Case Of Cerebral Venous Sinus Thrombosis Research Articles

Cerebral Venous Thrombosis at High Altitude: Analysis of 28 Cases

Objective: An association between cerebral venous sinus thrombosis (CVST) and high altitude has been previously proposed, but limited published data exist to support this association. We investigated 28 cases of CVST occurring at high altitude and sought to describe patient demographics, altitude and acclimatization, hematological laboratory findings, neuroimaging, treatment, and prognosis in these cases. Methods: Twenty-eight cases of symptomatic CVST occurring at high altitude were identified between the months of August 2017 and December 2018, in collaboration with Military Hospital, Rawalpindi and Combined Military Hospital, Skardu (Pakistan). Follow-up visits were performed at 1 and 6 months. Results: Twenty-seven (96%) of the patients were males, and the mean age was 33 years. In total, 32.1% were smokers. The mean NIHSS score on presentation was 5.5. 85.7% of the cases occurred at altitude higher than 8,000 feet. On average 107.8 days were spent at a high altitude prior to CVST. Totally, 71.4% had acclimatized for >2 weeks. The mean hemoglobin (Hb) value was 16.7 g/dL and 50% had d-dimer levels higher than 1,000 ng/mL. On MRI, 25% showed signs of hemorrhage and 14.3% showed infarcts. Treatments provided include low-molecular-weight heparin and Rivaroxaban and were associated with good outcomes. Conclusion: CVST is not uncommon at high altitude (>8,000 feet). It is predominantly a male disease. Most patients have high Hb and high D-dimer levels. The overall outcome was good.

A CASE OF CEREBRAL SINUS VENOUS THROMBOSIS RESULTING IN MORTALITY IN PREGNANT WOMAN: LATE DIAGNOSIS

Cerebral venous sinus thrombosis (CVST) is a rare condition. The most frequent symptoms and signs are headache, focal seizures with or without secondary generalization, unilateral or bilateral paresis and papilledema. We report a case of CVST in a 30-yearold female that presented with headache, diminution of vision, swelling and pain in both eyes and bilateral restricted extraocular movements. She expired after 3 days of treatment as she was diagnosed late. Due to its diverse and varied clinical presentation, CVST should be considered as differential in almost any brain syndrome.

Clinical profile and geographical distribution of cerebral venous sinus thrombosis at a tertiary care hospital

Cerebral Venous Sinus Thrombosis (CVST) is an important cause of stroke in India. Pregnancy and oral contraceptives are identified as common causes of CVST in western world and this study aims to identify the etiological factors in this terrain. To study the clinical profile and geographical distribution of patients with CVST. A retrospective observational analytical study. Case records of CVST cases are extracted from medical record section of Kasturba hospital. Statistical analysis is done using R software (Choropleth maps) and SPSS (South Asia Bangalore). One hundred forty five case records of CVST are studied. Seventy percent are males. Head ache is most common symptom. Polycythemia (23%) Hyperhomocystinemia (19%) and Puerperal CVST (5%) are important etiological factors. Geographical distribution showed a difference in incidence from coastal regions to other plateau areas. A larger community based study is required.

Safety and efficacy of the use of large bore intermediate suction catheters alone or in combination for the treatment of acute cerebral venous sinus thrombosis: A multicenter experience.

Systemic anticoagulation is the standard treatment for cerebral venous sinus thrombosis (CVST). Several endovascular techniques have been described as salvage therapy for anticoagulation refractory CVST cases. We aim to evaluate the safety and feasibility of endovascular aspiration thrombectomy using the new generation, large bore suction catheters alone or in combination with stentriever devices for the treatment of CVST. We collected data on 16 consecutive patients with CVST who received endovascular aspiration thrombectomy at three large academic centers. Second generation reperfusion catheters were used as a large bore suction catheter and advanced to the affected sinus using a coaxial technique. Suction was performed using pump suction. At times, a stentriever was used as an anchor to facilitate advancing the suction catheter and to increase thrombectomy capabilities. Median decade of age was the 50s and nine patients were women. Fifty percent of the patients had multiple sinuses involved. All patients received systemic anticoagulation prior to endovascular aspiration thrombectomy. The most common reason to pursue endovascular aspiration thrombectomy in CVST patients was deterioration of initial clinical status (10/16). The mean time from admission to endovascular aspiration thrombectomy was 1.5 days (range 0-6 days). Good recanalization was obtained in all patients. There were no major peri-procedural complications. Most patients were discharged to either home or a rehabilitation facility. Endovascular aspiration treatment using large bore suction catheters for CVST is a safe and feasible approach for the treatment of anticoagulation refractory CVST. Heterogeneity of the clinical and radiological presentation requires further investigation to optimize patient selection before evaluating the efficacy of this technique in larger prospective studies.

A Case Report of Cerebral Venous Sinus Thrombosis in Palestine: The Importance of Rapid Diagnosis and Treatment of CVST

Cerebral venous sinus thrombosis (CVST) is an often under-diagnosed, life-threatening condition. We report the first case of CVST in Palestine of a 39-year-old female who presented with a history of loss of consciousness preceded by severe vertigo and headache. Brain CT scan without contrast was done, in which no abnormality was detected. Further Brain MRI and MRV studies with contrast showed thrombosis of left transverse sinus with extension to left sigmoid sinus and left jugular vein. The patient was anticoagulated and admitted to the ICU for regular monitoring and frequent brain CT scans to rule out hemorrhagic transformation. The patient made a full recovery. Lab and molecular studies were carried out as an outpatient to investigate the etiology of this presentation. The aim of this case report is to demonstrate the importance of early detection and treatment of CVST for a successful outcome.

Abstract TP277: The Neurointensivists’ Role in Management of Cerebral Venous Sinus Thrombosis

Introduction: Cerebral venous sinus thrombosis (CVST) represents an important cause of both ischemic and hemorrhagic strokes in young people. While recent guidelines recommend management in a stroke unit, the impact of Neurocritical care in this condition has not been studied. We aimed to assess whether the introduction of a Neurocritical Care program influenced clinical outcomes in CVST patients. Methods: We retrospectively reviewed electronic medical records of adult patients admitted to Yale New Haven Hospital’s Neuroscience ICU (NICU) between 2010 and 2017 with a diagnosis of CVST. Demographics, vascular risk factors, comorbidities, length of stay and discharge modified Rankin scale (mRS) were collected. Patients were excluded for transfer after 24 hours of initial presentation. We compared two time periods, before (epoch 1, 2010-2012) and after (epoch 2, 2013-2017) the introduction of continuous staffing of CVST cases by neurointensivists in the NICU. Univariable and multivariable logistic regression were utilized to model the odds of poor outcome (dichotomized mRS 0-2 vs 3-6). Results: Fifty-three patients with CVST met the inclusion criteria during the study period (mean age 39 (+/- 17) years, 51 % female). 20 patients were identified for Epoch 1 and 33 patients for Epoch 2. Overall, 40 patients (76%) had a good (mRS 0-2) outcome. For epochs 1 and 2, good outcomes were observed in 12 (60%) and 28 (85%) patients, respectively (p=0.04). In both univariable and multivariable regression analysis (adjusted for age and sex), admission during epoch 2 was associated with a significantly reduced odds of a poor outcome (OR 0.27, CI 0.07 - 0.98; p =0.048) and (OR 0.27, CI 0.07- 1; p=0.05), respectively. Conclusions: In this small, single-center cohort of patients with CVST, most patients experienced a good outcome. The institution of continuous neurointensivist coverage was independently associated with better outcomes. Further validation in prospective, multicenter cohort studies is needed.

CEREBRAL VENOUS SINUS THROMBOSIS IN PATIENTS WITH METASTATIC TESTICULAR CANCER DURING CHEMOTHERAPY: REPORTS OF TWO CASES

Cerebral venous sinus thrombosis (CVT) is rare but sometimes develops in association with malignant neoplasm. We report two cases of CVT that occurred during cisplatin-based chemotherapy for testicular cancer. A 46-year-old man with stage IIA non-seminomatous germ cell tumour was treated with conventional doses of etoposide and cisplatin (EP). On day 11 of the third treatment course, he developed a systemic seizure. Brain computed tomography (CT) and magnetic resonance (MR) imaging could not detect the cause. Enhanced chest-pelvic CT revealed pelvic thrombosis. Administration of phenytoin for epilepsy of unknown cause and heparin for thrombosis was started. He had completed 4 courses of EP therapy without seizure recurrence. After re-evaluating the brain CT images retrospectively, we found high density of superior sagittal sinus (SSS) and strongly suspected CVT. Another patient was a 47-year-old man with stage IIIB seminomatous germ cell tumour treated with bleomycin, etoposide, and cisplatin (BEP) therapy. On day 11 of the second treatment course, he developed a systemic seizure. Brain CT revealed subarachnoid haemorrhage localised in the right parietal lobe. CT venography revealed a filling defect in the superior sagittal sinus (SSS). MR venography revealed a SSS stenosis. We diagnosed the cause of the seizure as CVT and started administration of anticoagulant therapy. After the thrombus had diminished, chemotherapy was restarted and another 2 courses of BEP therapy was completed.

Cerebral Venous Sinus Thrombosis Masquerading as High Altitude Cerebral Edema at Extreme Altitude

Introduction: Extreme altitude travel has gained popularity globally for adventurous, scientific, and military endeavors. Cerebral venous sinus thrombosis (CVST) at extreme altitude is a rare, covert, and emergent condition requiring immediate intervention. Case Presentation: A case of CVST masqueraded as high altitude cerebral edema (HACE) at 6700 m/22000 ft in Karakoram Himalayas. Atypical oligosymptomatic presentation along with terrain, weather, and communication restrictions complicated diagnosis and management, leading to demise. CVST, confirmed on autopsy, was not associated with any pre-existing risk factors. Conclusion: CVST at extreme altitude can occur spontaneously due to prolonged hypobaric hypoxia which can precipitate thrombosis through capillary damage, haemoconcentration, and a hypercoagulable state.

Nephrotic Syndrome May Be One of the Important Etiologies of Cerebral Venous Sinus Thrombosis

Thrombosis is a common complication of nephrotic syndrome (NS). However, cerebral venous sinus thrombosis (CVST) secondary to NS is rarely reported. Here we report a case series study of 5 cases of CVST with NS, so as to make a better understanding and management of this disorder. A retrospective study was performed in 5 consecutive patients with CVST in combination with NS between 2009 and 2015. The clinical manifestations, laboratory and radiological findings, treatment, and clinical outcomes were analyzed. This cohort of case series consists of 1 woman and 4 men, aged 16-49 years. All patients complained initially of an acute or subacute headache. CVST attacked during NS occurrence in 3 patients, and during NS recurrence in 2 patients. The median duration of signs and symptoms prior to clinical diagnosis and treatment was 12.80 ± 7.53 days. In all patients, it was magnetic resonance venography that detected the thrombosis in the cerebral venous sinus, with the most common site of CVST to be the superior sagittal sinus (5 of 5 patients). Two or more segments of sinus were involved simultaneously in 4 patients. The treatment of CVST in NS involved therapy of CVST in the general population. All the 5 patients had full recovery, and no one relapsed with a follow-up of 26.60 ± 29.75 months. NS may be one of the important etiologies of CVST. When patients with NS had progressing headache, seizure, or other unexplained neurological symptoms, CVST should be considered.

A Case of Post-traumatic Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a potentially lifethreatening condition. It may lead to a considerable mortality if not recognized and treated in a timely manner [1,2]. Nonetheless, Due to its nonspecific clinical presentations, early diagnosis is not always possible. There are several predisposing factors for CVST, of which the most common conditions are hereditary thrombophilia, post-operative states; and use of oral contraceptives [3]. Hereby we report an interesting case of CVST following brain contusion. It is important to always keep a high degree of suspicion for CVST, even when other diagnoses seem more possible.

A retrospective analysis of cerebral venous sinus thrombosis-a series of 25 cases

Objectives: To explore the character of Cerebral Venous Sinus Thrombosis (CVST), and to improve the early diagnosis and treatment of such a disease. Methods: Retrospective analysis of the ­patient ages, risk factors, clinical presentations, imaging characters and treatment of 25 CVST cases. Results: The most common age coverage of CVST attacks is from 18 to 45, the most common risk factors include female oral contraceptive (32%) and post-delivery or post-abortion (20%). The most common presentation is headache (80%), followed by paralysis (44%) and seizure (40%). Neuroimaging shows that transverse sinus is the most commonly affected sinus, followed by superior sagittal sinus. Low molecular heparin is effective to CVST and the prognosis of most patients is good. Conclusion: The diagnosis of CVST should be considered in young patients with recent unusual headaches or with stroke-like symptoms, in patients with intracranial hypertension, and in patients with hemorrhagic infarcts. To make a definite diagnosis and treat the patients in time, Enhanced MRI+MRV or Enhanced CT+CTV should be performed immediately, and if necessary, DSA should be performed.

The efficacy and safety of low-molecular-weight heparin and unfractionated heparin in the treatment of cerebral venous sinus thrombosis.

Objective:To compare the efficacy and safety of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in the treatment of patients with cerebral venous sinus thrombosis (CVST), and to provide an appropriate treatment option in these patients.Method:This is a randomized double blind clinical trial conducted between December 2013 and December 2014. The subjects were selected among patients referred to Neurology Department, Imam Reza Hospital; affiliated to Kermanshah University of Medical Sciences, Kermanshah, Iran. Fifty-two cases of CVST were included in this study and randomly divided into 2 groups. Twenty-six cases received LMWH and the other 26 cases received UFH. The primary outcomes include hospital mortality rate and neurologic deficits as assessed by the National Institutes of Health Stroke Scale (NIHSS). The secondary end point was disability as measured by the Modified Rankin Scale (MRS).Results:We observed the rate of mortality and neurological deficits and disability based on NIHSS, and the MRS did not differ between the 2 groups.Conclusion:The efficacy of LMWH and UFH in reduction of neurologic deficit and functional disability in patients with CVST are similar.

Cerebral Venous Sinus Thrombosis on Unenhanced CT

Objective: The aim of the study was to investigate computed tomography (CT) signs of cerebral venous sinus thrombosis (CVST), so as to increase clinicians’ awareness of CVST and improve the sensitivity of the diagnosis. Materials and Methods: We retrospectively analyzed all the CVST cases primary diagnosed by CT and confirmed further by magnetic resonance imaging (MRI) or other clinical methods within the past 4 years in our institution. In total, 11 cases including 6 male and 5 female patients with a mean age of 31.0 years were studied. All patients had emergency CT examination for complaints of headache. The initial CT examinations were performed within 7 days after the onset in 7 cases and over 7 days in the other 4 cases. Six cases had continuous follow-up CT examinations, twice in 4 and 3 times in 2. The analysis items focus on the density change by measuring the CT values of involved venous sinuses in different phases, as well as indirect signs including venous infarction and hemorrhage. As a comparison, we measured CT values of normal venous sinuses in 40 healthy people with age ranging from 20 to 60 years. Results: Of the patients with CT examinations performed within a week after the onset, 6 cases displayed uniform high density in related venous sinuses with a mean value of 72 HU. One week later, the densities declined slightly or reached isodensity with a mean value of 58 HU. The follow-up CT demonstrated the density changes of sinuses with the extension of the course of CVST, from high density gradually attenuating into mixed density, and into isodensity at last. During 7 to 10 days after the onset in 3 cases, the involved sinuses showed central high density with peripheral isodensity. A change of involved sinuses from high-density to isodensity occurring in different sites was found in 1 case on follow-up CT. Cortical vein thrombosis with secondary hemorrhage in 2 cases and CVST with subarachnoid hemorrhage in 2 cases were revealed in our study. Conclusions: On CT, the CVST presented as the attenuation of the sinuses from high to isodensity with its resolution course. In the first week, the involved sinuses mainly appear as high density, then in 7 to 10 days decrease to mixed density as central high density and peripheral isodensity, and gradually to uniform isodensity at last. The secondary infarction and hemorrhage are important indirect signs of CVST. Understanding the abnormal density change of venous sinuses and intracerebral indirect signs on CT could improve our diagnostic sensitivity for CVST.

Clinical characteristics of cerebral venous sinus thrombosis with thalamic lesions in imaging examination

A retrospective study was performed on 3 patients with cerebral venous sinus thrombosis (CVST) who were characterized with thalamic lesions in MRI examination. Among 3 CVST cases, one were male, and 2 was female, aged from 17 to 68. All cases had risk factors of CVST such as acute dehydration and puerperium. The main clinical symptoms included headache, nausea and vomiting, hypomnesis, hemiplegia and coma. MRI examination showed one case with unilateral thalamic lesions and 2 cases with bilateral thalamic lesions. Magnetic resonance venography (MRV) and DSA revealed straight sinus lesions in 3 cases, inferior sagittal sinus lesions in 2 cases, superior sagittal sinus lesion in one case, and transverse sinus lesion in one case, respectively. The patients with unilateral or bilateral thalamic lesions, especially those who had risk factors of CVST, should be diagnosed correctly and timely. doi: 10.3969/j.issn.1672-6731.2014.08.014

Chicken or Egg: Which Came First?

Cerebral venous sinus thrombosis (CVST) is quite an unusual diagnosis in pregnancy and puerperium. It can present with a wide range of symptoms and signs, and a high index of suspicion is required to diagnose this disorder. The diagnosis is challenging and could if left undiagnosed, result in life-threatening complications. Yet its management is simple with excellent prognosis, with an early diagnosis and timely intervention. We report a case of CVST in a young pregnant patient who presented with features of raised intracranial tension and loss of consciousness, after several weeks of hyperemesis gravidarum. She was treated with intravenous fluid resuscitation, low molecular weight heparin, steroids, and anti-cerebral edema measures. She subsequently made excellent recovery and is under follow-up. J Neurol Res. 2014;4(5-6):142-145 doi: http://dx.doi.org/10.14740/jnr294w

Chicken or Egg: Which Came First?

Cerebral venous sinus thrombosis (CVST) is quite an unusual diagnosis in pregnancy and puerperium. It can present with a wide range of symptoms and signs, and a high index of suspicion is required to diagnose this disorder. The diagnosis is challenging and could if left undiagnosed, result in life-threatening complications. Yet its management is simple with excellent prognosis, with an early diagnosis and timely intervention. We report a case of CVST in a young pregnant patient who presented with features of raised intracranial tension and loss of consciousness, after several weeks of hyperemesis gravidarum. She was treated with intravenous fluid resuscitation, low molecular weight heparin, steroids, and anti-cerebral edema measures. She subsequently made excellent recovery and is under follow-up. J Neurol Res. 2014;4(5-6):142-145 doi: http://dx.doi.org/10.14740/jnr294w

Cerebral venous sinus thrombosis and venous hemorrhagic infarction in a young woman.

Cerebral venous sinus thrombosis (CVST) is an uncommon cause of cerebral infarction, compared to arterial diseases. It is often unrecognized at initial presentation due to the diversity of causes and clinical manifestations. A 29-year-old female patient complained of severe headache and presented at the emergency room with altered consciousness. Brain computed tomography and brain magnetic resonance image revealed the left sigmoid sinus thrombosis with venous hemorrhagic infarction (VHI) in the left temporal lobe. The patient had no past medical and family history of bleeding diathesis. The laboratory finding at the admission showed severe iron-deficiency anemia (IDA), and protein C and S activities were decreased. After the neurosurgery, iron replacement, and neurorehabilitation, the patient had a good recovery. There has been no known recurrence. We report our therapeutic intervention on a very rare case of CVST and VHI, with IDA as a probable cause of cerebral thrombosis.

A case of delayed emergence from anesthesia caused by postoperative brain edema associated with unexpected cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is rare but displays various and often dramatic clinical symptoms. Few cases of CVST have been reported in the field of anesthesiology. We encountered an unexpected case of CVST that presented with delayed emergence from anesthesia after resection of a brain tumor. A 55-year-old man was scheduled for resection of an oligoastrocytoma in his right frontal lobe. After smooth induction of general anesthesia, anesthesia was maintained uneventfully for about 7 h with target-controlled infusion (TCI) of propofol and remifentanil, except for a seizure generated when the right anterior central gyrus was stimulated to allow motor evoked potential monitoring. Immediately after the cessation of TCI, spontaneous respiration was restored. However, the patient was unexpectedly comatose, and no response to painful stimuli or coughing during tracheal suctioning was observed. A computed tomogram taken 2 h after surgery showed diffuse brain edema, even though the neurosurgeons did not notice any cerebral swelling during closing of the dura mater. A magnetic resonance venogram revealed thromboses in the superior sagittal and straight sinuses. On the 9th postoperative day, the patient died without recovering consciousness or his brainstem reflexes. Anesthesiologists should be aware of CVST as a cause of delayed emergence from anesthesia after craniotomy.

Evaluation of Plasma d-Dimer Plus Fibrinogen in Predicting Acute CVST

Prompt diagnosis of cerebral venous sinus thrombosis is a challenge owing in part to its complex and non-specific early clinical symptoms. This study aims to evaluate the value of clinically useful biomarkers (d-dimer and fibrinogen) for cerebral venous sinus thrombosis prediction. Two-hundred and thirty-three suspected cerebral venous sinus thrombosis patients were enrolled in this prospective study. Thirty-four cases confirmed as cerebral venous sinus thrombosis using imaging modalities, whereas the other 199 cases served as mimic controls. Plasma samples of 34 healthy controls were further collected from age- and gender-matched volunteers. d-dimer and fibrinogen levels of all patients and controls were measured before imaging and treatment. The dynamic d-dimer and fibrinogen levels in cerebral venous sinus thrombosis cases after anticoagulation were monitored for up to 180 consecutive days. At admission before treatment the average d-dimer and fibrinogen levels in cerebral venous sinus thrombosis group were 968·9 ± 160·1 μg/l and 6·9 ± 1·3 g/l, both of which were significantly elevated when compared with that of the controls. In cerebral venous sinus thrombosis patients, 94·1% had d-dimer elevation, 73·5% had fibrinogen elevation, and 67·6% had both elevated d-dimer and fibrinogen. During acute phase, the sensitivity and specificity of predicting cerebral venous sinus thrombosis using only d-dimer were 94·1% and 97·5%, whereas that of d-dimer in combination with fibrinogen were 67·6% and 98·9%. After administering anticoagulation, d-dimer levels gradually recovered; however, fibrinogen levels fluctuated with 33·3% of the patients still exhibiting elevated values up until 180 days. d-dimer may serve as an important screening tool to determine the urgency of obtaining magnetic resonance imaging/magnetic resonance venography or digital subtraction angiography in patients presenting with clinical symptoms that are suspected of cerebral venous sinus thrombosis. Furthermore, d-dimer in combination with fibrinogen may increase the predictive value of acute cerebral venous sinus thrombosis.

Abstract WP19: Safety and Validity of mechanical Thrombectomy and Thrombolysis on Severe Cerebral Venous Sinus Thrombosis

BACKGROUND: Although the vast majority of patients suffering from cerebral venous sinus thrombosis (CVST) obtain an optimistic clinical outcome after heparin or warfarin treatment, nevertheless, there remains a subgroup of patients that do not respond to the conventional anticoagulation treatment. These patients, especially the younger people as documented by hospital based studies, have a high morbidity and mortality rate. While the wide spectrum of clinical presentation in most CVST patients makes the diagnosis difficult at an earlier time, endovascular thrombolysis offers an aggressive option to treat CVST. OBJECTIVE: To verify the safety and validity of mechanical thrombectomy combined with thrombolysis in patients with severe CVST. METHODS: A total of 52 patients diagnosed with CVST from January 2007 to December 2010 were enrolled and treated with mechanical thrombectomy combined with thrombolysis. Patients underwent urokinase 100 ~1500×10 3 IU intravenous sinus injection via a jugular catheter after confirming CVST diagnoses by magnetic resonance imaging (MRI)/magnetic resonance venography (MRV) or digital subtraction angiography (DSA). Information obtained on the patients included recanalization status of venous sinuses as evaluated by MRV or DSA, at admission, during operation and 3 and 6 months follow-up after treatment. RESULTS: The percent of patients that showed complete and partial recanalization were 86% and 6% respectively after the mechanical thrombectomy combined with thrombolysis treatment, while 8% of the patients showed no recanilization. The modified Rankin Scale (mRS) scores were 1.0±0.9, 0.85±0.63 and 0.37±0.53 at discharge and at 3 and 6 months follow-up respectively. A total of 6 patients died despite receiving aggressive treatment. No relapsed cases were seen after 3 to 6 months of follow-up. CONCLUSION: Thrombectomy combined with thrombolysis is safe and valid to use in severe cases of CVST. However, a large scale multicenter clinical trial is warranted.