Cerebral Venous Sinus Stenosis Research Articles

Clinical differences between acute CVST and non-thrombotic CVSS

BackgroundCerebral venous sinus thrombosis (CVST) is a rare stroke subtype, which has many overlapping symptoms with non-thrombotic cerebral venous sinus stenosis (CVSS) in the acute phase. Despite these similarities, their therapeutic regimens and outcomes are entirely different, and treatment delay is life-threatening. This study aims to address their clinical differences to help promote proper patient care. Methods34 cases of CVST and 34 cases of non-thrombotic CVSS diagnosed with digital subtraction angiography (DSA) in the acute phase (symptoms onset within 7days) were consecutively enrolled in this prospective non-randomized and controlled study. Differences between CVST and CVSS in their clinical manifestation, plasma biomarkers, and MR or DSA imaging were compared. ResultsCVST and CVSS overlap in many ways, but differ in their respective medical histories and neurological deficits. However, 20.6% of CVST and 64.7% of CVSS occur without a definitive medical history, and 70.6% of CVST and 64.7% of CVSS occur without focal neurologic deficits. In the acute phase of CVST, d-dimer and fibrinogen are found to be abnormally elevated in 94.1% and 73.5% of cases, respectively. In the CVSS group, d-dimer and fibrinogen are only elevated in 17.6% and 5.9% of cases, respectively (binary logistic regressions test, all P<0.001). In the CVST group, the predominant features in MRI/MRV and DSA imaging include local brain lesions, flow void signal loss, non-visualization, and a local filling defect sign at the involved sinus. Conversely, in the CVSS group, imaging revealed symmetrically small bilateral ventricles and the spread of cerebral edema in MRI/MRV. DSA imaging in the CVSS group revealed external compression and a narrow sinus with disproportionate venous engorgement. Despite these findings, positive imaging only appears in a minority of patients in the two groups during the acute phase (Table 4). ConclusionsDSA may be beneficial to diagnose CVST in ambiguous patients suspected to have either CVST or CVSS. Clinically useful biomarkers (d-dimer and fibrinogen) may predict CVST in the emergency room in the ambiguous patients with or without equivocal MRI/MRV imaging.

Stenting treatment of venous sinus stenosis for intractable pulsatile tinnitus

To evaluate the application, effectiveness and safety of stenting in venous sinus stenosis for intractable pulsatile tinnitus via endovascular treatment. From January 2010 to July 2011, 12 cases with intractable pulsatile tinnitus originating from cerebral venous sinus stenosis underwent stenting treatment. All of them were diagnosed by digital subtraction angiography (DSA). There was ipsilateral stenosis in junction segment of sigmoid and transverse sinuses. The diverticulum of sigmoid sinus was found in 6 cases. Eleven patients underwent stenting placement and angioplasty for venous sinus stenosis. All pulsatile tinnitus symptoms disappeared immediately after stenting. No related complication was found during stenting and over a follow-up period of 3 - 22 months. There was no recurrence of pulsatile tinnitus. Stent placement is a safe and effective procedure for pulsatile tinnitus with cerebral venous sinus stenosis.

Does Bilateral Transverse Cerebral Venous Sinus Stenosis (TSS) Really Exist in Patients without Increased Intracranial Pressure (ICP)? (P07.263)

Objective: To identify patients with asymptomatic TSS and normal ICP and describe their characteristics. Background TSS is common among patients with elevated ICP, particularly those with idiopathic intracranial hypertension. Although it is believed that TSS exists in the general population, and is not specific to elevated ICP, the prevalence of TSS among individuals with normal ICP is unclear. Design/Methods: Among 240 adult patients who underwent standardized brain MRI/MRV with contrast at our institution between 09/2009 and 09/2011, 50 had TSS. Medical records were reviewed for symptoms of increased ICP, evidence of papilledema, CSF constituents and opening pressure (OP) and reason for brain imaging. We identified 5/50 (10%) well-documented patients without papilledema and CSF-OP ≤25 cmH 2 O, and 2/50 without measured ICP, but who had no papilledema or other symptoms of increased ICP. Imaging was re-interpreted by a neuroradiologist to assess for signs suggestive of elevated ICP and to characterize the stenoses further. Results: All patients were women (5 African-American, 2 Caucasian, mean age: 41, mean BMI: 37.1). CSF contents were normal but OP were at the upper limit of normal (22, 23, 24, 24, 25cm H 2 O). Indications for MRI/MRV included pituitary abnormality (1), migraine (4), and anomalous-appearing optic nerves (2). All had bilateral TSS. Six had a short TSS and empty sella; one had a long TSS but no empty sella; one had flattening of the globes; two had dilated optic nerve sheaths. None had bony changes. Conclusions: Asymptomatic bilateral TSS does exist in patients with ICP ≤25cmH 2 O, but is likely uncommon. Interestingly, CSF-OP was at the upper limit of normal in our patients, who also had other radiologic signs suggestive (but not specific) of chronically-raised ICP. Findings of bilateral TSS on brain imaging should probably prompt further investigations for raised ICP. Disclosure: Dr. Kelly has nothing to disclose. Dr. Saindane has nothing to disclose. Dr. Bruce has nothing to disclose. Dr. Ridha has nothing to disclose. Dr. Riggeal has nothing to disclose. Dr. Newman has received personal compensation for activities with Biogen Idec. Dr. Biousse has nothing to disclose.

CVST, Distinguished from Nonthrombotic Cvss before Treatment – a Must

Dear editor, there has been recent emphasis on the significant number of patients with idiopathic intracranial hypertension (IIH) found to have associated nonthrombotic dural cerebral venous sinus stenosis (CVSS) (1). However, cerebral venous sinus thrombosis (CVST) accounts for 9·4% of patients with presumed IIH (2).CVST is life-threatening and CVSS mainly make visual loss, which maybe severe in up to 25% of patients and 3% of patients develop a fulminant or malignant coursewith rapidly progressive visual loss (3,4). Acute CVST overlapped with nonthrombotic CVSS in both clinical presentation and imaging but differ in treatment regimen and clinical outcome (5); the overlap often misleads doctors to make a misdiagnosis and treatment delay. A typical case represented by a 28-year-old female with onset of severe headache and blurred vision for threedays was found to have remarkable bilateral papilledema; the intracranial pressure was 50 cmH20 with normal composition of cerebral spinal fluid.No local lesion was found in magnetic resonance imaging (MRI) and the blood tests data were plasma d-dimer 253 mg/l, fibrinogen 3·2 µg/l, leukocyte count 6·4 × 109/l, other items were not pertinent. She was given the diagnosis of CVST initially according to the diffused brain swelling and local lesion at right medial transverse sinus shown on magnetic resonance venography (MRV) (Fig. 1a); the patient then underwent urokinase 1·5 million International Unit (IU) intravenously for thrombolysis, followed by low molecular weight heparin 0·2 ml twice daily, through subcutaneous injection for seven-days. The increased intracranial pressure, headache, and the blurred vision were severe and developing. After performing digital subtraction angiography (DSA), the diagnosis of nonthrombotic CVSS was confirmed (Fig. 1b); the patient then underwent stent placement immediately (Fig. 1c), the intracranial pressure decreased to 20 cm H20 at the 24 h after stenting, and the symptoms above improved promptly. At the eighth-month follow-up, the papilledema completely resolved. This case alerted that it is necessary to distinguish CVST from nonthrombotic CVSS with DSA when the clinical and laboratory data and magnetic resonance (MR) imaging of the patient were ambiguous, instead of anticoagulation or thrombolysis hastily. Fig. 1 The MRV and DSA imaging of CVSS. (a) MRV before stenting; (b) DSA before stenting; (c) DSA after stenting.

Plasma Biomarker may Help to Distinguish Acute CVST from Non-Thrombotic CVSS in Emergency

Cerebral venous sinus thrombosis (CVST) is one of the important causes of stroke in young people and a lethal event (1). Acute CVST is overlapped with non-thrombotic cerebral venous sinus stenosis (CVSS) in both clinical presentation and brain imaging (2); both of them are predominantly involved in young women, and have severely non-explained headache with vomiting and the imaging feature of non-integrity venous sinus in magnetic resonance venography (MRV) (2). However, the treatment option and the clinical outcomes are entirely different, CVST is typically treated with anticoagulants, whereas non-thrombotic CVSS is treated with dehydration and stenting (3,4). Although CVST can be distinguished from CVSS by digital subtraction angiography (DSA), it is unfeasible in the emergency department (ED). Moreover, thrombolysis should be performed emergently to some intractable and severe CVST. Thus, distinguishing these two diseases in hyperacute stage is crucial. Report showed that D-dimer may helpful in supporting CVST (5), but the result in CVSS is not clear. We compared the levels of plasma biomarkers (D-dimer and fibrinogen) between 34 cases of acute CVST (symptom onset within seven-days) and 34 synchronal cases of age- and gender-matched non-thrombotic CVSS; all of them are confirmed the final diagnosis with DSA. The results revealed significant difference of the two biomarkers in the two groups; 94·1% (32/34) cases in acute CVST group and 5·9% (2/34) in non-thrombotic CVSS group had abnormally elevated D-dimer; 73·5% (25/34) in acute CVST group and 17·6% (6/34) in non-thrombotic CVSS group had abnormally elevated fibrinogen (χ2 = 52·941 and 18·285, all P < 0·001). More importantly, D-dimer and fibrinogen can easily be performed at real time in ED. The results can be obtained within 30 mins after the patient arrives, which is quicker than obtaining the magnetic resonance imaging or DSA imaging. So, these two biomarkers may be helpful and feasible in ED to predict acute CVST in patients with equivocal clinical symptoms, or to distinguish CVST from CVSS when the imaging of MRI/MRV is equivocal.

Pulsatile Tinnitus Neuroradiological Diagnosis and Treatment

Pulsatile tinnitus can be annoying for a patient and also the only hint to a potentially devastating and life-threatening neurological disease. In order to better understand its clinical spectrum and management we analyzed the files of 84 patients seen at our hospital suffering from this entity. We reviewed the records of 84 consecutive patients with pulsatile tinnitus. The mean age was 51 years (range from 3 to 82 years, 58 women and 26 men). The evaluation of tinnitus was on average 13 months after onset. Noninvasive techniques (ultrasound, CT, MRI, MRA, First-pass-Gadolinium-MRA) and angiography were employed for work-up tailored to the individual patient. Endovascular treatment was performed using a biplane interventional angiography system (1024 × 1024 matrix) by arterial and transvenous approach. A vascular pathology was found in 36 (42%) patients (dural arteriovenous fistula: 17; carotid-cavernous-fistula: 6; arteriosclerotic carotid stenosis: 7; dissection of the ICA: 5; fibromuscular dysplasia with ICA stenosis: 5; cerebral venous sinus thrombosis: 2; cerebral venous sinus stenosis: 1; ICA aneurysm: 1; abnormal loop of the anterior inferior cerebellar artery: 1). In 12 patients (14%) nonvascular pathologies such as glomus tumor or intracranial hypertension due to different reasons caused the tinnitus (paraganglioma: 5, meningioma: 1, sarcoidosis: 1, intracranial hypertension due to intracranial tumors: 4, intracranial hypertension due to aqueduct stenosis: 1). We conclude that patients with pulsatile tinnitus should be worked-up primarily with non-invasive techniques, e.g. first-pass gadolinium MRA, MRI and doppler sonography. If these are negative or to clarify abnormal findings further selective angiography is needed for diagnosis and treatment.