulsive seizures disappeared. Conclusion: Venous perfusion injury should be avoided in severe cases of CVST, and endovascular treatment using various devices is a therapeutic option in such cases.

Cerebral Venous Sinus Thrombosis without Thrombotic Thrombocytopenic Syndrome in a Male Patient after Ad26.COV2.S Vaccination

Objective: Here we present one of the first cases of Janssen (Johnson & Johnson Ad26.COV2.S vaccine-associated cerebral venous sinus thrombosis (CVST) in a male patient, and the presumed first case without associated thrombotic thrombocytopenic syndrome (TTS). Method: Patient was identified as a vaccine-related adverse effect due to the unusual presentation of CVST in a male following COVID-19 vaccination, though without thrombocytopenia. Results: Patient presented with left-sided weakness and transient dysarthria. Imaging revealed extensive CVST. Thorough coagulopathy work-up was negative and platelet levels remained within the normal range. Patient improved with non-heparin anticoagulation. Discussion: As more people worldwide continue to be vaccinated against COVID-19, the incidence of vaccine-related complications can be expected to rise. Multiple cases of CVST have been reported in patients following COVID-19 vaccination with associated TTS, nearly all in women. However, this is not the only presentation. Cerebral venous sinus thrombosis should be a consideration in patients who present with headache or altered mental status after COVID vaccination, despite normal platelet levels.

Post-SARS-CoV-2-vaccination cerebral venous sinus thrombosis: an analysis of cases notified to the European Medicines Agency.

Background and purposeCerebral venous sinus thrombosis (CVST) has been described after vaccination against SARS‐CoV‐2. The clinical characteristics of 213 post‐vaccination CVST cases notified to the European Medicines Agency are reported.MethodsData on adverse drug reactions after SARS‐CoV‐2 vaccination notified until 8 April 2021 under the Medical Dictionary for Regulatory Activities Term ‘Central nervous system vascular disorders’ were obtained from the EudraVigilance database. Post‐vaccination CVST was compared with 100 European patients with CVST from before the COVID‐19 pandemic derived from the International CVST Consortium.ResultsIn all, 213 CVST cases were identified: 187 after AstraZeneca/Oxford (ChAdOx1 nCov‐19) vaccination and 26 after a messenger RNA (mRNA) vaccination (25 with Pfizer/BioNTech, BNT162b2, and one with Moderna, mRNA‐1273). Thrombocytopenia was reported in 107/187 CVST cases (57%, 95% confidence interval [CI] 50%–64%) in the ChAdOx1 nCov‐19 group, in none in the mRNA vaccine group (0%, 95% CI 0%–13%) and in 7/100 (7%, 95% CI 3%–14%) in the pre‐COVID‐19 group. In the ChAdOx1 nCov‐19 group, 39 (21%) reported COVID‐19 polymerase chain reaction tests were performed within 30 days of CVST symptom onset, and all were negative. Of the 117 patients with a reported outcome in the ChAdOx1 nCov‐19 group, 44 (38%, 95% CI 29%–47%) had died, compared to 2/10 (20%, 95% CI 6%–51%) in the mRNA vaccine group and 3/100 (3%, 95% CI 1%–8%) in the pre‐COVID‐19 group. Mortality amongst patients with thrombocytopenia in the ChAdOx1 nCov‐19 group was 49% (95% CI 39%–60%).ConclusionsCerebral venous sinus thrombosis occurring after ChAdOx1 nCov‐19 vaccination has a clinical profile distinct from CVST unrelated to vaccination. Only CVST after ChAdOx1 nCov‐19 vaccination was associated with thrombocytopenia.

Immunization Update 2021

Immunization Update 2021

Predictive Value of Combination of D-dimer and Fibrinogen in Diagnosing Acute CVST.

Background:Cerebral venous sinus thrombosis (CVST) is an uncommon subtype of stroke, and the role of D-dimer and fibrinogen in early diagnosis of CVST has been studied with varying results. The present study aims to study the role of the combination of D-dimer and fibrinogen in early diagnosis of acute CVST.Methods:Forty consecutive confirmed acute CVST cases admitted at a tertiary care center were recruited for the study. D-dimer and fibrinogen were assessed by a rapid semiquantitative latex agglutination assay.Results:Out of the 40 CVST patients, 21 (52.50%) were females. The mean age of the patients was 37.58 years ± 19.17 years. Common clinical features were headache (N = 38 [95%]), papilloedema (N = 15 [37.5%]), and seizures (N = 12 [30%]). Although the sensitivity (75%) of the combination of D-dimer and fibrinogen assay was lower than that of D-dimer or fibrinogen alone, the specificity and positive predictive value (75% each) was higher.Conclusion:The combination of D-dimer and fibrinogen testing may aid in an early diagnosis of acute CVST and in better management.

Structural Imaging Characteristic, Clinical Features and Risk Factors of Cerebral Venous Sinus Thrombosis: A Prospective Cross-Sectional Analysis from a Tertiary Care Hospital in Pakistan.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that accounts for 0.5–1.0% of all strokes. Clinical presentation, predisposing factors, neuroimaging findings, and outcomes of CVST are extremely diverse, which causes a high index of suspicion in diagnosis. Therefore, early diagnosis of CVST is crucial for prompt treatment to prevent morbidity and mortality. Objective: The purpose of this prospective study is aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan. Material and Methods: Consecutive patients enrolled in this study had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) along with a clinical presentation to confirm the diagnosis of CVST. Categorical data were presented as percentages. Continuous variable and categorical data were compared (parenchymal lesions vs. non-parenchymal lesions) using the Student’s t-test and Chi-square test, respectively. Results: A total of 3261 patients with stroke were presented during the study period. Out of all patients, 53 confirmed patients with CVST (1.6%) were recruited; the predominant population was female (84.91%), having a male to female ratio of 1:4. Mean age of the cohort was 28.39 ± 7.19 years. Most frequent symptoms observed were headache (92.45%) followed by vomiting (75.47%), seizures (62.26%), papilledema (54.72%), visual impairment (41.51%), and altered consciousness disturbance (52.83%). The presumed risk factors associated with CVST were puerperium (52.83%), use of oral contraceptives (13.21%), antiphospholipid syndrome (7.55%), elevated serum levels of protein C and S (5.66%), and CNS infection (3.77%). On cranial CT scans, 50 patients (94.33%) showed abnormalities while 32 patients exhibited various parenchymal lesions. Seizures were more frequent in CVST patients with parenchymal lesions compared with subjects lacking parenchymal lesions. Seventy-two sinuses, either single or in combination, were involved in CVST patients, being more common in patients with parenchymal lesions than those without parenchymal lesions. The most frequent locations of CVST were the superior sagittal and transverse sinus. Conclusion: In short, non-contrast CT brain may be used as a first line investigation in suspected cases of CVST. Our study also demonstrates some regional differences in the clinical features, risk factors, and neuroimaging details of CVST as described by some other studies. Therefore, care must be taken while diagnosing and predicting the outcome of the CVST.

Safety Monitoring of the Janssen (Johnson & Johnson) COVID-19 Vaccine - United States, March-April 2021.

On February 27, 2021, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for Janssen (Ad.26.COV2.S) COVID-19 vaccine (Janssen Biotech, Inc., a Janssen Pharmaceutical company, Johnson & Johnson) (1). The Janssen COVID-19 vaccine, the third COVID-19 vaccine authorized for use in the United States, uses a replication-incompetent human adenoviral type 26 vector platform* (2) and is administered as a single intramuscular dose, whereas the first two authorized vaccines use an mRNA platform and require 2 doses. On February 28, 2021, the Advisory Committee on Immunization Practices (ACIP) issued interim recommendations for use of Janssen COVID-19 vaccine among persons aged ≥18 years (3). During April 13-23, CDC and FDA recommended a pause in use of Janssen vaccine after reports of six cases of cerebral venous sinus thrombosis (CVST) with thrombocytopenia (platelet count <150,000/μL of blood) among Janssen vaccine recipients (4). Similar thrombotic events, primarily among women aged <60 years, have been described in Europe after receipt of the AstraZeneca COVID-19 vaccine, which uses a replication-incompetent chimpanzee adenoviral vector (5-7). The U.S. CVST cases that prompted the pause in Janssen vaccination, as well as subsequently detected CVST cases, are described elsewhere (8). This report summarizes adverse events among Janssen vaccine recipients, including non-CVST cases of thrombosis with thrombocytopenia syndrome (TTS), reported to the Vaccine Adverse Events Reporting System (VAERS), a passive surveillance system, and through v-safe, an active monitoring system. As of April 21, 2021, 7.98 million doses of the Janssen COVID-19 vaccine had been administered. Among 13,725 VAERS reports reviewed, 97% were classified as nonserious and 3% as serious,† including three reports among women of cases of thrombosis in large arteries or veins accompanied by thrombocytopenia during the second week after vaccination. These three cases and the previously detected CVST cases are consistent with 17 cases of TTS,§ a newly defined condition. Approximately 338,700 Janssen COVID-19 vaccine recipients completed at least one v-safe survey during the week after vaccination; 76% reported a systemic reaction, 61% reported a local reaction, and 34% reported a health impact.¶ Fatigue and pain were commonly reported symptoms in both VAERS and v-safe. The overall safety profile is consistent with preauthorization clinical trials data. Prompt review of U.S. vaccine safety data detected three additional cases of non-CVST TTS, in addition to the previously recognized CVST cases that initiated the pause in use of the Janssen COVID-19 vaccine. Ongoing monitoring of adverse events after COVID-19 vaccination, including vaccination with the Janssen single-dose vaccine, is essential for evaluating the risks and benefits of each vaccine.

US Case Reports of Cerebral Venous Sinus Thrombosis With Thrombocytopenia After Ad26.COV2.S Vaccination, March 2 to April 21, 2021

Cerebral venous sinus thrombosis (CVST) with thrombocytopenia, a rare and serious condition, has been described in Europe following receipt of the ChAdOx1 nCoV-19 vaccine (Oxford/AstraZeneca), which uses a chimpanzee adenoviral vector. A mechanism similar to autoimmune heparin-induced thrombocytopenia (HIT) has been proposed. In the US, the Ad26.COV2.S COVID-19 vaccine (Janssen/Johnson & Johnson), which uses a human adenoviral vector, received Emergency Use Authorization (EUA) on February 27, 2021. By April 12, 2021, approximately 7 million Ad26.COV2.S vaccine doses had been given in the US, and 6 cases of CVST with thrombocytopenia had been identified among the recipients, resulting in a temporary national pause in vaccination with this product on April 13, 2021. To describe reports of CVST with thrombocytopenia following Ad26.COV2.S vaccine receipt. Case series of 12 US patients with CVST and thrombocytopenia following use of Ad26.COV2.S vaccine under EUA reported to the Vaccine Adverse Event Reporting System (VAERS) from March 2 to April 21, 2021 (with follow-up reported through April 21, 2021). Receipt of Ad26.COV2.S vaccine. Clinical course, imaging, laboratory tests, and outcomes after CVST diagnosis obtained from VAERS reports, medical record review, and discussion with clinicians. Patients' ages ranged from 18 to younger than 60 years; all were White women, reported from 11 states. Seven patients had at least 1 CVST risk factor, including obesity (n = 6), hypothyroidism (n = 1), and oral contraceptive use (n = 1); none had documented prior heparin exposure. Time from Ad26.COV2.S vaccination to symptom onset ranged from 6 to 15 days. Eleven patients initially presented with headache; 1 patient initially presented with back pain and later developed headache. Of the 12 patients with CVST, 7 also had intracerebral hemorrhage; 8 had non-CVST thromboses. After diagnosis of CVST, 6 patients initially received heparin treatment. Platelet nadir ranged from 9 ×103/µL to 127 ×103/µL. All 11 patients tested for the heparin-platelet factor 4 HIT antibody by enzyme-linked immunosorbent assay (ELISA) screening had positive results. All patients were hospitalized (10 in an intensive care unit [ICU]). As of April 21, 2021, outcomes were death (n = 3), continued ICU care (n = 3), continued non-ICU hospitalization (n = 2), and discharged home (n = 4). The initial 12 US cases of CVST with thrombocytopenia after Ad26.COV2.S vaccination represent serious events. This case series may inform clinical guidance as Ad26.COV2.S vaccination resumes in the US as well as investigations into the potential relationship between Ad26.COV2.S vaccine and CVST with thrombocytopenia.

Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature

BackgroundCOVID-19 infection has been known to predispose patients to both arterial and venous thromboembolic events such as deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke. A few reports from the literature suggest that Cerebral Venous Sinus Thrombosis (CVSTs) may be a direct complication of COVID-19. ObjectiveTo review the clinical and radiological presentation of COVID-19 positive patients diagnosed with CVST. MethodsThis was a multicenter, cross-sectional, retrospective study of patients diagnosed with CVST and COVID-19 reviewed from March 1, 2020 to November 8, 2020. We evaluated their clinical presentations, risk factors, clinical management, and outcome. We reviewed all published cases of CVST in patients with COVID-19 infection from January 1, 2020 to November 13, 2020. ResultsThere were 8 patients diagnosed with CVST and COVID-19 during the study period at 7 out of 31 participating centers. Patients in our case series were mostly female (7/8, 87.5%). Most patients presented with non-specific symptoms such as headache (50%), fever (50%), and gastrointestinal symptoms (75%). Several patients presented with focal neurologic deficits (2/8, 25%) or decreased consciousness (2/8, 25%). D-dimer and inflammatory biomarkers were significantly elevated relative to reference ranges in patients with available laboratory data. The superior sagittal and transverse sinuses were the most common sites for acute CVST formation (6/8, 75%). Median time to onset of focal neurologic deficit from initial COVID-19 diagnosis was 3 days (interquartile range 0.75–3 days). Median time from onset of COVID-19 symptoms to CVST radiologic diagnosis was 11 days (interquartile range 6–16.75 days). Mortality was low in this cohort (1/8 or 12.5%). ConclusionsClinicians should consider the risk of acute CVST in patients positive for COVID-19, especially if neurological symptoms develop.

Cerebral Venous Sinus Thrombosis in a 40-year-old Lady with JAK2-positive Polycythemia Vera: A Case Report

Cerebral venous sinus thrombosis (CVST) has a range of underlying cause. Here a case of CVST with an uncommon etiology is presented and discussed. A 40-year-old female presented with headache for 2 years and progressive visual loss for 4 months. She had conjunctival congestion and bilateral papilloedema with pale disc on right side. Computed tomography (CT) scans and contrast magnetic resonance imaging (MRI) of brain were normal but venography (MRV) revealed widespread thrombosis of dural sinuses including superior sagittal sinus. Cerebrospianal fluid (CSF) pressure was high (360 mm of H₂O) while other CSF parameters were normal. She was polycythemic (hemoglobin 18.1 g/dl, hematocrit 60.2%), Bone marrow study revealed pan-myeloid hyperplasia whereas trephine biopsy revealed hypercellular marrow with trilineage expansion suggestive of myeloproliferative disorder possibly polycythemia vera. JAK-2 mutation was also detected. CVST has different patterns of presentations including isolated intracranial hypertension leading to visual loss. It is essential to identify and treat underlying condition like polycythemia vera.

Cerebral venous sinus thrombosis associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection

Introduction/Objective. Coagulopathy induced by severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) can be an underlying cause of cerebral venous sinus thrombosis (CVST), a less common type of stroke with a variable clinical presentation and high mortality rate. The objective of the paper is to present a series of CVST cases associated with SARS-CoV-2 infection. Methods. This retrospective study evaluated clinical, laboratory and radiological presentations, risk factors, barriers to diagnosis, treatment and outcome of patients with SARS-CoV-2 infection-induced CVST. Results. The study comprised six patients diagnosed with COVID-19-induced CVST during an 18-month period. The majority (66.7%) had no significant risk factors for developing CVST. The median time from the initial COVID-19 diagnosis to the onset of neurologic deficit was seven days (interquartile range 0.5?7 days). Clinical presentation comprised non specific neurological symptoms: headache (83.3%) and decreased consciousness (33.3%), together with elevated levels of D-dimer and inflammatory biomarkers. The transverse (n = 4, or 66.7%), superior sagittal sinuses (n = 3, or 50%) and sigmoid sinus (n = 2, or 33.3%) were most commonly affected. Five patients (83.3%) had minimal to no symptoms at discharge (mRS ? 2). In-hospital mortality in our current series was relatively high (16.7%). Conclusion. The high mortality rate of SARS-CoV-2-associated CVST urges clinicians to suspect CVST in patients with a history of COVID-19 infection presenting with non-specific neurological symptoms in order to provide proper treatment and prevent complications.

Predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre in Central India

Cerebral venous sinus thrombosis (CVST) is a less common cause of stroke when compared to arterial thrombosis but its clinical presentation is varied and atypical. Early diagnosis may prevent morbidity & mortality which in untreated cases has been reported as 13.8 -48%. Materials and Methods: This prospective observational study included 40 radiologically diagnosed cases of CVST, to evaluate the predictors of outcome by using modified Rankin’s Scale (mRS). The primary outcome measure was death or dependency at the end of 12 weeks. Results: Of 40 patients, 18 cases (45.5%) had mRS 0-3 & 22(55%) had mRS >3. Mean age of the cases was 32.22 yrs with M:F= 1: 0.81. Purperium was the commonest risk factor. In univariate analysis, Age>30(p==0.10), Coma (p=0.010) and Cheyne stokes breathing (p- 30, cerebral haemorrhage and Deep venous sinus thrombosis were the predictors of poor outcome. Rankin’s score of < 2 had good prognosis at 12 weeks follow up. Overall mortality was 15% at 12 weeks follow up. Conclusion: CVST is an important cause of stroke in puerperium. Neuroimaging plays pivotal role in diagnosis. Modified Rankin’s scale is a simple score system risk stratification of patients with neurodeficit. Low MRS score at hospitalization is associated with better outcome at 12 weeks. Keywords: Cerebral venous sinus thrombosis (CVST), modified Rankin’s scale (mRS) < 2, good outcome.

Thyroid Diseases Are an Underestimated Risk Factor for Cerebral Venous Sinus Thrombosis.

Introduction: Cerebral venous sinus thrombosis (CVST) is a rare disease that generally accounts for just 1% of all strokes. Of the multiple risk factors that have been identified, the most common are genetic or acquired thrombophilia and the use of oral contraceptives, while the less common include local infections and mechanical causes. Thyroid diseases have been described as rare risk factors for CVST (<2% of all cases), without exact knowledge of the underlying pathophysiology. This retrospective study aimed to re-evaluate the relevance of thyroid disease as risk factor for CVST, with particular emphasis on hyperthyroidism.Patients and Methods: Confirmed cases of CVST were (re-)evaluated in terms of risk factors including thyroid parameters. Results were compared to previous data from the International Study on CVST.Results: Between 1996 and 2016, 182 patients with confirmed CVST were treated in our hospital with a median age of 44 years and a female proportion of 74.7%. Genetic or acquired thrombophilia along with the use of oral contraceptives were found to be the most common risk factors. Thyroid diseases were present in 20.9% of CVST patients; this included patients with previous (9.9%) and current thyroid dysfunction (11%).Discussion and Conclusions: Thyroid diseases may represent a more common risk factor for CVST than previously described. This holds true even if patients with current thyroid dysfunction are purely taken into account. However, 58% of patients had more than one additional risk factor, suggesting a multifactorial hypercoagulability.Clinical Trials Register: Registered at the German Clinical Trials Register: http://www.drks.de, DRKS00017044.

Cerebral Venous Sinus Thromboses in Patients with SARS-CoV-2 Infection: Three Cases and a Review of the Literature

IntroductionEarly studies suggest that acute cerebrovascular events may be common in patients with coronavirus disease 2019 (COVID-19) and may be associated with a high mortality rate. Most cerebrovascular events described have been ischemic strokes, but both intracerebral hemorrhage and rarely cerebral venous sinus thrombosis (CVST) have also been reported. The diagnosis of CVST can be elusive, with wide-ranging and nonspecific presenting symptoms that can include headache or altered sensorium alone. ObjectiveTo describe the presentation, barriers to diagnosis, treatment, and outcome of CVST in patients with COVID-19. MethodsWe abstracted data on all patients diagnosed with CVST and COVID-19 from March 1 to August 9, 2020 at Boston Medical Center. Subsequently, we reviewed the literature and extracted all published cases of CVST in patients with COVID-19 from January 1, 2020 through August 9, 2020 and included all studies with case descriptions. ResultsWe describe the clinical features and management of CVST in 3 women with COVID-19 who developed CVST days to months after initial COVID-19 symptoms. Two patients presented with encephalopathy and without focal neurologic deficits, while one presented with visual symptoms. All patients were treated with intravenous hydration and anticoagulation. None suffered hemorrhagic complications, and all were discharged home. We identified 12 other patients with CVST in the setting of COVID-19 via literature search. There was a female predominance (54.5%), most patients presented with altered sensorium (54.5%), and there was a high mortality rate (36.4%). ConclusionsDuring this pandemic, clinicians should maintain a high index of suspicion for CVST in patients with a recent history of COVID-19 presenting with non-specific neurological symptoms such as headache to provide expedient management and prevent complications. The limited data suggests that CVST in COVID-19 is more prevalent in females and may be associated with high mortality.

Cerebral venous sinus thrombosis associated with SARS-CoV-2; a multinational case series

BackgroundSARS-CoV-2 induced coagulopathy can lead to thrombotic complications such as stroke. Cerebral venous sinus thrombosis (CVST) is a less common type of stroke which might be triggered by COVID-19. We present a series of CVST cases with SARS-CoV-2 infection. MethodsIn a multinational retrospective study, we collected all cases of CVST in SARS-CoV-2 infected patients admitted to nine tertiary stroke centers from the beginning of the pandemic to June 30th, 2020. We compared the demographics, clinical and radiological characteristics, risk factors, and outcome of these patients with a control group of non-SARS-CoV-2 infected CVST patients in the same seasonal period of the years 2012–2016 from the country where the majority of cases were recruited. ResultsA total of 13 patients fulfilled the inclusion criteria (62% women, mean age 50.9 ± 11.2 years). Six patients were discharged with good outcomes (mRS ≤ 2) and three patients died in hospital. Compared to the control group, the SARS-CoV-2 infected patients were significantly older (50.9 versus 36.7 years, p < 0.001), had a lower rate of identified CVST risk factors (23.1% versus 84.2%, p < 0.001), had more frequent cortical vein involvement (38.5% versus 10.5%, p: 0.025), and a non-significant higher rate of in-hospital mortality (23.1% versus 5.3%, p: 0.073). ConclusionCVST should be considered as potential comorbidity in SARS-CoV-2 infected patients presenting with neurological symptoms. Our data suggest that compared to non-SARS-CoV-2 infected patients, CVST occurs in older patients, with lower rates of known CVST risk factors and might lead to a poorer outcome in the SARS-CoV-2 infected group.

Cerebral venous sinus thrombosis in pregnancy and puerperium

Cerebral venous sinus thrombosis (CVST) is more common in women than in men, possibly due to gender-specific risk factors in young adults. The purpose of this study was to investigate whether the clinical and radiological findings, other risk factors, and clinical course of CVST associated with pregnancy and puerperium differ from those of other CVST cases. We retrospectively reviewed patients diagnosed with CVST in our hospital between September 2007 and December 2019. The risk factors, clinical and radiological characteristics, and follow-up data for female patients with CVST were compared between cases associated with pregnancy and puerperium with those of other cases. A total of 50 female patients with CVST were included in the study. Twenty-four (48%) cases occurred during pregnancy and puerperium. The mean age of the pregnant or puerperal patients was lower than that of the other patients (p = 0.007). There was no significant difference between the groups in terms of clinical and neuroradiological findings or presence of any additional risk factors including hereditary thrombophilia. There was also no difference in terms of in-hospital mortality rates and modified Rankin Scale (mRS) scores at 6months between the groups. The clinical presentation of CVST and the frequencies of the presence of other risk factors including genetic thrombophilia in pregnant and puerperal patients were similar to those of non-pregnant female patients. Screening for additional risk factors, especially genetic thrombophilia, should therefore not be neglected in CVST occurring during pregnancy and puerperium.

Cerebral Venous Sinus Thrombosis in Adults with Prothrombotic Conditions: A Systematic Review and a Case from Our Institution.

Cerebral venous sinus thrombosis (CVST) is a rare condition characterized by elevated intracranial pressure due to impaired cerebral venous drainage, potentially leading to life-threatening consequences. We searched the PubMed electronic database for ‘cerebral venous sinus thrombosis’ and ‘prothrombotic’ cases reported in adults (19+ years) and conducted a systematic review for the published literature in the English language pooled with a case from our institution. Data were analyzed regarding patient demographics, risk factors, clinical features, treatment modalities, and outcomes when available.Thirty cases of CVST were identified (29 case reports, of whom two were described in a case series, and the one case from our institution). The patients’ mean age was 39 years (range: 19 - 65). The male: female ratio was 1.14:1. The majority (73.3%) had at least one preexisting risk factor, with prescription drug use being the most common risk factor (33.3%) shared among all patients. Most patients (83.3%) presented with at least two symptoms. The most common presenting symptoms were headache (70%), gastrointestinal disturbance (50%), and seizures (40%). Focal deficits (36.7%), vision disturbances (30%), and altered consciousness (20%) were the remaining presenting complaints. Twelve cases (40%) commented on papilledema, with 10 (83.3%) having papilledema present. Anticoagulation abnormalities were examined in 26 cases (86.7%), out of which four cases (15.4%) had isolated protein S (PS) deficiency, three cases (11.5%) had isolated antithrombin III (ATIII) deficiency, and one case (3.8%) had isolated protein C (PC) deficiency. The most common initial imaging modality (22 cases, 73.3%), and most commonly used overall (23 cases, 76.7%), was computed tomography (CT). Magnetic resonance imaging (MRI) was the second most common imaging modality for initial use (five cases, 16.7%), diagnosis or confirmation of CVST (eight cases, 26.7%), and overall (21 cases, 70%). Heparin treatment was involved in the treatment of 18 cases (60%), and warfarin treatment was used in 10 cases (33.3%). Heparin-warfarin combination treatment was utilized in eight cases (26.7%). Most patients survived (28 cases, 93.3%), while the two remaining patients died secondary to brain death from the CVST (6.7%).The findings from this study highlight the clinical characteristics of CVST. Therefore, this study aims to increase awareness of this rare entity. Physicians should maintain a high index of suspicion in order to diagnose patients presenting in the proper clinical context, given this case shares various forms of presentations with other common clinical conditions but requires long-term anticoagulation.