Cortical Venous Sinus Thrombosis Research Articles

Brush Sign in Cortical Venous Sinus Thrombosis

Brush Sign in Cortical Venous Sinus Thrombosis

ANTICOAGULANT DRUG INDUCED SUPRA THERAPEUTIC INR AND ITS MANAGEMENT

This paper has the management of Drug Induced Supra therapeutic INR and a case presentation of 33-year-old Male patient who was on oral anticoagulant (Vitamin K antagonist-VKA) and antiplatelet therapy presented with supra-therapeutic international normalized ratio (INR) with history of Single episode of blood stained Sputum. The patient is known case of posterior circulation stroke with left ventricular clot, Cortical venous sinus thrombosis with left parietal hematoma and secondary seizure, ischemic heart disease (IHD) status post Percutaneous Transluminal Coronary Angioplasty (PTCA) to LAD with left ventricular ejection fraction (LVEF) - 30% and hyper-homocysteinemia. The patient presented with history of single episode of blood stain sputum and with no other complaints. His routine blood investigation revealed INR of 9.50 hence the patient was admitted and treated accordingly. Patients INR returned to normal after appropriate medical management. Patient was discharged with a titrated dose, advised on treatment, education and adherence counselling.

Neurological Predictors of Functional Outcome in Cortical Venous Sinus Thrombosis.

Objectives Cerebral venous sinus thrombosis (CVST) has a wide clinical spectrum. Despite favorable prognosis, identifying CVST patients with a possible poor functional outcome can be challenging. This study aims to establish the neurological predictors of outcome in CVST. Materials and Methods We analyzed 70 patients of CVST and categorized them into three groups: Group I with isolated intracranial hypertension; Group II—focal syndrome of neurological deficit; Group III—subacute encephalopathy. Demographic, disease characteristics, and radiological parameters were also analyzed for prediction of hospital course. Functional outcome was assessed by modified Rankin scale (mRS) dichotomized as good (mRS: 0–2) or poor outcome (mRS ≥ 3). Statistical Analysis Univariate and multivariate logistic regression analyses were performed to find out the independent effects of prognostic factors to be used for outcome prediction. Results The mean age was 36.71 ± 14.9 years with 40 (68.8%) males. Most common presenting complaints were headache 35 (50%), hemiparesis 14 (20%), and seizures 12 (17.4%). Group I included 44 (62.9%), group II 17 (24.3%) and group III 12 (12.9%) patients. During hospitalization 28 (40%) patients needed intensive care unit (ICU) care, among them 7 (10%) required ventilation. There were eight times more chances of ICU care (odds ratio [OR]: 7.4; 2.5–24.4) and 23 times more need for ventilation (OR: 23; 2.5–88.9) whenever patients were in group II or III. Good outcome (mRS < 2) was noted in 52 (74.2%) patients. Headache was associated with good functional outcome, whereas hemiparesis with poor outcome. Neurological grouping was the independent predictor of functional outcome; patients with focal neurological deficit (group II) were 20 times more likely to have dependent life at the time of discharge ( p < 0.05) with the mortality rate of 2.9%. Conclusions Neurological grouping is a practical tool for prediction of function outcomes. Early anticipation of prognosis helps in decision-making in the clinical practice.

Vaccine-induced thrombotic thrombocytopenia (VITT): first report from India

BackgroundVaccine-induced thrombotic thrombocytopenia (VITT) is a rare but devastating adverse event following adenoviral vector-based vaccinations for COVID-19, resulting in thrombosis, especially of the cerebral and splanchnic vasculature. Despite the progress in laboratory techniques for early diagnosis, VITT remains a clinical diagnosis supplemented by coagulation studies. We report on VITT for the first time from India.CaseWe describe cortical venous sinus thrombosis and intracerebral bleed associated with severe thrombocytopenia in two young men who had no other contributory cause besides a recent ChAdOx1 nCoV-19 vaccination. The diagnosis was supported with PF-4 antibodies in one patient. The second patient’s test could not be processed to technical limitations. Both patients were treated with IVIG at 1 g/kg for 2 days and anticoagulation (Apixaban). One patient fully recovered with no residual deficits, and the other is under treatment and recovering.ConclusionVITT can cause devastating fatality and morbidity in otherwise healthy patients via potential immune-mediated effects. Clinicians should have a high suspicion index and treat VITT in the appropriate setting even if the PF-4 antibody testing by ELISA is unavailable or delayed. Though counterintuitive, clinicians must not delay the administration of non-heparin anticoagulation, IVIG and restrict platelet transfusion even in the presence of intracerebral haemorrhage.

Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants.

For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.

Cerebral Venous Thrombosis in Acute Lymphoblastic Leukemia with Severe COVID-19: a Case Report.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has brought an unprecedented upheaval in our health-care systems. Amongst the many challenges posed by the disease, increased risk of thromboembolism has presented a distinct new front for increased mortality and morbidity. While there are multiple documented evidences for the same, the exact mechanism, knowledge of groups at-risk, and mitigation strategies are evolving. We present a case of a young individual who was diagnosed with acute lymphoblastic leukemia (ALL), was started on appropriate chemotherapy, and subsequently developed severe COVID-19 pneumonia. He was treated for COVID-19 pneumonia and recovered from the illness. However, his recovery from COVID-19 was further complicated by cortical venous sinus thrombosis (CVT). Contrast enhanced magnetic resonance imaging (CEMRI) brain and magnetic resonance venography (MRV) revealed the diagnosis of CVT with hemorrhagic parenchymal changes. He was managed with therapeutic anticoagulation and cerebral decongestants and was subsequently shifted to oral anticoagulant therapy. While the case was managed at a tertiary care setting, it opened up the question of identifying the high-risk groups and to formulate guidelines for extended thromboprophylaxis in these patients.

Abstract P700: Stroke in Lupus Spectrum Disorder: A Single-Center Case Series in the Kentucky Appalachian Region

Background: Lupus spectrum disorders (LSDs) encompass systemic lupus erythematosus (SLE), lupus nephritis, antiphospholipid syndrome (APS), and mixed connective tissue disease. Neuro-vascular disorders associated with LSDs include headache, transient ischemic attack, vascular cognitive impairment, immune-mediated cerebral vasculitis, thrombo-embolic stroke, cortical venous sinus thrombosis (CVST), and intracranial hemorrhage. We conducted a retrospective survey of neuro-vascular complications of LSDs in a university hospital-based stroke service within Kentucky Appalachia. Methods: Consecutive hospital admissions and consultations were retrospectively surveyed from January 2012 to January 2017. Inpatient medical records were reviewed to accumulate laboratory data and neuro-imaging studies. Diagnoses of SLE and other LSDs conformed to Systemic Lupus International Collaborating Clinics criteria. Results: During this 5-year survey, 10,953 cases of ischemic or hemorrhagic stroke were admitted or consulted and 75 patients (0.7%) met criteria for LSD. Female:male ratio favored women over men (4:1) and the median age was 48 years (range 22 - 87). The most common LSD was SLE and/or APS (n = 61; 81.3% total). The most frequent neuro-vascular complication was acute thrombo-embolic stroke (n = 30; 40%). Among 42 (56%) ischemic stroke patients, 17 had multifocal infarcts, 11 had isolated cortical strokes, and 7 had lacunes in the subcortical structures or brainstem. The majority of ischemic stroke patients (n = 48; 64%) did well and were ultimately discharged to home; 19 (25.3%) were re-admitted with recurrent stroke. Four patients had vasculitis (5.3%) and three had moyamoya syndrome (4%). Intracranial hemorrhage affected four patients (5.3%); hemorrhagic cerebral micro-angiopathy occurred in three (4%). Two patients had CVST (2.7%). Conclusion: Neuro-vascular complications of LSDs are heterogeneous and affect youthful patients with female preponderance. The large proportion of thrombo-embolic stroke in our population may be attributed to immune-mediated arterial coagulopathy or cardiac structural disease. Most patients with LSD complicated by ischemic stroke had good outcome, but there was high risk of readmission due to recurrence.

Practice Changing Articles in Neuroanesthesiology and Neurocritical Care in Recent Years: A Literature Review.

Neuroanesthesiology and neurocritical care are constantly evolving branches of clinical neuroscience, and patient management is often influenced by literature such as randomized controlled trials, systematic reviews, and meta-analyses. Many controversies still exist in the management of neurologically injured patients, and most research in this field does not translate into significant changes in clinical practice. This review aims to discuss studies of clinical importance published in preeminent journals over the time period 2017-2020, which may have the potential to influence our current management protocols. In this review, key articles have been selected to represent neuroemergencies where recent evidence may prompt changes in practice. In preparing this article, contents of prominent journals between 2017 and 2020 were reviewed, and relevant articles were also identified from abstraction services. Areas chosen for consideration are high-quality trials researching the management of pathologies such as epilepsy, traumatic brain injury and acute ischemic stroke, cortical venous sinus thrombosis, as well as hemorrhagic stroke. For each subject, a brief review of the article is followed by "take home" points. We have attempted to perform a review of some of the highest impact medical journals from 2017 till 2020 and have summarized articles with the potential to change clinical practices for readers so that management protocols for acute neuroemergencies to ensure good outcomes may be formulated.

Primary antiphospholipid antibody syndrome presenting with cortical venous sinus thrombosis

Primary antiphospholipid antibody syndrome presenting with cortical venous sinus thrombosis

Venous encephalopathy

Dural arteriovenous fistulae (DAVF) accounts for 10-15% of rare acquired intracranial vascular malformations which can present with a wide range of symptoms but DAVF presenting with onset of encephalopathy and cognitive decline as non-hemorrhagic neurological deficits has rarely been reported. A 44-year-old gentleman complained of headache followed by episodes of confusional behavior presenting to the emergency with two episodes of GTC seizures. He had history of cortical superficial venous sinus thrombosis and was treated with anticoagulants for one year. On admission his vitals were stable, GCS-6, no meningeal signs but decerebrate posturing with bilateral extensor planter response. CT venography reported non-opacification of superior sagittal, straight, left transverse and bilateral sigmoid sinuses (Fig1&2). Extensive collateral venous channels were seen in brain, parenchyma, basal cisterns and along the convexities. Few types of collateral were opacified in the arterial phase though intracranial arteries were normal. DSA revealed multiple DAVF (>5) fed by various arteries (Fig3&4). Endovascular embolization and recanalization was attempted but was not successful and patient was started on subcutaneous heparin. DAVF is referred to the abnormal communication between the intracranial artery and dural venous sinuses. DAVF can present with a myriad of clinical features so it is frequently misdiagnosed. The two unique features in this patient of DAVF were the presence of multiple sinuses and rare clinical presentation as venous encephalopathy. We assume that in this case the transformation in symptomatology from encephalopathy to seizures was heralded by increased arterial blood supply due to multiple sites of the fistulae.

Cerebral Venous Thrombosis and Acute Pulmonary Embolism following Varicella Infection.

Varicella infection is caused by varicella-zoster virus (VZV) and commonly presents as a self-limiting skin manifestation in children. VZV also causes cerebral arterial vasculopathy and antibody-mediated hypercoagulable states leading to thrombotic complications in children, although there are very few such reports in adults. Postulated causal factors include vasculitis, direct endothelial damage, or acquired protein S deficiency secondary to molecular mimicry. These induced autoantibodies to protein S could lead to acquired protein S deficiency and produce a hypercoagulable state causing venous sinus thrombosis. Here we report the case of a 26-year-old man who presented with cortical venous sinus thrombosis and acute pulmonary embolism following varicella infection. Both conditions responded to anticoagulation treatment.LEARNING POINTSVaricella infection caused by varicella-zoster virus (VZV) can rarely present with thrombotic complications after a period of latency.Postulated causal factors include vasculitis, direct endothelial damage, and acquired protein S deficiency secondary to molecular mimicry.The prognosis of post-varicella thrombosis is good, but a prothrombotic screen after recovery to diagnose hereditary prothrombotic states is advisable.

Diagnosis and Management of Cerebral Venous Diseases in Neuro-Ophthalmology: Ongoing Controversies.

Diseases of the cerebral venous system frequently lead to neuro-ophthalmic complications. Cortical venous sinus thrombosis and dural arteriovenous fistulas may be complicated by elevation of intracranial pressure, with secondary papilledema or abducens palsies. There is increasing recognition that stenosis at the transverse sinus-sigmoid sinus junction plays a role in the pathophysiology of idiopathic intracranial hypertension and offers a new avenue of treatment in patients who fail medical therapy. Diseases of the cavernous sinus manifest with their own set of neuro-ophthalmic symptoms, reflecting the presence of all 3 ocular motor nerves and the oculosympathetic fibers within its walls, along with its role as the primary drainage pool of the globe and orbit. Numerous questions and controversies remain regarding the diagnosis and optimal treatment of cerebral venous disease, including the role of venous stenting in idiopathic intracranial hypertension, the role of anticoagulation in cavernous sinus thrombosis, and the risks and benefits of embolization of mild indirect cavernous carotid fistulas.

Niemann Pick Disease (NPD) presenting as cortical venous sinus thrombosis: a rare presentation (P1.322)

Niemann Pick Disease (NPD) presenting as cortical venous sinus thrombosis: a rare presentation (P1.322)

Decompressive Hemicraniectomy Versus Medical Management in Cerebral Venous Thrombosis with Signs of Raised Intracranial Pressure

Background: Mass effect is the major cause of death in cortical venous sinus thrombosis and there is no clear cut the role of decompressive hemicraniectomy. Aims: To study the outcome of patients with large venous infarct and acutely increased intracranial pressure subjected to either conservative treatment or decompressive surgery. Materials & Methods: 20 consecutive patients admitted with moderate to large venous infarct were examined for features of raised intracranial pressure (ICP) . Cranial CT and or MRI and CT venogram or MR venogram and or cerebral DSA were examined for site of Sino venous occlusion. Results: There were 20 patients with 10 each in conservatively and surgically treated group. Cranial CT/MRI head revealed large venous infarct with midline shift and mass effect in all patients. Overall 15 of 16 survivors had good outcome at 3 months without any significant residual deficit irrespective of mode of treatment used. There is no statistical difference between medical and surgical groups in mRS 1 month, 3 months and death with p value 0.651, 0.185 and 0.474 respectively. Conclusion: Patient with large venous infarct with signs of raised intracranial pressure carries good overall outcome with timely care irrespective of conservative or surgical management.

Study of neurological manifestations in patients of falciparum malaria

Background: Several types of neurological manifestations are associated with falciparum malaria. Cerebral malaria is one of the most dreaded complications. A significant number of survivors are left with disabling neurological sequelae, most of which are self-limiting. Neurological involvement is more frequent with falciparum malaria because of its unique characteristics leading to micro-vascular involvement.Methods: Present study was conducted at department of General Medicine, VIMSAR, Burla (Odisha). This observational study included in total 110 patients, who were confirmed cases of falciparum malaria. Clinical profile including detailed neurological examination with relevant investigations was done. Spectrum of neuropsychiatric manifestations were observed.Results: Out of 110 patients male and female ratio was 1:1 (M 55 and F 55). The mean age of presentation in male was 36.09 + 14.85 yrs. and in female was 31.85 + 14.00 yrs. The major presenting symptoms were fever, headache, vomiting, altered sensorium, altered behaviour and convulsions in their decreasing order of frequency. On neurological evaluation, diminished level of consciousness was found in 56.4% cases. 14% cases had GCS score ≤ 7 and 63% had GCS score ≥ 11. Convulsion was found in 31% cases, cranial neuropathy in 10.9%, cerebellar dysfunction in 12.7%, neck rigidity in 22.7%, speech abnormality in 3.6%, peripheral neuropathy in 8.2%, fundoscopic changes suggestive of retinal involvement in 44.5% cases. Atypical manifestation like; Intracerebral haemorrhage, subarachnoid haemorrhage, cortical venous sinus thrombosis were also found in few cases. 32.72% patients had Neuropsychiatric manifestations at discharge in the form of focal neurological deficits, psychosis, depression, speech disorder, memory loss, cerebellar abnormality &amp; peripheral neuropathy.Conclusions: Neurological manifestations in falciparum malaria patients are common and encompass a wide spectrum of clinical presentation. In an endemic area, falciparum malaria should be kept as a differential diagnosis in patients presenting with atypical neurological manifestations.

The clinical profile of cortical venous sinus thrombosis at a tertiary referral hospital in India

The clinical profile of cortical venous sinus thrombosis at a tertiary referral hospital in India

Convulsions in pregnancy-not always eclampsia role of neuro-imaging in diagnostic dilemma

Background: Convulsions in pregnancy is always considered and treated as Eclampsia unless otherwise proved. Eclampsia is associated with increased risk of maternal death varying from 1.8 % to 14 % in developed countries. Despite availability of Intensive care units and improved antenatal care, some women still die from Eclampsia. Cerebral complications are the major cause of death in eclampsia patients. Hypercoagulopathy of pregnancy is a high risk factor for these patients in respect to development of cerebro vascular thrombosis and ischaemic strokes. Eclampsia patients who are refractory to the routine treatment have been found to have various Central Nervous System pathological conditions amenable to the medical treatment.Objective: To study the neuro pathophysiology behind a seizure in pregnancy and to reduce the morbidity associated with it. To study the role of neuro-imaging in patients with convulsions in pregnancy not responding to treatment with magnesium sulphate (MgSo4).Methods: It was a prospective study design which included 50 antenatal mothers. All patients were admitted in the eclampsia room with history of convulsions and all of them were put on MgSo4 therapy and Antihyperertensives. The patients who were refractory to the treatment such as having recurrent convulsions despite therapy with MgSo4 were selected for neuro- imaging with Computed Tomography scan. Neuro-imaging was done using Phillips Tomoscan CT scanner where slices of 10-mm thickness were taken through the entire brain in the trans-axial plane. Abdomen shielding was done with lead shield to prevent radiation hazard in the antenatal period.The results were documented and analysed using appropriate statistical method.Results: The CT scanning report revealed: Cerebral oedema (30/50), Encephalopathy (10/50), Intra Cranial Haemorrhage (02/50) Cerebral infarction (01/50), Cortical venous sinus thrombosis (01/50), Tuberculomas (01/50), Neurocysticercosis (01/50) and Hydrocephalus (01/50). Three patients out of 50 had normal CT scan report. Conclusion: Patients with convulsions in pregnancy who were refractory to the treatment with MgSo4 and Antihypertensives have been found to have very significant and morbid CNS pathological conditions. Neuro imaging in these patients have done a pivotal role in identifying the abnormality and rectifying it with medical means which had definitely improved patients conditions and have reduced morbidity and mortality. Health Renaissance 2015;13 (3): 144-151

Headache in cerebral venous sinus thrombosis revisited: Exploring the role of vascular congestion and cortical vein thrombosis.

Background and purpose Headache constitutes the most common symptom of cerebral venous sinus thrombosis (CVST), but its pathophysiology is unclear. We sought to investigate the potential mechanism for headache genesis in patients with CVST based on its imaging correlates. Methods A subgroup of CVST patients having headache as the predominant symptom without significant parenchymal lesion were retrospectively analysed for imaging features of vascular congestion (VC), in addition to cortical venous (CVT) and dural sinus thrombosis (DST) on magnetic resonance imaging. Headache and imaging patterns were classified into lateralized and nonlateralized phenotypes and their correlation was sought. Results Among 41 patients included, 28 had lateralized headache (LH group; 15 males; mean age 32.25 ± 9.19 years) while 13 had nonlateralized headache (non-LH group; six males; mean age 27.15 ± 8.65 years). Headache characteristics in both the groups were quite similar. Imaging showed VC in 39 of 41 and CVT among 35 of 41 patients, which were lateralized in 23 of 39 and 18 of 35 patients, respectively. Nearly all lateralized imaging patterns (21 of 23 for VC and 17 of 18 for CVT) occurred in the LH group and ipsilateral to (concordant) headache, while the non-LH group showed lateralized VC and CVT in only two and one patient respectively. Sinus thrombosis was lateralized in both groups irrespective of headache laterality. Whole cohort headache-imaging laterality (including patients with nonlateralized headache and nonlateralized imaging) concordance was 31 of 39, 24 of 35 and 18 of 41 for vascular congestion, cortical vein thrombosis and dural sinus thrombosis respectively. Conclusion Co-localization of VC and CVT with overlying headache might provide a possible explanation of headache and its laterality in patients with CVST.

Cranial nerve palsy following central neuraxial block in obstetrics – a review of the literature and analysis of 43 case reports

BackgroundCranial nerve palsy is a rarely reported complication of central neuraxial block in obstetrics. The aetiology is diverse and includes both decreased and increased intracranial pressure. MethodsMedline, CINAHL, and EMBASE databases were searched to identify cases of cranial nerve palsy following obstetric central neuraxial block. Possible aetiology, clinical symptoms and signs, treatment, and time to resolution were assessed. ResultsForty-one articles containing 43 case reports of cranial nerve palsy following obstetric central neuraxial block were identified. Four cranial nerve palsies were bilateral; the remainder being unilateral. The cranial nerves most commonly affected were the abducens (17 case reports) and facial (12 case reports) nerves. Epidural block was implicated in 25 cases. Classical post-dural puncture headache preceded cranial nerve palsy in 27 cases. Subdural haematomas were reported in six cases and cortical venous or transverse sinus thrombosis in one case. Epidural blood patch was administered for treatment of cranial nerve palsy in 17 cases. Thirty-five patients had complete resolution of symptoms but in eight the cranial nerve palsy was permanent. No case reports of olfactory, oculomotor, glossopharyngeal, accessory or hypoglossal nerve palsy were identified. ConclusionIntracranial hypotension is the most common aetiology of cranial nerve palsy after central neuraxial block in obstetrics. Neuroimaging is recommended in every case, to exclude other neurological causes. Epidural blood patch was the most utilised treatment for post-dural puncture cranial nerve palsy, but outcomes were variable. The majority of cranial nerve palsies resolved over the subsequent weeks and months.

Central Nervous System Vasculopathy In Varicella Zoster Virus Infection

Varicella zoster virus is an exclusively human double-stranded DNA virus that is the causative factor for two ubiquitous conditions: varicella in children and zoster in adults. Both conditions are associated with neurological complications. Centripetal trans-axonal spread via cranial nerve ganglia appears to afford entry into the central nervous system. There is increasing evidence of varicella zoster virus playing a role in the development of giant cell arteritis. First associated with transient ischemic attacks and ischemic strokes, vasculopathy secondary to varicella zoster virus infections has now been associated with aneurysms that may or may not lead to subarachnoid hemorrhage, multifocal vasculitis, arterial dissection, dolicoectasia, cortical venous sinus thrombosis, ischemic cranial neuropathies and spinal cord infarction. Prior knowledge of the myriad clinical manifestations helps in early diagnosis and treatment of the complications.