Diagnosis Of Cerebral Venous Sinus Thrombosis Research Articles

Abstract WP216: "BEAST" at the University of Virginia: Demographic and Phenotypic Data of Patients Contributing to a Biorepository to Establish the Etiology of Sinovenous Thrombosis

Introduction: Cerebral venous sinus thrombosis (CVST) occurs in 3-4 per 1 million individuals per year, accounting for approximately 1% of all strokes. Multiple etiologic risk factors for CVST have been identified, with known inherited thrombophilias accounting for 22% of cases. In 15% of cases, no known risk factor is identified. Studying the genetics of CVST holds the potential to identify at-risk groups, determine disease severity and prognosis, and consider novel therapies. BEAST is an international effort to identify genetic determinants of CVST, from which a recent discovery genome-wide association study (GWAS) identified 2 new associated loci. Methods: We are enrolling patients at least 18 years of age with a diagnosis of CVST who are willing to provide informed consent and a biospecimen to a central DNA repository. Patients are identified prospectively in clinical practice, and retrospectively using the Univ of Virginia clinical data repository. Results: Since 2012, twenty-eight patients have been enrolled. Demographic and phenotypic data are presented in the Table. Patients range in age from 19 to 65 years, with a mean of 40.5 (SD 14). Headache was the most common presenting symptom, occurring in 60%, followed by seizure (25%), mental status disturbance (21%), aphasia (11%) and mono- or hemiparesis (7%). Imaging revealed focal cerebral edema and/or venous infarction in 7 patients (25%) and hemorrhage in 5 patients (18%); no arteriovenous fistulae were identified. Acute treatments included intravenous or low molecular weight heparin (25/28, 89%) and anti-epileptic medications (7/28, 25%); three patients underwent local thrombolysis or endovascular intervention (11%). Conclusion: Understanding the association between phenotype and genetic determinants of CVST has the potential to advance the diagnosis and management of this challenging entity. Enrollment in BEAST continues and a replication cohort GWAS is anticipated in the near future.

Cerebral Venous Sinus Thrombosis Presenting Feature of Systemic Lupus Erythematosus

CVST (cerebral venous sinus thrombosis) may sometimes be associated with autoimmune disorders that require specific treatment. The clinical and magnetic resonance imaging (MRI) findings of systemic lupus erythematosus (SLE) patients with CVST are presented and contrasted with CVST without SLE. Consecutive patients with CVST admitted in neurology service during 2012-2016 were included. The diagnosis of CVST was confirmed by MR venography or digital subtraction angiography. SLE was diagnosed according to American College of Rheumatology criteria. The clinical and MRI findings of CVST with SLE and those without SLE were compared. Forty-three consecutive patients with CVST were included during the study period, 3 of whom had SLE .Their age ranged between 20 and 35 years and all were females. The clinical markers of SLE were present in all and included oral ulceration in 3 patients, serositis in 2 patients, and arthritis and psychosis in 1 patient. The SLE patients did not have antiphospholipid antibodies or lupus anticoagulant. The manifestation of CVST in SLE was similar to the other patients with CVST. The CVST in SLE required long-term anticoagulation and immunosuppression with cyclophosphamide pulse in 1 patient and oral prednisolone in 2 patients. The outcome was good, partial, and poor in 1 patient each. CVST may be the presenting feature of SLE, but these patients often have clinical clues to SLE. These patients need prolonged anticoagulation and immunosuppression.

RATE, Clinical Presentations and Maternal Outcome of Cerebral Venous Sinus Thrombosis in Pregnancy at Omdurman Maternity Hospital Khartoum, Sudan

Introduction: Cerebral venous sinus thrombosis (CVST) is a relatively rare cerebrovascular disease. The clinical presentation is highly variable and diagnosis of CVST relies presence of thrombus by neuroimaging modality. CVST results in maternal mortality. Objective: The aim of this study is to identify rate, clinical presentations and maternal outcomes of cerebral venous sinus thrombosis at Omdurman Maternity Hospital, Khartoum, Sudan. Methodology: Its hospital based study for 42 cases diagnosed with CVST; the data are managed and analyzed using Statistical Package of Social Sciences (SPSS) version 17. Results: CVST rate 0.25=2.5/1000. Half of the patients are primiparous. Headache is the main presenting symptom 90.5%, papilledema (66.7%), convulsions (21.4 %), coma (9.5%), neurological deficits (9.5%) and abnormal behavior (7.1%). Overlapping of the symptoms is reported. CVST risk factors are oral contraceptive pills history (26.2%), Diabetes Mellitus (11.9%), Pregnancy Induced Hypertension (9.5%) and deep venous thrombosis (9.5%). 18 patients (42.9%) reported no relevant history or apparent risk factor. (71.4%) recovered with no disability, case disability rate is 16.7%, case fatality rate is 11.9% with high statistical significant in patients less than 20 years and those between 26 and 30 years (P=0.023). It was also higher with PIH (P=0.013), OCP (P=0.004) and cerebral hemorrhages (P=0.043). Conclusion: CVST reported high at OMH and most of them are primiparous. CVST can happen independently, CVST contributes in maternal mortality. Neuroimaging modalities improve CVST diagnosis.

Cerebral venous sinus thrombosis: A diagnostic challenge in a rare presentation

Cerebral venous sinus thrombosis (CVST) is an uncommon, life-threatening condition with a variable clinical presentation that makes it a challenge of diagnosis. A 39-year-old male patient presented to the hospital with complete loss of conscious and admitted to Medical Intensive Care Unit for investigation without any obvious history that was difficult for diagnosis. In this case, the patient presented with coma that is a rare presentation of CVST with no obvious clinical history and he was male patient that means he is free of all gender-specific risk factors of CVST. The brain computed tomography (CT) scan showed hypodense lesion in the left upper parietal region with no hemorrhage. The lesion was low-signal intensity (SI) on T1WIs and high SI on T2WIs and restricted on diffusion-weighted images like arterial infarctions, but magnetic resonance angiography (MRA) was normal that excluded arterial infarction. Gadolinium-enhanced MR venography (MRV) showed the filling defect of CVST. CVST can be present by a mysterious clinical presentation that makes it as a challenge of diagnosis even by medical imaging by CT and MR imaging (MRI). A combination of MRI and MRV is the best, noninvasive, and nonionizing imaging modality for the diagnosis of CVST.

Clinical characteristics and outcome of cerebral venous sinus thrombosis: A 4-year Hospital-based study from 2008 to 2011

Background and Objective: Cerebral venous sinus thrombosis (CVST) is associated with serious morbidity and mortality. This study aimed to analyze the characteristics of patients with CVST, clinical features, and predisposing factors of CVST in a series of 43 patients. Subjects and Methods: We conducted a retrospective study including 43 patients with confirmed diagnosis of CVST, admitted at Hamad Hospital, Doha, Qatar, between January 1, 2008, and December 30, 2011. Results: We identified 43 patients with CVST, the mean age of the patients was 34.3 ± 12.3 years (range: 17–82 years). There were 29/43 (67.4%) males and 14/43 (32.6%) females. The most frequent predisposing factor of CVST was local infection in 13/43 (30.2%), the mean duration of symptoms before presentation was 7.7 ± 9.5 days (range: 1–42 days), and the most common presenting symptom was headache found in 41 (95.3%) patients with the superior sagittal sinus being involved most frequently in 36 (83.7%) patients. The case fatality rate was 4.6%. Conclusion: In our hospital, CVST affects males more than females, with infection being the main predisposing factor and a mortality of 4.6%. Further prospective studies are needed to explain the predominance of infection as a predisposing factor.

Non-contrast computed tomography in the diagnosis of cerebral venous sinus thrombosis.

BackgroundThe aim of the study was to investigate the sensitivity and specificity of non-contrast computed tomography (NCCT) in the diagnosis of cerebral venous sinus thrombosis (CVST).Methods. Screening our neurological department database, we identified 53 patients who were admitted to neurological emergency department with clinical signs of CVST. Two independent observers assessed the NCCT scans for the presence of CVST. CT venography and/or MR venography were used as a reference standard. Interobserver agreement between the two readers was assessed using Kappa statistic. Attenuation inside the cerebral venous sinuses was measured and compared between the patient and the control group.ResultsCVST was confirmed in 13 patients. Sensitivity and specificity of NCCT for overall presence of CVST were 100% and 83%, respectively, with Kappa value of 0.72 (a good agreement between observers). The attenuation values between CVST patients and control group were significantly different (73.4 ± 14.12 HU vs. 58.1 ± 7.58 HU; p = 0.000). The ROC analysis showed an area under the curve (AUC) of 0.916 (95% CI, 0.827 – 1.00) and an optimal cutoff value of 64 HU, leading to a sensitivity of 85% and specificity of 87%.ConclusionsNCCT as a first-line investigation has a high value for diagnosis of CVST in the emergency setting. The additional measurement of the sinus attenuation may improve the diagnostic value of the examination.

Cerebral Venous Sinus Thrombosis From a Tertiary Care Teaching Hospital in India.

The prognosis of cerebral venous sinus thrombosis (CVST) may be dependent on underlying causes and magnetic resonance imaging findings. We report the clinical, laboratory, and radiologic spectrum, and outcome of consecutive patients with CVST. Consecutive patients with CVST over the last 15 years were subjected to detailed history, clinical examination, and laboratory tests as per fixed protocol. The diagnosis of CVST was based on MR venography. The magnetic resonance imaging findings and the sinuses involved were noted. The patients were treated with low-molecular-weight heparin or unfractionated heparin for 14 days, followed by oral anticoagulation. Hospital mortality and 3-month outcome (good or poor) were recorded and correlated with various clinical and laboratory parameters. There were 86 patients whose median age was 30 (6 to 76) years; 47 of them were females. Headache was present in 91.9%, vomiting in 68.6%, focal weakness in 53.5%, seizure in 51.2%, and altered sensorium in 53.5%. Female-specific etiology was present in 34%, prothrombotic condition in 62.8%, infections in 19.8%, and malignancy in 2.8%; no cause could be established in 25.6% of patients. Hyperhomocystinemia was present in 45.9% of patients. Five patients died in the unfractionated heparin group. At 3 months, 77 patients were followed up, of whom 68 had complete, 3 had partial, and 6 had poor recovery. The 3-month outcome was related to Glasgow Coma Scale score and type of heparin used. In our study multiple prothrombotic conditions were common, and low-molecular-weight heparin reduces mortality and results in good outcome.

Clinical features, risk factors, and outcome of cerebral venous thrombosis in Tehran, Iran.

Introduction:Despite increasing the use of magnetic resonance imaging (MRI), cerebral venous sinus thrombosis (CVST) has remained an under-diagnosed condition. In this study, characteristics and frequency of various risk factors of CVST patients in a tertiary referral hospital were closely assessed.Methods:Patients with an unequivocal diagnosis of CVST confirmed by MRI and magnetic resonance venography during 6 years of the study were included. All data from the onset of symptoms regarding clinical signs and symptoms, hospital admission, seasonal distribution, medical and drug history, thrombophilic profile, D-dimer, neuroimaging, cerebrospinal fluid findings, mortality, and outcome were collected and closely analyzed.Result:A total of 53 patients with female to male ratio of 3.07 and mean age of 33.7 years were included in the study. Headache and papilledema were the most frequent clinical features (44 and 36 patients, respectively). An underlying disease (diagnosed previously or after admission) was the most common identified risk factor for CVST in both females and males (21 patients). A total of 15 women used the oral contraceptive pill (OCP) where 12 of them had simultaneously other predisposing factors. Overall, 19 patients (36%) had more than one contributing factor. D-dimer had a sensitivity of 71.4% in CVST patients. The mortality of patients in this study was 3.7% (n = 2). Focal neurologic deficit and multicranial nerve palsy were associated with poor outcome which defined as death, recurrence, and massive intracranial hemorrhage due to anticoagulation (P = 0.050 and 0.004, respectively).Conclusion:Unlike most of the CVST studies in which OCP was the main factor; in this study, an underlying disease was the most identified cause. Considering the high probability of multiple risk factors in CVST that was shown by this study, appropriate work up should be noted to uncover them.

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.

Clinical characteristics of cerebral venous sinus thrombosis.

Objectives:To investigate the risk factors, clinical presentation, neuroimaging features, treatment, and prognosis of patients with cerebral venous sinus thrombosis (CVST).Methods:We retrospectively analyzed the data of 19 patients with a diagnosis of CVST admitted to Beijing Chao-Yang Hospital affiliated to Capital Medical University, Beijing, China between January 2010 and December 2013.Results:There were 9 men and 10 women (age range: 27-75 years). Headache (84.2%) and focal signs (57.9%) were the 2 most common symptoms. Direct evidence of thrombosis was found on CT in 42.1%, and on MRI in 52.6%. Two or more sinuses were involved in 78.9% of cases, in which the transverse sinus plus sigmoid sinus were the most commonly involved combination. All patients received anticoagulant therapy. Most patients (84.2%) had no neurological sequelae at discharge, and only 3 patients (15.8%) recovered with sequelae.Conclusion:Our study provides detailed information on the clinical manifestations, neuroimages, management, outcome, and risk factors of the patients with CVST.

Cerebral venous sinus thrombosis concomitant with leptomeningeal carcinomatosis, in a patient with epidermal growth factor receptor-mutated lung cancer.

A 64-year-old woman presented with dizziness, after two weeks of experiencing symptoms. Chest computed tomography revealed a peripheral nodule in her left upper lobe, and brain magnetic resonance imaging (MRI) demonstrated the presence of multiple brain masses. The patient underwent whole-brain radiotherapy based on a tentative diagnosis of lung cancer with multiple brain metastases. The diagnosis was confirmed by endobronchial biopsy as T4N3M1b, stage IV lung adenocarcinoma with an epidermal growth factor receptor mutation. On the 31st day of hospitalization, the patient developed severe headache. Subsequent magnetic resonance venography revealed defects in the superior sagittal, right sigmoid, and right transverse venous sinuses and the right internal jugular vein. Anticoagulation therapy with unfractionated heparin and warfarin was immediately administered following diagnosis of cerebral venous sinus thrombosis (CVST). Brain MRI demonstrated leptomeningeal gadolinium enhancement in front of the pons and medulla. Positive cerebrospinal fluid tumor cytology confirmed the diagnosis of leptomeningeal carcinomatosis. Following four weeks of antithrombotic therapy, complete thrombolysis was confirmed by magnetic resonance venography. Effective treatment with gefitinib was administered, and the patient survived for 10 months after the diagnosis of CVST and leptomeningeal carcinomatosis. Adequate early diagnosis and treatment of CVST enabled an excellent survival rate for the patient, despite leptomeningeal carcinomatosis. Following the development of headaches in patients with lung cancer, CVST, although rare, should be considered. Furthermore, following a diagnosis of CVST, leptomeningeal carcinomatosis should be investigated as an underlying cause.

Red cell distribution width in patients with cerebral venous sinus thrombosis.

We have read the article ‘‘Red cell distribution width identifies cerebral venous sinus thrombosis in patients with headache’’ by Demir et al. They aimed to investigate the validity of red cell distribution width (RDW) in cerebral venous sinus thrombosis (CVST) diagnosis in patients presenting with headache. They concluded that RDW is a highly valuable marker in the diagnosis of CVST in patients presenting with headache. This study gives important information on this clinically relevant condition. The ready availability of this parameter at no additional cost may encourage its wider use in clinical practice in the future. Thanks to the authors for their contribution. However, we think that some points should be discussed. Newly inflammatory markers are considered a major risk factor predisposing to cardiovascular morbidity and mortality. Recently, elevated RDW has been identified and proposed to be of importance. Red cell distribution width is a measure of the variability in the size of circulating red blood cells and is a part of the complete blood count panel. Red cell distribution width is expressed as the coefficient of variation in the erythrocyte volume. Some studies have reported that elevated RDW levels are associated with poor prognosis in the setting of stable angina, acute coronary syndrome, coronary bypass surgery, heart failure, stroke, peripheral arterial disease, older age, and in the patients with or without coronary artery disease. Red cell distribution width is associated with iron deficiency, inflammation, uraemia, transfusion, ethnicity, neurohumoral activation, thyroid disease, hepatic dysfunction, bone marrow dysfunction, inflammatory diseases, chronic or acute systemic inflammation, and use of some medications. Finally, because the present study has designed as a retrospective cross-sectional study, the authors cannot define how much time elapsed from time of bloodletting to time of RDW determination. In conclusion, we strongly believe that those findings obtained from the current study will lead to further studies examining the relationship between RDW and CVST. However, one should keep in mind that RDW itself may not give exact information to clinicians about the inflammatory status of patients with CVST. So, from that point of view, we think that it should be evaluated accompanied with other serum inflammatory markers.

Acute cerebral venous sinus thrombosis: A rare complication of binge drinking

The association of alcoholism with stroke is known. However, acute cerebral venous sinus thrombosis (CVST) presenting as a complication of binge drinking is rare. Two such rare cases are presented here. Since, there is an overlap of symptoms between veisalgia and CVST, the diagnosis of CVST may be missed or delayed in alcoholic patients. It is important to keep a rare possibility of acute CVST in mind while dealing with patients who present with neurological symptoms following binge drinking. Imaging plays a vital role in making an early and specific diagnosis, thus preventing complications.

Cerebral venous sinus thrombosis on MRI: A case series analysis

Background: Cerebral venous sinus thrombosis (CVST) is a rare form of stroke seen in young and middle aged group, especially in women due to thrombus of dural venous sinuses and can cause acute neurological deterioration with increased morbidity and mortality if not diagnosed in early stage. Neurological deficit occurs due to focal or diffuse cerebral edema and venous non-hemorrhagic or hemorrhagic infarct. Aim and Objectives: To assess/evaluate the role of Magnetic Resonance Imaging (MRI) and Magnetic Resonance Venography (MRV) as an imaging modality for early diagnosis of CVST and to study patterns of venous thrombosis, in detecting changes in brain parenchyma and residual effects of CVST using MRI. Materials and Methods: Retrospective descriptive analysis of 40 patients of CVST diagnosed on MRI brain and MRV was done. Results: 29/40 (72.5%) were males and 11/40 (27.5%) were females. Most of the patients were in the age group of 21-40 years (23/40-57.5%). Most of the patients 16/40 (40%) presented within 7 days. No definite cause of CVST was found in 24 (60%) patients in spite of detailed history. In 36/40 (90%) of cases major sinuses were involved, deep venous system were involved in 7/40 (17.5%) cases, superficial cortical vein was involved in 1/40 (2.5%) cases. Analysis of stage of thrombus (acute, subacute, chronic) was done based on its appearance on T1 and T2WI. 31/40 (77.5%) patients showed complete absence of flow on MRV, while 9/40 (22.5%) cases showed partial flow on MR venogram. Brain parenchyma was normal in 20/40 (50%) patients while 6/40 (15%) cases had non-hemorrhagic infarct and 14/40 (35%) patients presented with hemorrhagic infarct. Conclusion: Our study concluded that MRI brain with MRV is sensitive in diagnosing both direct signs (evidence of thrombus inside the affected veins) and indirect signs (parenchymal changes) of CVST and their follow up.

Red Cell Distribution Width Identifies Cerebral Venous Sinus Thrombosis in Patients With Headache

Diagnosing cerebral venous sinus thrombosis (CVST) in patients referring to emergency service or neurology outpatient unit with complaints of headache is a challenging task. Magnetic resonance (MR) venography is the gold standard, but there are limitations regarding its use. To evaluate the validity of red cell distribution width (RDW) in CVST diagnosis in patients presenting with headache. A total of 138 patients comprising 37 patients with CVST and 101 control primer headache cases were included in this retrospective cross-sectional study. Control group consists of hospitalized patients with primary headache. Venous blood hemoglobin (Hb), platelet, mean corpuscular volume (MCV), RDW, fibrinogen, and vitamin B12 levels of the patients were recorded at the first referral. Diagnosis of CVST was established by MR venography. The RDW ratio of patients with a diagnosis of CVST was significantly higher than that in patients with primary headache (15.3 ± 1.4 vs 13.3 ± 0.5; P <.0001). Fibrinogen and vitamin B12 levels were not significantly different between the 2 groups. In a total of 11 patients, there was more than 1 thrombosis. In 21 of the patients with CVST, gene mutation was detected. There was no significant difference between the patients with and without mutations regarding RDW values. Diagnostic validity of RDW was found to be excellent in differentiating patients with CVST and primary headache (area under the curve = 0.996; 95% CI: 0.990-1.000). Optimum RDW cutoff value was determined as 14.1% (sensitivity: 91.9%, specificity: 99%, positive predictive value: 92.8, negative predictive value: 0.082). We suppose that among patients presenting with the complaint of headache, RDW value may lead to diagnose CVST.

Cerebral venosus sinus thrombosis in a healthy women taking oral contraceptive: a case report and review of literature

SUMMARY Cerebral venous sinus thrombosis (CVST) is rare than arterial thrombosis. It can affect all age groups but is seen mostly in young women. The diagnosis of CVST is not easy because of variability of clinical symptoms and signs. The patients can present with headache, papilledema, focal deficit, seizures and coma. The most frequent symptom is severe headache. The most common causes of CVST are pregnancy, puerperium, systemic inflammatory diseases, inherited and acquired coagulation disorders, trauma, lumbar puncture, drugs and infection. The use of oral contraceptive (OC) increases the risk of cerebral sinus thrombosis. If there is an additional hereditary prothrombotic factor, the risk of CVST is more. CVST affects superior sagittal sinus and the lateral sinuses more frequently. More than one sinus is affected in one-third of cases. Computed tomografi helps to exclude other intracranial condition but diagnostic value of CT in CVST is limited. Combination of magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) have replaced cerebral angiography for diagnosis of CVST. The treatment of CVST contain supportive (hydration, antibiotheraphy, anticonvulsant) and anticoagulan treatment. Heparin is effective and safety for the treatment of CVST because of this, it is the first-line treatment. The safety of heparin treatment also has been shown in those patients who had hemorrhagic infarcts. Outcomes of CVST is variable from death to complete improvement, but in general it is favorable. Recurrence of CVT is not common. Herein we present a 33-years old previously healthy women with CVST who taking OC.

A Case of Cerebral Sinus Venous Thrombosis Resulting in Mortality in Severe Preeclamptic Pregnant Woman

Cerebral venous sinus thrombosis (CVST) is a rarely encountered condition during pregnancy. A 21-year-old pregnant woman with labour pains was hospitalized in our clinic. Diagnosis of severe preeclampsia was made based on her clinical and laboratory findings. She suffered from convulsive episodes during postpartum period which lead to initiation of treatment for eclampsia. However neurological and radiological examinations were performed after emergence of additional neurological symptoms disclosed the diagnosis of CVST. In this paper, we aimed to present a case with CVST which diagnosis was confused with eclampsia and resulting in maternal mortality.

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.

Intracranial haemorrhage with a twist

D. Magnetic resonance venogram. The diagnosis of cerebral venous sinus thrombosis (CVST) was missed preoperatively but suspected intraoperatively when, strikingly, the vein of Labbé was unusually dark, firm and rubbery. Some of the superficial cortical veins were similar in appearance and consistency, and one of these was sent for pathological examination. We traced the vein of Labbé back to the left transverse sinus and suspected it to be thrombosed as well. The brain was swollen and discoloured and the haematoma uneventfully evacuated. MRI venography confirmed the diagnosis of CVST postoperatively (Fig. 1B). A retrospective review of the CT scan on admission revealed left transverse sinus hyperdensity (Fig. 1A). Despite its recognition as a potentially life-threatening clinical entity since 1825,[1]Ameri A. Bousser M.G. Cerebral venous thrombosis.Neurol Clin. 1992; 10: 87-111PubMed Google Scholar CVST remains a diagnostic challenge owing to its protean clinical and radiological presentation.[2]Singh T. Chakera T. Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: an easily misdiagnosed cause of cerebral haemorrhage.Australas Radiol. 2002; 46: 351-365Crossref PubMed Scopus (13) Google Scholar CVST accounts for fewer than 2% of patients with non-traumatic intracranial haemorrhage but haemorrhagic transformation of a venous infarct has been reported in 20% to 40% of patients with CVST.3Gum G.K. Numaguchi Y. Foster R.W. et al.Superior sagittal sinus thrombosis with intracerebral hematoma.Comput Radiol. 1987; 11: 199-202Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 4Keiper M.D. Ng S.E. Atlas S.W. et al.Subcortical hemorrhage: marker for radiographically occult cerebral vein thrombosis on CT.J Comput Assist Tomogr. 1995; 19: 527-531Crossref PubMed Scopus (29) Google Scholar While most hemorrhages associated with CVST are small, patchy, or merely petechial foci in larger hypodense areas,1Ameri A. Bousser M.G. Cerebral venous thrombosis.Neurol Clin. 1992; 10: 87-111PubMed Google Scholar, 3Gum G.K. Numaguchi Y. Foster R.W. et al.Superior sagittal sinus thrombosis with intracerebral hematoma.Comput Radiol. 1987; 11: 199-202Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 4Keiper M.D. Ng S.E. Atlas S.W. et al.Subcortical hemorrhage: marker for radiographically occult cerebral vein thrombosis on CT.J Comput Assist Tomogr. 1995; 19: 527-531Crossref PubMed Scopus (29) Google Scholar rapid and dramatic enlargement of lobar hemorrhagic infarction has on rare occasions been observed in the setting of this condition.[5]Stefini R. Latronico N. Cornali C. et al.Emergent decompressive craniectomy in patients with fixed dilated pupils due to cerebral venous and dural sinus thrombosis: report of three cases.Neurosurgery. 1999; 45 (discussion 629-30): 626-629Crossref PubMed Scopus (133) Google Scholar Early diagnosis and expeditious treatment of CVST are essential. This particular patient’s diagnosis was missed on admission and, anecdotally, this appears to be an experience shared more broadly.[2]Singh T. Chakera T. Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: an easily misdiagnosed cause of cerebral haemorrhage.Australas Radiol. 2002; 46: 351-365Crossref PubMed Scopus (13) Google Scholar Although the need for aetiological workup and medical treatment via anticoagulation and/or thrombolytic therapy are widely accepted, surgical options also exist for this condition.6Soleau S.W. Schmidt R. Stevens S. et al.Extensive experience with dural sinus thrombosis.Neurosurgery. 2003; 52 (discussion 542-4): 534-544Crossref PubMed Scopus (117) Google Scholar, 7Bentley J.N. Figueroa R.E. Vender J.R. From presentation to follow-up: diagnosis and treatment of cerebral venous thrombosis.Neurosurg Focus. 2009; 27: E4Crossref PubMed Scopus (29) Google Scholar Our patient was found to have protein S deficiency, but other risk factors for CVST are oral contraceptive pill use, pregnancy and oestrogen replacement in females, and underlying malignancies, deficiencies of protein C and factor V Leiden, and vasculitis or anti-phospholipid antibodies.[7]Bentley J.N. Figueroa R.E. Vender J.R. From presentation to follow-up: diagnosis and treatment of cerebral venous thrombosis.Neurosurg Focus. 2009; 27: E4Crossref PubMed Scopus (29) Google Scholar The patient underwent anticoagulation therapy and made an excellent clinical recovery. Intracranial haemorrhage with a twistJournal of Clinical NeuroscienceVol. 19Issue 4PreviewA 55-year-old, previously healthy male train conductor with a history of migraines developed a gradual-onset left temporal headache while at work, followed by new-onset word-finding difficulty. During helicopter transfer from a small regional emergency department to a tertiary referral hospital, the man’s aphasia worsened, and he became densely right hemiplegic and somnolent. After emergent intubation and hyperventilation with concomitant intravenous administration of mannitol, he was taken to the operating room for a definitive procedure. Full-Text PDF

The clinical spectrum of intracerebral hematoma, hemorrhagic infarct, non‐hemorrhagic infarct, and non‐lesional venous stroke in patients with cerebral sinus–venous thrombosis

The clinical spectrum of different neuroradiological features of cerebral sinus-venous thrombosis (CSVT) varies considerably. We sought the relationship between different neuroradiological aspects and clinical presentations in these patients. The diagnosis of cerebral sinus-venous thrombosis has been confirmed by conventional angiography, MRI combined with MR venography following established diagnostic criteria. We analyzed clinical data, symptoms and signs, imaging findings, location and extent of the thrombus, and parenchymal lesions, retrospectively. There were 220 consecutive patients with cerebral sinus-venous thrombosis; 98 (45%) had non-lesional sinus-venous thrombosis (NL CSVT), 51 (23%) had non-hemorrhagic infarct (NHI), 45 (20%) had hemorrhagic infarct (HI), and 26 (12%) had intracerebral hemorrhage (ICH). In patients with hemorrhagic lesion (HI+ICH), advanced age, headache (99%), behavioral disturbances (55%), consciousness disturbances (35%), seizures (41%), and language deficits (42%) were significantly higher than the other patients (NL+NHI) (P < 0.001). High blood pressure at admission, puerperium, sigmoid and straight sinus thrombosis, multiple sinus and vein involvement were more frequent in patients with hemorrhagic lesion than those with non-hemorrhagic lesion. Patients with hemorrhagic lesion were more dependent or died (32%) than the other patients (12%) (P < 0.001), and most of the patients with NL and NHI had no disability compared with the other patients at the 3 month of follow-up (96% and 65%; P < 0.001). Headache, convulsion, behavioral disorder, seizures, and speech disorders were the most frequent clinical symptoms of patients with hemorrhagic CSVT. Specific risk factors, including pregnancy/puerberium, early and extended thrombosis of large sinus, and presence of high blood pressure at admission, are associated with hemorrhagic lesion and unfavorable outcome.