Multiple Sinus Thrombosis Research Articles

Critical Prognostic Factors in Cerebral Venous Sinus Thrombosis: An Observational Study.

Cerebral venous sinus thrombosis (CVST) presents with a wide variety of neurological symptoms in various combinations and has a high mortality rate of up to 50%. Recent advances in neuroimaging and therapeutic interventions have brought it down to 10%-20%. The study aims to identify critical prognostic factors associated with poor outcomes in patients with CVST. All cases of CVST aged >18 years from July 2015 to July 2020 who were not terminally ill and bedridden before the illness were evaluated at the entry point for various risk factors and after 30 days for outcome assessment with the modified Rankin scale (mRS). The outcome was dichotomized, applying mRS <3 as a good outcome, and analyzed with the Chi-square test or the Fischer's exact test in a bivariate analysis to identify associated variables. A total of 149 subjects were studied. Glasgow Comma Scale (GCS) <9 (P<0.001), focal neurological deficits (P = 0.05), the presence of a mass effect (P<0.001), and the need for decompressive hemicraniectomy (P<0.001) were associated with poor outcomes. Age, gender, diagnostic delay, seizures at onset, papilledema, parenchymal lesions, deep sinus involvement, and multiple sinus thrombosis were not associated with a poor outcome. In our study, early diagnosis and treatment of CVST is associated with an overall favorable outcome even in the presence of traditional poor prognostic factors such as age, seizures at onset, deep sinus involvement, and multiple sinus involvement in the face of conventional risk factors. A large country-wide prospective study might help in elucidating the poor prognostic factors.

Benefits of Prolonged Anticoagulant Treatment in a Series of Cerebral Venous Thrombosis in Pediatric Patients

Background: Cerebral sinus venous thrombosis (CSVT) is a rare complication in children, usually secondary to an underlying condition. Recent guidelines recommend treating all pediatric patients with CSVT, but also suggest that treatment longer than three months should not be justified in provoked cases in which the risk factor has disappeared. Methods: Retrospective observational study analyzing data of CSVT in children (1-18 years-old) admitted in a single hospital. Demographic data, clinical presentation, etiology, extension, treatment and outcome were evaluated. Results: Thirty-one patients had a confirmed CSVT. Sixteen were girls, mean age was 7.3 years (SD 4.39). Sigmoid sinus (n=17) and transverse sinus (n=14) were the most frequent sinuses affected. Multiple sinus thrombosis was found in 20 patients (64.5%). Underlying condition was described in 29 cases: infectious disease (n=20), major head trauma (n=4), chemotherapy (n=3), arteriovenous malformation (n=2). More frequent symptoms were: headache (n= 15), decreased level of consciousness (n=5), seizures (n=3), focal neurological deficit (n=2), papilledema (n=2), diplopia (n=2), vision impairment (n=1), and coma (n=4). All patients received anticoagulant treatment. Complete vein recanalization after 3 months was achieved in 53.3% of the cases. Treatment was prolonged up to 6 months in those patients with partial or no response (n=14). Seven of them improved radiological findings. Complete and partial vein recanalization were reported in 73.3% and 20% of the patients. Conclusion: Anticoagulation was useful to achieve complete vein recanalization in this series. Extending anticoagulation up to 6 months could be useful to improve outcome of pediatric patients with CSVT in selected cases.

Cerebral venous sinus thrombosis: Clinical profile and surgical outcome

Thrombosis of the cerebral venous sinuses (CVST) is common cause of acute neurological deficit and altered sensorium. Most of the patients are young and can suffer severe morbidity and mortality if not treated aggressively. Early diagnosis and management is necessary for good outcome in case of CVST. Material and Methods: Retrospective observational study over a period of 4 year 3 months from oct' 2013 to feb'2018 in our institute. CVST was affirmed by MRI brain venogram of 84 patients were included in this study. Decompressive craniectomy done in case of mass effect or herniation. All patients were treated according to standard guideline and protocol. Result:This study include 51 (60.7%) females and 33 (39.2%) males with the age of 39 ± 10 years and 29 ± 7 years, respectively. Out of which 25 patients (29.7%) had hemiparesis/hemiplegia, vomiting and headache was manifested in 79 (94%) patients, seizures in 13(15%), and fever in 30(35.7%). 38(45.2%) out of 84 patients were presented with sagittal sinus thrombosis, 10(11.9%) of 84 with multiple sinus thrombosis and 35(41.6) of 84 patients with transverse/sigmoid sinus thrombosis. On funduscopic examination papilledema in 25(29.7%) patients. Patients had diagnosis of CVST during peripartum period altogether 8(15.6%) out of 51 female. 1 patient had bilateral cavernous sinus thrombosis. Signs of infection seen in patients in the study as Chronic supportive otitis media (CSOM), fever, 11(13.09%) patients had paranasal sinus (PNS) infections, 10 (11.9%) patients had evidence and history of lack of hydration. 8 (9.5%) patients of the total deceased during the course of treatment and 79 (94%) out of 84 patients were discharged with partial or/and total recovery. Three 25(29.7%) required decompressive craniectomy. Multiple sinus thrombosis had poor prognosis. Conclusion:Most commonly involved sinus is superior sagittal sinus while transverse or sigmoid sinus and bilateral cavernous sinus thrombosis follows it being

SAT-519 Armour Thyroid and Liothyronine Combination Potentiated Thrombosis

Objective To describe a case presentation of multiple sinus thrombosis while on combination therapy of liothyronine and Armour Thyroid for Hashimoto’s thyroiditis with other risk factors of thrombosis. Methods A case report with medical history, diagnostic and treatment course is presented with discussion. Results A 47-year-old female with a history of Hashimoto’s thyroiditis on liothyronine and Armour Thyroid, on oral contraceptive use and cigarette smoking presented to Emergency Room with complaints of severe headache, neck pain and dizziness later developing confusion, word-finding difficulty and various left-sided neurological deficit. She was found to have superior sagittal sinus and right transverse sinus thrombosis, both with partial to complete occlusion and involved hematoma. Patient went through endovascular intervention for successful thrombectomy with recanalization, and neurosurgical intervention for decompressive evacuation of hematoma. Patient was found to have undetectably low thyroid stimulating hormone level, and her base-line level from one year ago was 0.147 milli-international units per liter while having been on liothyronine and Armour Thyroid for years. Patient was started on daily oral levothyroxine and recovered eventually from neurological deficits. Repeated thyroid function test showed improving results. Evaluation for other causes of thrombosis included positive results for prothrombin gene mutation, confirming her inherited thrombophilia condition that has been undiagnosed until this event. Discussion Primary hypothyroidism is one of the most prevalent endocrine disorders, occurring in up to 5% of the population. While synthetic thyroxine has been standard therapy for the primary hypothyroidism for many years, many alternative thyroid therapies have resurfaced recently. For instance, there has been increasing trend of using liothyronine in addition to levothyroxine with symptomatic benefit despite insufficient evidence. Armour Thyroid, which is a natural porcine derivative thyroid supplement often used as a weight loss supplement without proper monitor by physician, has repeatedly been controversial. Many studies have raised concerns for cardiovascular disease including arrhythmia with high thyroid hormone level. Also a number of case reports have shown association with hyperthyroidism and pro-thrombotic state. Although there are scarce publications associating liothyronine or Armour Thyroid and hypercoagulable thrombotic event, significant drug interactions may exist with patient who are more vulnerable with inherited condition or other risk factors.

Characteristics and Outcomes of Patients with Cerebral Venous Sinus Thrombosis.

ObjectivesCerebral venous sinus thrombosis (CVST) is a disease with potentially serious consequences. The clinical presentation and outcomes of these patients have not been described in Oman. We sought to describe the clinical characteristics and outcomes of patients with CVST.MethodsWe conducted a retrospective study in two tertiary care centers in Oman, which included all Omani adults with radiologically confirmed CVST. We recorded and analyzed patients’ demographic, clinical, and outcome data.ResultsFifty-four patients had radiologically confirmed CVST. The commonest presenting feature was headache (85.0%), followed by focal motor deficits (48.0%) and seizures (27.0%). In this cohort, 24.0% were pregnant or postpartum, 11.0% had an inherited thrombophilia, 11.0% were on hormonal therapy, and 11.0% had systemic lupus erythematous; 38.9% of patients had multiple sinus thrombosis while 35.2% had sigmoid and transverse sinus thrombosis. Antiphospholipid antibody syndrome and infection accounted for 7.0% and 13.0% of causes, respectively, while cancer accounted for 2.0%. No cause was identified in 33.0% of cases. Only 1.9% of patients died, while 29.6% had a residual neurological deficit at hospital discharge. Age was a predictor for residual neurological deficit (p = 0.003).ConclusionsPregnancy and postpartum were the most common predisposing factors for CVST in our cohort. Although the mortality rate is low, the risk of residual neurological deficit remains high. We recommend a prospective study for better characterization and outcome assessment.

Clinical analysis of cerebral venous sinus thrombosis and its combined treatment of anticoagulation and endovascular thrombolysis

Objective To investigate the clinical and imaging manifestations of cerebral venous sinus thrombosis (CVST), and the clinical effect of combined treatment of anticoagulation and endovascular thrombolysis. Methods and Results The clinical manifestations of 22 CVST patients were highly variable. Headache (90.91%, 20/22) was the most frequent symptom, and conscious disturbance, seizure and focal neurological deficits were commonly present. Plasma D-dimer level was elevated in 12 patients (54.55%). Lumbar puncture was performed in 14 patients, in whom intracranial hypertension was present in 9 patients (9/14) with no characteristic changes in routine and biochemical examination of cerebrospinal fluid (CSF). Brain CT/MRI and CTV/MRV showed direct signs of CVST in all 22 patients, involving superior sagittal sinus, transverse sinus, sigmoid sinus, straight sinus and cortex veins, parenchymal lesions (infarction, hemorrhage and white matter abnormalities) in 13 patients (59.09%), subarachnoid hemorrhage (SAH) in 2 patients (9.10%) and subdural hematoma in one patient (4.55%). The involved cerebral sinuses revealed by DSA were superior sagittal sinus in 13 patients (59.09% ), transverse sinus in 17 patients (77.27%), sigmoid sinus in 14 patients (63.64%), inferior sagittal sinus in 2 patients (9.10%), straight sinus in 4 patients (18.18%), vein of Galen in one patient (4.55%) and jugular vein in one patient (4.55%). Two thrombosed sinuses were found in 9 patients (40.91% ) and 3 or more thrombosed sinuses in 8 patients (36.36% ). As no clinical improvements and progressive exacerbation were observed several days after heparin sodium intravenous drip or lower molecular weight heparin (LMWH) hypodermic injection with oral warfarin anticoagulant therapy, urokinase thrombolysis in venous sinus or artery was applied in 21 patients (95.45%). After (25.70 ± 12.18) d treatment with anticoagulation, the modified Rankin Scale (mRS) score of 13 patients (59.09% ) reached 0-1, 4 patients (18.18% ) 2 and 5 patients (22.73% ) 3-4, with the total effective rate reaching 77.27% (17/22). Conclusions The severely affected CVST usually have multiple sinus thromboses, deep venous thrombosis and parenchymal lesions. Endovascular thrombolysis together with primary anticoagulation may result in good outcomes in these patients. DOI: 10.3969/j.issn.1672-6731.2017.12.006

Clinical profile and outcome of cerebral venous sinus thrombosis at tertiary care center

ABSTRACT Background: Thrombosis of the cerebral venous sinuses (CVST) is an uncommon form of stroke, usually affecting young individuals. Clinical features of CVST are diverse, and for this reason, high degree of clinical suspect is mandatory to diagnose the conditions. Materials and Methods: This study was conducted over a period of 1 year (Jan 2011 to Dec 2011). This was a retrospective, observational, and noninterventional study. This study was conducted in the Department of Medicine at a tertiary care teaching center. Total 50 patients where diagnosis of CVST was confirmed by computed tomography/magnetic resonance imaging brain venogram were included in this study. All patients with diagnosis of CVST were treated according to the standard protocol and guidelines. Statistical Analysis: The mean and standard deviation were obtained. The Chi-square test was used to analyze the data and P &lt; 0.05 was considered as statistically significant. Results: Of total 50 patients with diagnosis of CVST, 21 (42%) were males and 29 (58%) were females with 39 ± 10 years and 29 ± 7 years, respectively. Total 45 (90%) patients presented with symptoms of headache and vomiting, 13 (26%) had seizures, 12 (24%) had hemiplegia, and 19 (38%) had fever. A total of 13 (26%) patients had papilledema on fundoscopy. Total 9 (31%) out of 29 patients had diagnosis of CVST during peripartum period. Total 12 (24%) patients had hyperhomocysteinemia. Total 23 (46%) patients had sagittal sinus thrombosis, 10 (20%) had multiple sinus thrombosis, 16 (32%) had sigmoid/transverse sinus thrombosis. There was 1 (2%) patient who had bilateral cavernous sinus thrombosis, who presented with bilateral proptosis, conjunctival congestion, and external ophthalmoplegia with a history of acute or chronic maxillary and sphenoid sinusitis. Total 38 patients had evidence of infection in the form of fever, paranasal sinus (PNS) infections, Chronic suppurative otitis media (CSOM). Total 19 (38%) patients had a history and evidence of dehydration. Total 8 (16%) patients died during the course of treatment and 42 (84%) were discharged with partial and/or total recovery. Three (6%) patients required neurosurgical intervention in the form of decompressive craniotomy. Eight (16%) patients died with cerebral edema with transtentorial herniation. The mean age of death in male was significantly greater than in female patients with P &lt; 0.02. Majority of patients succumbed had sigmoid, transverse, and/or multiple sinus involvement. Patients with multiple sinus thrombosis had greater case fatality rate. Conclusions: The current study highlights the burden of CVST in the study population with headache and vomiting, which was the most common presenting complaint. The superior sagittal sinus thrombosis was the most common and bilateral cavernous sinus thrombosis was the uncommon affection in CVST. One third of female population was affected in peripartum period. The infection and/or dehydration was the most commonly associated precipitating event for development of CVST and more than one fifth of the population had evidence of hyperhomocysteinemia. Mortality was more in patients with affection of sigmoid, transverse, and/or multiple sinus involvement in male patients and superior sagittal sinus thrombosis in female patients. The treatment of CVST has to be aggressive as morbidity and mortality is relatively minimal compared with the arterial stroke.

C0540: A Pediatric Case of Acute Lymphoblastic Leukemia with Multiple Sinus Thrombosis and Deep Vein Thrombosis

C0540: A Pediatric Case of Acute Lymphoblastic Leukemia with Multiple Sinus Thrombosis and Deep Vein Thrombosis

Clinical profile and outcome of cerebral venous sinus thrombosis at tertiary care center.

Background:Thrombosis of the cerebral venous sinuses (CVST) is an uncommon form of stroke, usually affecting young individuals. Clinical features of CVST are diverse, and for this reason, high degree of clinical suspect is mandatory to diagnose the conditions.Materials and Methods:This study was conducted over a period of 1 year (Jan 2011 to Dec 2011). This was a retrospective, observational, and noninterventional study. This study was conducted in the Department of Medicine at a tertiary care teaching center. Total 50 patients where diagnosis of CVST was confirmed by computed tomography/magnetic resonance imaging brain venogram were included in this study. All patients with diagnosis of CVST were treated according to the standard protocol and guidelines.Statistical Analysis:The mean and standard deviation were obtained. The Chi-square test was used to analyze the data and P < 0.05 was considered as statistically significant.Results:Of total 50 patients with diagnosis of CVST, 21 (42%) were males and 29 (58%) were females with 39 ± 10 years and 29 ± 7 years, respectively. Total 45 (90%) patients presented with symptoms of headache and vomiting, 13 (26%) had seizures, 12 (24%) had hemiplegia, and 19 (38%) had fever. A total of 13 (26%) patients had papilledema on fundoscopy. Total 9 (31%) out of 29 patients had diagnosis of CVST during peripartum period. Total 12 (24%) patients had hyperhomocysteinemia. Total 23 (46%) patients had sagittal sinus thrombosis, 10 (20%) had multiple sinus thrombosis, 16 (32%) had sigmoid/transverse sinus thrombosis. There was 1 (2%) patient who had bilateral cavernous sinus thrombosis, who presented with bilateral proptosis, conjunctival congestion, and external ophthalmoplegia with a history of acute or chronic maxillary and sphenoid sinusitis. Total 38 patients had evidence of infection in the form of fever, paranasal sinus (PNS) infections, Chronic suppurative otitis media (CSOM). Total 19 (38%) patients had a history and evidence of dehydration. Total 8 (16%) patients died during the course of treatment and 42 (84%) were discharged with partial and/or total recovery. Three (6%) patients required neurosurgical intervention in the form of decompressive craniotomy. Eight (16%) patients died with cerebral edema with transtentorial herniation. The mean age of death in male was significantly greater than in female patients with P < 0.02. Majority of patients succumbed had sigmoid, transverse, and/or multiple sinus involvement. Patients with multiple sinus thrombosis had greater case fatality rate.Conclusions:The current study highlights the burden of CVST in the study population with headache and vomiting, which was the most common presenting complaint. The superior sagittal sinus thrombosis was the most common and bilateral cavernous sinus thrombosis was the uncommon affection in CVST. One third of female population was affected in peripartum period. The infection and/or dehydration was the most commonly associated precipitating event for development of CVST and more than one fifth of the population had evidence of hyperhomocysteinemia. Mortality was more in patients with affection of sigmoid, transverse, and/or multiple sinus involvement in male patients and superior sagittal sinus thrombosis in female patients. The treatment of CVST has to be aggressive as morbidity and mortality is relatively minimal compared with the arterial stroke.

Headache in Cerebral Venous Thrombosis

P37 Objectives: Although headache is the most frequent and often the earliest symptom of cerebral venous thrombosis (CVT), few studies have attempted to define its clinical features. Our aim is to describe the main characteristics of headache in CVT patients. Methods: From March 1996 to June 2000 we prospectively evaluated 39 patients. After clinical examination, diagnostic confirmation was obtained by magnetic resonance imaging and/or angiography. Information about headache was recorded on a standardized form, including location, severity, duration, quality, worsening and associated features. Results: The group included 69% females (mean age 35 years; range 8–81). Headache occurred in 35 patients (89.7%), and was the initial symptom in 84.6%. In 28.6% an isolated intracranial hypertension syndrome occurred. Among 66 % with severe headaches, 70% had multiple sinus thrombosis and 43.4% had intraparenchymal lesions. Four patients (11.4%) had a thunderclap-like headache. Headache onset was acute (&lt; 48 hours) in 9 patients (26%), subacute (48 hours to 30 days) in 7 (20%) and chronic (&gt; 30 days) in the remaining 54%. Headache was mostly focal (63%) and pulsatile in 48.6% patients. Pain worsened with head movements in 31.4% of patients, physical activity in 23% and coughing or sneezing in 20%. The most striking feature was the presence of focal signs (aphasia, motor and sensory deficits and visual field defects) in 74% of patients. In 11 of the 23 patients with severe headache, mean initial CSF pressure was 37.6 cmH2O and in those with thunderclap headache it was 51.7 cmH2O. Prior history of headache was present in 17 of CVT patients (48.6%). Conclusions: Headache was a frequent symptom, usually severe and focal at onset in our CVT patients. The severity of headache seems to be associated with initial CSF pressures, however, a clear relationship with intraparenchymal lesions was not observed. A striking feature was the association of headache and other neurological abnormalities. Thunderclap headache is seldom considered in patients with CVT. Prior headache was frequent and may contribute to diagnostic delays. The recognition of headache characteristics may help earlier identification of CVT patients in the emergency room.

Headache in Cerebral Venous Thrombosis

P37 Objectives: Although headache is the most frequent and often the earliest symptom of cerebral venous thrombosis (CVT), few studies have attempted to define its clinical features. Our aim is to describe the main characteristics of headache in CVT patients. Methods: From March 1996 to June 2000 we prospectively evaluated 39 patients. After clinical examination, diagnostic confirmation was obtained by magnetic resonance imaging and/or angiography. Information about headache was recorded on a standardized form, including location, severity, duration, quality, worsening and associated features. Results: The group included 69% females (mean age 35 years; range 8–81). Headache occurred in 35 patients (89.7%), and was the initial symptom in 84.6%. In 28.6% an isolated intracranial hypertension syndrome occurred. Among 66 % with severe headaches, 70% had multiple sinus thrombosis and 43.4% had intraparenchymal lesions. Four patients (11.4%) had a thunderclap-like headache. Headache onset was acute ( 30 days) in the remaining 54%. Headache was mostly focal (63%) and pulsatile in 48.6% patients. Pain worsened with head movements in 31.4% of patients, physical activity in 23% and coughing or sneezing in 20%. The most striking feature was the presence of focal signs (aphasia, motor and sensory deficits and visual field defects) in 74% of patients. In 11 of the 23 patients with severe headache, mean initial CSF pressure was 37.6 cmH2O and in those with thunderclap headache it was 51.7 cmH2O. Prior history of headache was present in 17 of CVT patients (48.6%). Conclusions: Headache was a frequent symptom, usually severe and focal at onset in our CVT patients. The severity of headache seems to be associated with initial CSF pressures, however, a clear relationship with intraparenchymal lesions was not observed. A striking feature was the association of headache and other neurological abnormalities. Thunderclap headache is seldom considered in patients with CVT. Prior headache was frequent and may contribute to diagnostic delays. The recognition of headache characteristics may help earlier identification of CVT patients in the emergency room.