Cerebral Venous Sinus Thrombosis Patients Research Articles

The clinical characteristics of neutrophil extracellular trap in patients with severe cerebral venous sinus thrombosis and its prognostic value in acute and subacute patients

Objective: To explore the clinical characteristics of neutrophil extracellular trap (NET) in patients with severe cerebral venous sinus thrombosis (CVST) and to study their prognostic value in the acute and subacute phases. Methods: This study is a retrospective case series analysis. Clinical and pathological data of 52 patients with severe cerebral venous sinus thrombosis who underwent endovascular treatment in the Department of Neurosurgery, Tianjin Huanhu Hospital from June 2019 to June 2022 were retrospectively analyzed. There were 20 males and 32 females, with an age of (40.1±13.6) years(range:18 to 66 years). Forty-five healthy physical examinees were included in the control group. High-resolution MRI was used to stage the thrombus, with 11 cases in the acute group, 28 cases in the subacute group, and 13 cases in the chronic group. Thrombus specimens were obtained through endovascular treatment, and the fluorescence intensity of NET in peripheral blood at different time points was analyzed by immunofluorescence contrast,including the double-stranded DNA structure and adhesion protein components (citrolinated histone H3 (CitH3), myeloperoxidase-DNA complex(MPO-DNA), neutrophil elastase (NE)). The NET markers were determined by ELISA. Spearman rank correlation analysis was used to analyze the correlation between the NET markers in peripheral blood of patients with severe cerebral venous sinus thrombosis in the acute and subacute phases and the volume of venous sinus thrombus, the degree of venous sinus recanalization after treatment, and the discharge modified Rankin scale(mRS)score. The accuracy of NET markers in predicting the prognosis of patients with severe cerebral venous sinus thrombosis was analyzed by drawing receiver operating characteristic (ROC) curve and calculating the area under the curve (AUC). Results: The results of immunofluorescence staining and ELISA showed that no NET structure was formed in the peripheral blood of the control group, while CitH3, MPO-DNA and NE levels in the peripheral blood of CVST patients were increased, among which the acute stage group was the highest, followed by the subacute group, and the chronic group was the lowest. Spearman correlation analysis showed that CitH3, MPO-DNA and NE levels in peripheral blood of patients in acute group and subacute group were positively correlated with thrombus volume and mRS score at discharge (P<0.05). The levels of CitH3 and MPO-DNA in peripheral blood of patients with complete venous sinus recanalization were lower than those of patients with partial venous sinus recanalization (P<0.01). ROC curve analysis results showed that MPO-DNA and NE had no predictive ability for the prognosis of CVST patients (P values were 0.614 and 0.324, respectively), and the AUC of CitH3 was 0.800 (95%CI: 0.638~0.962, P=0.032), the best cut-off value was 13.5 μg/L, the sensitivity was 100%, and the specificity was 58.8%. Conclusions: A large number of NET are formed in patients with severe cerebral venous sinus thrombosis in acute stage. Patients with severe cerebral venous sinus thrombosis in acute stage and subacute stage with high peripheral blood NET content has a low rate of complete sinus revascularization and poor neurological function recovery after treatment.

Endovascular Treatment for Cerebral Venous Sinus Thrombosis: Comparison among Different Endovascular Procedures

Background: Cerebral venous sinus thrombosis (CVST) is a rare, treatable cause of stroke. Even though CVST has an established medical treatment, 15% of patients remain refractory to treatment. These patients may be candidates for endovascular treatment (EVT), yet the selection of patients remains a challenge. The study aims to understand the profile and outcome of patients treated with EVT and the type of procedure associated with good outcomes. Methods: This is a single-center, retrospective analysis of CVST patients who underwent EVT from 2009 till 2022. Patients who received only medical management were excluded. Modified Rankin Scale (mRS) ≤2 at 3 months was taken as the primary outcome. Secondary outcomes assessed were hospital stay, death, recurrence, mRS ≤ 2 at discharge, and angiographic recanalization. Results: Fifty-two patients were included. Twenty-eight (53.8%) were males; the mean age was 33.3 ± 12.3 years. Headache (n = 44, 84.6%) predominated among the symptoms. The common risk factors were anemia (n = 13, 25.5%) and hyperhomocysteinemia (n = 13, 25.5%). Worsening of sensorium (n = 21, 40.3%) and non-improvement of symptoms (n = 15, 28.8%) were the common indications for the procedure. Twenty-five (48.1%) people underwent in situ thrombolysis (IST). Death occurred in eight (15.3%) patients. Thirty-six (73.5%; 36/49) patients had a good outcome at 3 months. IST had a significantly better outcome (mRS ≤ 2, n = 20, 80%) compared to other procedures (P = 0.04). Hospital stay was lesser in the IST subgroup, but without statistical significance. Midline shift &gt;5 mm (odds ratio [OR] 6.8 [1.5–30.9], P = 0.01) and Glasgow Coma Scale &lt;9 before the procedure (OR 27.2 [3.1–236.4], P = 0.002) predicted bad outcomes at 3 months. Female gender (OR 4.5 [1.07–8.8], P = 0.03), presence of altered sensorium (OR 10.2 [1.2–87.5], P = 0.01), encephalopathic syndrome (P = 0.02), presence of parenchymal bleed (OR 3.7 [0.9–4.5], P = 0.04), and midline shift (OR 4.8 [1.1–20.2], P = 0.03) were associated with poor outcome at discharge. Conclusion: EVT yielded good outcomes in carefully selected, medically refractory patients of CVST. IST performed well compared to other procedures.

Cerebral venous sinus thrombosis detected using diffusion-weighted magnetic resonance imaging during maintenance temozolomide chemotherapy in a patient with glioblastoma: illustrative case.

Cerebral venous sinus thrombosis (CVST) sometimes occurs in the background of hypercoagulopathic disorders, including malignancy, chemotherapy, etc. Glioblastoma (GBM) is a malignancy found in the central nervous system, and reports on cases of GBM complicated by CVST are sparse. The authors herein report a case of GBM complicated by CVST during maintenance temozolomide (TMZ) chemotherapy and describe the utility of diffusion-weighted magnetic resonance imaging (MRI) for the detection of CVST. A 65-year-old male was treated for left temporal GBM. After surgical removal of the lesion, the patient was treated with chemoradiation therapy, which included 60 Gy local radiation with concomitant TMZ chemotherapy. He was subsequently received TMZ maintenance therapy. Routine MRI performed 7 months after surgery revealed no evidence of tumor recurrence. However, diffusion-weighted imaging (DWI) revealed a high-intensity signal at the posterior portion of the superior sagittal sinus, indicating the presence of a thrombus. In addition to the preexisting symptoms, the patient experienced some disorientation. Angiography revealed an obstruction in the superior sagittal sinus, right transverse sinus, right sigmoid sinus, and straight sinus. His symptoms improved with endovascular and anticoagulant therapy. Performing DWI during routine follow-up can help in the early diagnosis of CVST in patients with malignant gliomas.

Clinical Significance of D-dimer Level and Numeric Rating Scale with Amount of Sinus Involvement in Cerebral Sinus Thrombosis Patients.

Cerebral venous sinus thrombosis (CVST) is a cerebral vascular disorder that currently occurs quite often and has very varied clinical symptoms. Headache is the main symptom most commonly found in patients with CVST and multiple sinus involvement often have a more severe prognosis and poor clinical outcome. This study aimed to learn the relationship between D-dimer level, numeric rating scale (NRS), and amount of sinus involvement in CVST patients. This study was a retrospective observational analytic study with a cross-sectional approach using medical records and supporting data (D-dimer level and imaging finding) on patients diagnosed with CVST at Dr Hasan Sadikin Hospital Bandung. Sixty-five CVST patients met the study criteria with mean age of 47 years and mostly female (76.9%). Patients with single sinus involvement had a median initial NRS of 4 (range 2-6) and multiple sinus involvement was higher at 8 (range 5-9). Statistical test results showed a significant difference between D-dimer level, NRS and amount of sinus involvement (P<0.001). D-dimer level, NRS, and amount of sinus involvement are associated with amount of sinus involvement in CVST patients. Involvement of multiple sinus will cause higher NRS with higher D-dimer level.

The Plasma Proteomic Landscape of Thrombotic Events across Multi-Center Cohorts

Background: Diagnosis and risk prediction of thrombosis is challenging due to nonspecific symptoms, diverse risk factors, symptom overlap with other conditions and the variability in thrombosis presentations. Little is known on the impact of thrombosis on the plasma proteome across the spectrum of its clinical representations. Objective: The aim of this study was to explore the plasma proteomic landscape across multi-center thrombosis cohorts. The focus was on identifying protein signatures representative of thrombosis in general or among patients at risk of thrombosis, those with a history of thrombosis, those at acute phase and those with COVID-19 associated thrombosis. Method: Using state-of-the-art mass spectrometry-based proteomics, we analyzed 420 plasma proteome samples both cross-sectional and longitudinal from 211 patients, including those at risk of thrombosis, in the acute thrombotic phase (cerebral venous sinus thrombosis patients) and with COVID-19-associated thrombosis (Figure 1). Linear models and unsupervised co-expression clustering were used to explore common and distinct protein signatures among the cohorts. Results: Across the analyzed samples 475 proteins were quantified, with 86% showing a CV below 30%, and we found a strong correlation between protein levels quantified by MS and ELISA. Plasma proteomic alterations exhibited variation across cohorts, with the most pronounced changes observed in COVID-19 patients. While co-expression analysis unveiled distinct protein clusters associated with SARS-CoV-2 signaling pathways (CRP, SAA1) and Vitamin K-dependent (VKA) coagulation proteins (F9, F2, F10, PROS, PROC, PROZ, C4BPA), we did not identify a specific protein cluster related to thrombosis (Figure 2). Notably, VKA-therapy was associated with decreased abundance of VKA-dependent coagulation proteins, with F10 and PROZ showing significant alterations between patients who experienced a thrombosis compared to healthy controls. We observed an inverse correlation between the International Normalized Ratio and abundance of VKA-dependent coagulation proteins, with an increased correlation of F2 and F9 in patients who experienced a thrombotic event. Additionally, our analysis also highlighted potential variations in multi-center cohorts during sample handling, emphasizing the importance of standardized protocols in ensuring the reliability and comparability of results. Conclusion: Using a comprehensive MS-based proteomics approach, we identified clear plasma proteomic signatures associated with VKA-treatment and COVID-19 , but no distinct thrombosis signature across multi-center thrombosis cohorts.

Machine Learning Model for Predicting Mortality Risk in Pediatric Cerebral Venous Sinus Thrombosis

Introduction: Pediatric Cerebral Venous Sinus Thrombosis (CVST) is a rare but serious disorder with risk for neurologic sequelae and mortality. Prediction of health outcomes for risk stratification and tailored therapy is difficult based on available literature with single center studies and limited sample sizes. We sought to analyze the CVST data in Pediatric Health Information System (PHIS) database, a large, multicenter administrative database of pediatric inpatient data, to assess if supervised machine learning can assist in identifying pediatric CVST patients with increased risk of adverse outcomes. Methods: Patients 0 to 17 years of age with a diagnosis of CVST were identified in the PHIS database from 2011 to 2022. Demographic information, clinical characteristics, evaluation and management, and outcome data was extracted from diagnostic, imaging, procedure, and pharmaceutical billing codes. An XGBOOST model was fitted using 10-fold cross-validation with Bayesian optimization for hyperparameter tuning. The clinical parameters with values optimal for analysis from the “early era” (2011-2015) dataset were used to train for machine learning, and the test was applied to the “late era” (2016-2022) dataset. The final model was chosen based on the highest test set AUC score. The clinical parameters with significant SHAP values from the model were compared to published risk factors for mortality from an International Pediatric Stroke Study (IPSS) (RN Ichord, et al. Arch Dis Child 2015). Results: 6080 hospitalizations with CVST diagnosis (0.1% of all hospitalizations) were identified. The clinical parameters applied for machine learning included the following: age, gender, race, major complications (intracranial bleeding, hydrocephalus, coma), child opportunity index and ICU admission (Table 1.). The overall mortality rate at discharge was 4.2%. 2029 hospitalizations occurred in the early era and 4051 hospital admissions occurred in the late era. With the analyzable clinical parameters, the XGBOOST model could predict mortality with a probability of 0.7906. Of the clinical parameters used for machine learning (Figure 1), ICU admission, intracranial bleeding, hydrocephalus and coma had positive SHAP values indicating higher mortality risk prediction, whereas older age and being non-Hispanic white had negative SHAP values indicating lower mortality risk prediction. Similar risk associations for mortality were reported in the IPSS study, with patients with intracranial bleeding, younger age, and coma having higher mortality risk, consistent with our study finding. Conclusion: Our study in pediatric CVST, using machine learning, shows higher risk of mortality with ICU admission, and complications including intracranial bleeding, hydrocephalus, and coma; and lower risk of mortality with older age and non-Hispanic White status, which are consistent with IPSS study observations. Our study also illustrates how machine learning can be utilized by investigators to predict adverse clinical outcomes in pediatric CVST. In rare diseases which are difficult to study due to limited sample sizes like pediatric CVST, our study shows that data from large databases such as PHIS can be utilized for machine learning to predict health care outcomes, which can in turn inform future clinical practice to improve patient outcome.

Impaired Dynamic Cerebral Autoregulation in Patients With Cerebral Venous Sinus Thrombosis: Evaluation Using Transcranial Doppler and Silent Reading Stimulation.

Cerebral venous sinus thrombosis (CVST) may impair dynamic cerebral autoregulation (dCA) of the middle cerebral artery (MCA). However, most studies have focused on dCA of the MCA; a few studies are based on the posterior cerebral artery (PCA) during silent reading and neurovascular coupling (NVC). This study explored the effects of CVST on dCA of the MCA and PCA during silent reading and NVC. From January 2021 to August 2022, 60 CVST patients and 30 controls were enrolled in this study. Non-invasive continuous beat-to-beat blood pressure, cerebral blood flow velocity and other associated information on the MCA and PCA during silent reading were collected using a transcranial Doppler. NVC assessment was performed by opening and closing the eyes periodically based on voice prompts, and eye-opening visual stimulation was achieved by silently reading Chinese tourism materials. Visual stimulation signals can selectively activate Brodmann's areas 17, 18, and 19 of the occipital when reading silently with open eyes, prompting them to release neurotransmitters and dilate PCA. dCA was determined by transfer function analysis. In dCA of the PCA during silent reading, the CVST group's very low frequency phase was lower than that of the control group (p=0.047). In NVC, the difference in the indexes of the cerebrovascular conductance and visually evoked flow response of the CVST group were lower than those of the control group (p=0.017 and p=0.019, respectively). Compared with the control group, dCA and NVC of the PCA during silent reading were impaired in CVST patients.

Correlation Between P-Selectin Level and Platelet Aggregation in Cerebral Venous Sinus Thrombosis Patients

One of the causes of cerebral venous sinus thrombosis (CVST) is platelet hyperactivity. Adhesion and secretion are the beginning of platelet activation, which is indicated by a change in the Platelet-selectin (P-selectin) level. The end result of platelet activation is platelet aggregation. However, it is unknown whether the beginning of platelet activation ends with platelet aggregation. This study aimed to discover the correlation between P-selectin level and platelet aggregation in CVST. This study used a cross-sectional escriptive observational correlative approach. Subjects were the CVST outpatients visiting the Neurology Department of Dr. Hasan Sadikin General Hospital, Bandung, Indonesia, from July to September 2021. A total of 49 subjects met the inclusion and exclusion criteria. This study used citrate plasma samples for platelet aggregation and serum for P-selectin assessment. Platelet aggregation were assessed using the light transmission platelet aggregation method while P-selectin was assessed using Enzyme-linked immunosorbent assay (ELISA). Platelet aggregation median was 10.6% (range 0.2–82.4%), which reflected normoaggregation. Platelet hyperaggregation were seen in 9 samples (8.4%). Median of P-selectin was 2.4 ng/mL (range 0.1–10.1 ng/mL) which were normal. High P-selectin level was observed in 16 (32.7%) with 4/16 (25%) experiencing platelet hyperaggregation. Statistical analysis showed a weak negative correlation between P-selectin and platelet aggregation (r=-0.012; p=0.467). In conclusion, no correlation is seen between P-selectin and platelet aggregation, which may be due to the fact that platelets are influenced by many factors that are not examined in this study.

Analysis of 6 pediatric nephrotic syndrome cases with complications of cerebral sinovenous thrombosis and literature review.

Cerebral venous sinus thrombosis (CVST) is a rare but serious complication of nephrotic syndrome (NS) in children. To investigate the clinical characteristics of CVST in children with NS in order to timely diagnose this complication and reduce poor outcome. Collect and analyze clinical data and magnetic resonance venography (MRV) results of children with NS complicated with CVST. Data of 6 patients with NS complicated with CVST were collected. 4 of the patients were steroid-sensitive nephrotic syndrome (SSNS) and 2 were steroid-resistant nephrotic syndrome (SRNS). The occurrence of CVST was observed within a time frame ranging from 12 days to 3 years following the diagnosis of NS. One patient had two episodes of thrombosis in three years, while the other five patients had only one episode of thrombosis. All patients had proteinuria at the time of episode of thrombosis. All patients presented with headache, and three of them had strabismus, seizures, and transient blindness, respectively. Neurological examination was negative. All patients were diagnosed with CVST by MRV within 3-16 days of the onset of headache. Two patients had TRPC6 gene mutation. All patients had resolution of neurological symptoms after anticoagulation treatment. CVST may occur in the early stages of NS. There is currently a lack of specific diagnostic indicators to reliably identify the presence of CVST in patients with NS. Children with NS who have neurological symptoms should be promptly evaluated with imaging studies. Whether TRPC6 gene mutation is also a risk factor for CVST remains to be further studied.

Serum Levels of Ferritin, Iron, and Total Iron Binding Capacity in Cerebral Venous Sinus Thrombosis

Background: Cerebral venous sinus thrombosis (CVST) is a potentially life-threatening condition with a wide range of clinical presentations, from localized headache (the most common symptom) to mental status disturbances, seizures, and coma. Objectives: The main purpose of this study was to evaluate serum levels of ferritin, iron, and total iron binding capacity (TIBC) and their possible relationship with different parameters in CVST patients. Methods: Thirty patients with a definitive diagnosis of CVST based on brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) results participated in the study. During the first 24 hours after admission, 5 cc of blood sample was collected from each patient and delivered to the laboratory to measure serum ferritin, iron, and TIBC levels. Results: Twenty-four women and six men (mean age: 42.6 ± 16.33 years) participated in the study. The mean levels of serum iron, TIBC, and ferritin were within normal ranges (99.40 ± 29.97 mg/dL, 324.50 ± 49.57 mg/dL, and 87.36 ± 88.84 ng/mL, respectively). There were no significant relationships between serum ferritin, iron, TIBC levels, oral contraceptive pills consumption, history of CVST or cerebrovascular accident (CVA), underlying diseases, and the involved sinus. Conclusions: The current study showed no possible benefits of using serum ferritin, iron, and TIBC indices in CVST patients.

Otogenic Cerebral Sinus Thrombosis in Children: A Narrative Review.

Cerebral venous thrombosis (CVT) is a rare entity that remains a diagnostic challenge due to various clinical manifestations and a wide variety of causative agents. Local infections, such as acute (AOM) or chronic otitis media, can play a role in the pathogenesis of CVT. The proximity of the tympanic cavity and temporal bone air cells to the dural venous sinuses predisposes them to secondary thrombosis. The release of inflammatory cytokines and activation of the coagulation pathway in the middle ear space in response to infection may trigger the thrombotic mechanism in venous sinuses of the central nervous system. There is no consensus in the literature concerning the treatment of otogenic cerebral venous sinus thrombosis (CVST). Both the extent of the surgery and the use of anticoagulants are disputable. The aim of the study was to provide a thorough analysis of the literature concerning CVST in patients with AOM and acute mastoiditis (AM). The current surgical and conventional treatment strategies are presented. Special attention has been attached to the predisposing factors, the extent of the surgery, and the role of anticoagulants in the treatment of septic otogenic CVST.

The Role of Plasma D-dimer As An Initial Diagnostic Biomarker of Cerebral Venous Sinus Thrombosis In A Tertiary Level Hospital, Bangladesh – Case Control Study

Background: Cerebral venous sinus thrombosis (CVST) are an uncommon cause of stroke and is often more difficult to diagnose than usual causes of stroke.A number of studies have confirmed the usefulness of Ddimer level in CVST. The aim of the current study to evaluate the correlation of plasma D-dimer levels in diagnosis of CVST. Methods: This case-control study was conducted on 50 stroke patients and 50 healthy individuals as the control group who will attend in the Department of Neurology of Sir Salimullah Medical College &amp; Mitford Hospital, Dhaka Bangladesh during one year (2021-2022) with new onset headache and presentations suggestive of CSVT will be included in the study. Every medical or surgical condition which causes an increase in D-dimer level was considered as exclusion criteria. Results: Among patient group, 28(56%) patients were females, while 22(44%) patients were males, and the mean of age was 37.7±11.8 years. Headache was the most frequent presentation that observed in 90% of the patients. The patient with focal neurological signs, papilloedema and seizures came next in 52%, 44% and 30% respectively. The average duration of the symptoms was 6.9 ±3.2 days. Overall, the mean plasma level of D-dimer in CVST patients and controls were 526.7± 97.34 ng/mL and 332.3± 53.71 ng/mL respectively (Table: 3). Independent t-test revealed a significant difference (t= 2.167, p= 0.029). According to cut-off value of the assay (400 ng/mL) there were 44 CVST patients (88%) who were positive for the test compared with 7 (14%) among controls (p&lt; 0.001). Stratification of the study population according to male revealed a wide gap between patient and control males (541.7± 114.9 ng/mL and 320.2±71.13 ng/mL respectively) with a significant difference (p= 0.017) (Table: 4). However, in females, this gap was narrower (530.4± 100.9 ng/mL in females with CVST and 349.7±92.5 ng/ mL in healthy females) but still significant (p= 0.032). The test revealed that the area under the curve (AUC) was 0.879, 95%CI=0.807-0.95, p&lt;0.001. The sensitivity and specificity of the test at cut off value of 400ng/ mL were 0.88 and 0.86 respectively, indicating a very good discrimination value. The positive and negative predictive values of D-dimer in diagnosis of CVST were 86.27 % and 87.76% respectively. Conclusion: Our study suggests that measurement of D-dimer can be a reliable tool for diagnosis of CVST, especially in patients with acute and subacute disease. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 202-203

Identifying the risk factors for intracranial herniation in patients with cerebral venous thrombosis.

Cerebral venous sinus thrombosis (CVST) is not as well understood as an ischemic stroke of arterial origin. Although the prognosis of CVST is usually good, parenchymal lesions may occur in some patients, and the development of intracranial herniation may result in death. For this reason, recognizing the risk factors for intracranial herniation and accurately determining those patients who should undergo decompressive craniectomy is important. This study aims to determine the risk factors for intracranial herniation in patients with CVST. A total of 177 patients diagnosed with CVST between 2015 and 2021 in our tertiary center were retrospectively included in this study. Of the 177 patients, 124 were female and 53 were male with mean ages of 40.65 ± 13.23 and 44.13 ± 17.09, respectively. Among those, 18 patients had developed intracranial herniation. A significant statistical relationship was observed between superior sagittal sinus thrombosis, sinus rectus thrombosis, venous collateral score, nonhemorrhagic venous infarct, presence of malignancy, small juxtacortical hemorrhage, and cortical vein thrombosis. The binary logistic regression analysis results showed that the most significant variables were the venous collateral score of 0, malignancy, and small juxtacortical hemorrhages. This study identified small juxtacortical hemorrhages, the presence of malignancy, and a venous collateral score of 0 to be independent risk factors for intracranial herniation in CVST patients. Drawing on these results, we recommend close clinical observation of CVST patients, as they may be candidates for decompressive craniectomy.

Clinical features of patients with cerebral venous sinus thrombosis at plateau areas.

Cerebral venous sinus thrombosis (CVST) is believed to be associated with high-altitude exposure and has worse clinical prognosis in plateau areas than in plain areas, although this needs to be further verified. This retrospective study aims to compare the clinical differences of patients with CVST in plateau and plain areas and further ascertain the role of high-altitude exposure in the etiology of aggravating predisposition toward CVST. Twenty-four symptomatic CVST patients occurring at plateau areas (altitude≥4000m), in corresponding with 24 CVST patients occurring at plain areas (altitude≤1000m), were recruited according to the inclusion and exclusion criteria from June 2020 to December 2021. The collected data and compared parameters include clinical features, neuroimaging findings, hematology profile, lipid profile, and coagulation profile within 24h of hospital admission, as well as the treatment method and final outcome. There were no obvious differences of demographic characteristics, including gender, age, height, and weight between patients with CVST in plateau and plain areas, as well as medical history, neuroimaging findings, treatment protocols, and clinical outcome (all p>.05). Compared to patients with CVST at plain areas, time before hospital admission was longer and heartbeat was slower in patients with CVST at plateau areas (all p<.05). More importantly, elevated red blood cells counts, hemoglobin level, and altered coagulation function were found in patients with CVST at plateau areas (all p<.05). CVST patients in plateau areas presented with altered clinical characteristics, altered coagulation function, and aggravated predisposition toward venous thromboembolism compared with CVST patients in plain areas. Future prospective studies will be needed to further elucidate the influences of a high altitude on the pathogenesis of CVST.

Cerebral venous sinus thrombosis associated with SRA-negative heparin-induced thrombocytopenia: case report

BackgroundThere are very few documented reports in literature of cerebral venous sinus thrombosis (CVST) caused by immune-mediated heparin-induced thrombocytopenia (HIT). Further, there are very few reports of false negative serotonin release assays (SRAs) when testing for immune-mediated HIT.Case presentationWe present a case of a 60- year-old male with recent unfractionated heparin administration for venous thromboembolism prophylaxis, an elevated 4T score of 5 and acute CVST in which immune-mediated HIT was suspected. The enzyme-linked immunosorbent assay (ELISA) screening assay was positive for PF4 antibodies and subsequent reflexive SRA testing was negative. However, given the clinical picture, a false-negative SRA was suspected (and eventually confirmed), prompting use of the alternative PF4-dependent p-selectin expression assay (PEA) which was confirmed to be positive. The patient was successfully managed with a bivalirudin infusion and eventually transitioned to apixaban.ConclusionIt is uncommon for immune-mediated HIT with thrombosis to manifest as CVST. Similarly, false-negative SRA is uncommon in immune-mediated HIT. Take-away lessons from our case report include considering HIT in CVST patients with an elevated 4T score and considering the entire clinical picture and degree of suspicion for HIT when interpreting negative HIT testing results. The PEA, in conjunction with the 4Ts score, may be considered as an alternate diagnostic assay for HIT.

Hem coagulase induced cerebral venous sinus thrombosis in patients with uterine fibroids surgery.

Cerebral venous sinus thrombosis (CVST) is a rare, high-risk, and easily misdiagnosed disease. Currently, there are case reports of hem coagulase-induced thrombotic events, but no reports of CVST being associated with hem coagulase. A 35-years-old woman presented to the outpatient clinic with a severe headache and sudden memory loss with intravenous hem coagulase for postoperative bleeding after uterine fibroids surgery. Abnormal neurological signs included slowed reactions, poor memory, and decreased numeracy. Magnetic resonance imaging and computed tomography scan showed multiple cerebral infarcts, and the infarct area was non-arterial. Brain magnetic resonance venography showed obstruction of the left sigmoid sinus. High-resolution magnetic resonance imaging of the left sigmoid sinus showed abnormally high signal. The patient was treated with a subcutaneous Low-Molecular-Weight Heparin Sodium injection 0.4 ml, twice a day (7 days), and oral Warfarin Sodium 3 mg, once a day, while monitoring the international normalized ratio, adjust the warfarin sodium dosage according to the international normalized ratio level. One month later, the patient had no neurological symptoms and her cognitive function returned to normal. hem coagulase may be a contributing factor to CVST in patients undergoing uterine fibroids surgery and should be administered intravenously with caution.

Clinical characteristics of cerebral venous sinus thrombosis patients with new-onset of headache

ObjectiveThis study aimed to assess the clinical characteristics of cerebral venous sinus thrombosis (CVT) patients with new-onset headache and to identify the risk factors for headache in this population.MethodsWe retrospectively reviewed the demographic and clinical data of 69 CVT patients recruited between September 2017 and September 2019. Patients were classified into two groups, the headache group and the non-headache group, according to the presence or absence of new-onset headache symptoms at admission. The following characteristics and parameters were measured and analyzed, including gender, age, amount of thromboembolic cerebral venous sinus(ATCVS), and other relevant indicators.ResultsThe incidence of headache was 75% in this cohort. The proportion of female patients in the headache group was higher than that in the non-headache group. Patients in the headache group were younger than those without headache. CVT patients of headache group showed higher lymphocyte ratio (LR), blood urea nitrogen (BUN), and intracranial pressure (ICP) compared to the non-headache group, whereas mean corpuscular volume (MCV) and levels of protein (cerebrospinal fluid, CSF) and lactic dehydrogenase (LDH) in CSF were lower in headache patients. The data also revealed younger age and the increased level of chloride ion CI-(CSF) were the risk factors for the occurrence of headache in CVT patients.ConclusionAge, LR, MCV, BUN levels, ICP, protein (CSF), and LDH (CSF) in patients with headache were significantly different from those in the non-headache group at admission. Younger age and a level of CI- (CSF) were risk factors for headache in CVT patients. These findings may provide guidance for clinical diagnosis and treatment of CVT.

Association of neutrophil to lymphocyte ratio and D-dimer with functional outcome in patients with cerebral venous sinus thrombosis

BackgroundInvestigations on the risk factors for the prognosis of cerebral venous sinus thrombosis (CVST) are limited. This study aimed to explore whether specific inflammatory factors and coagulation indictors are associated with functional outcome in patients treated for CVST.MethodsThis retrospective study included 137 patients admitted to our hospital between January 2010 and October 2021. The functional outcome was assessed with the modified Rankin Scale (mRS) score at discharge. Patients were divided into two groups, 102 patients with favorable outcomes (mRS 0-1) and 35 patients with poor outcomes (mRS 2-6). The clinical indexes were compared between two groups. Multivariable logistic regression was performed to identify the independent influencing factors for poor outcomes of CVST patients. The prognostic indicators were analyzed using the receiver operating characteristic (ROC) curve.ResultsCompared with the favorable outcome group, the incidence of impaired consciousness and brain lesion, the levels of D-dimer, RDW, neutrophil count, neutrophil to lymphocyte ratio (NLR) and red blood cell distribution width to platelet ratio (%) on admission were significantly higher in the poor outcome group, while the level of lymphocyte count was significantly lower. After multivariable logistic regression analysis, baseline D-dimer level (odds ratio (OR), 1.180; 95% confidence interval (CI), 1.019-1.366, P = 0.027) and NLR (OR, 1.903; 95%CI, 1.232-2.938, P = 0.004) were significantly associated with unfavorable outcome at discharge. The ROC curve analysis showed that the areas under the curve of D-dimer, NLR and their combined detection for predicting worse outcome were 0.719, 0.707 and 0.786, respectively.ConclusionsElevated D-dimer level and NLR on admission were associated with an increased risk of poor functional outcome in patients with CVST.

Optic Nerve Sheath Fenestration for Progressive Visual Loss in Cerebral Venous Sinus Thrombosis: A Long-Term Retrospective Observational Study.

Progressive cerebral venous sinus thrombosis (CVST)-induced visual loss remains problematic, despite decreasing overall mortality owing to early diagnosis and aggressive treatment. Optic nerve sheath fenestration (ONSF) improves or stabilizes visual function in patients with idiopathic intracranial hypertension; however, its role in CVST awaits elucidation. We evaluated the efficacy and safety of ONSF in resolving CVST-induced visual impairment based on long-term observation. This observational study included 18 patients with progressive CVST-induced visual loss, who had undergone ONSF between 2012 and 2021. Patients received maximum medical therapy, including anticoagulants and intracranial pressure (ICP)-lowering medications. The best-corrected visual acuity (BCVA), visual fields (VFs), and optic nerve head were assessed at baseline, at 1week after ONSF, and over 6months after ONSF. Activities of daily living (ADL) and National Eye Institute Visual Function Questionnaire-25 (VFQ-25) scores were assessed at final follow-up. Thirty-one ONSF-treated eyes of 18 patients were included. The mean follow-up duration was 35.6months (range 1week-8years). Two patients were lost to follow-up. Before ONSF, all patients were still experiencing progressive visual loss despite receiving adequate anticoagulation and ICP-lowering therapy. Postoperative BCVA remained stable or improved in 25/31 eyes (80.6%) 1week postoperatively and 17/28 eyes (60.7%) upon final follow-up. All papilledema resolved postoperatively. No complications were reported except for one transient postoperative diplopia. The median ADL score was 100 (range 25-100), and the mean total VFQ-25 score was 40.6 (range 9.5-87.3). This was the largest study to describe ONSF's role in CVST based on a long-term follow-up. Considering its efficacy and favorable safety, ONSF can be considered an important adjunctive approach to resolving progressive visual loss of CVST patients, on the basis of anticoagulation and ICP-lowering therapy.

Clinical Values of Coagulation Factors X, XI, and XII in Cerebral Venous Sinus Thrombosis During Perinatal State.

Cerebral venous sinus thrombosis (CVST) has become a rare but potentially life-threatening condition in perinatal women. Early and rapid identification of CVST in pregnant women is a challenge for frontline clinical workers. In this study, 40 perinatal patients with CVST in our hospital were included in the five-year period, and 120 normal perinatal pregnant women in the obstetrics and gynecology department of our hospital were randomly enrolled in the five-year period as the control group, including 60 cases in pregnancy and puerperium. 5 mL of fasting venous blood was collected from puerperal CVST patients in the acute phase of onset (within 72 h of onset) and the recovery phase (fourth week of treatment). In the control group, 5 mL of fasting venous blood was collected. Coagulation factors X, XI, and XII, plasma D-Dimer were analyzed and compared. Coagulation factors X, XI, and XII in plasma of CVST patients were significantly increased compared with controls. Plasma coagulation factors X, XI, and XII and their combined detection (Union Model = 0.056 * FX: C + 0.046 * FXI: C + 0.081 * FXII: C) have diagnostic values for perinatal CVST. Plasma coagulation factors X, XI, and XII were significantly positively correlated with plasma D-dimer levels in perinatal CVST patients. Plasma coagulation factors X, XI, and XII have diagnostic values for perinatal CVST.