Puerperal Cerebral Venous Thrombosis Research Articles

Postpartum Cerebral Venous Thrombosis—A Single-Center Experience

Background: Cerebral venous thrombosis (CVT) is a rare variant of stroke in the general population, but an important subtype among pregnancy- and puerperium-related cases. Studies describing its risk factors and clinical characteristics are limited. The aim of our study is to disclose these aspects and compare with cases unrelated to pregnancy and puerperium. Materials and Methods: We performed a retrospective analysis including 88 consecutive cases from a tertiary neurology clinic with a diagnosis of CVT. Ten of the 88 cases (11.3%) appeared during the postpartum period. Results: The mean age of the puerperal CVT cases was 26.5 years. The main pregnancy-related risk factors besides puerperium were cesarean delivery (5/10), preeclampsia (2/10), and stillbirth (1/10). General risk factors for thrombosis, i.e., infection, smoking, and primary hypercoagulability, were identified in 50% of cases. Onset was in the first 3 weeks after delivery, with a mean value of 9.6 ± 5.6 days. Headache was present in 90% of postpartum CVT cases and in 76.1% of non-postpartum female cases. Seizures were more frequent in the postpartum group (60% vs. 34.8%). Onset was acute (<48 h) in 50% of postpartum cases and in 30.4% of the non-postpartum female group. The Rankin score at discharge was significantly lower in the postpartum group (0.22 vs. 0.7, p = 0.02), suggesting a more favorable short-term outcome. Conclusions: The early postpartum period represents an important risk for the development of CVT. Cesarean delivery and preeclampsia, besides general risk factors such as infection, smoking, and primary thrombophilia, contribute to enhanced risk. Puerperium-related CVT presents a more favorable outcome compared with CVT with other etiologies.

Cerebral venous sinus thrombosis a study to assess clinical profile among female patients in a tertiary care hospital

Background: The Incidence of Cerebral Venous Thrombosis (CVT) is around 3-4 cases among one million population affecting children and young adults. In India the puerperal CVT is 10-12 times more common than western countries. Even though there is apparent “rarity” of the condition but advances in knowledge and available investigation in terms of imaging (CT scan/MRI) diagnosis can be done early for appropriate treatment and decreasing the morbidity and mortality.Methods: A prospective study was conducted at Karnataka Institute of Medical Sciences, Hubli, Karnataka from December 2014 to November 2015. A total of 36 patients were included in the study.Results: Mean age of females in the study was 27.06±9.033years. 75% had seizures, 47.2% had headache, 19.4% had focal neurological deficit, 13.9% had altered sensorium, 8.3% had cranial nerve deficits 5.6% had speech deficits. 72.22% of patients and were in peripartum period and 27.8% were non-pregnant. 72.2% had superior sagittal sinus involvement, 47.2% had transverse sinus, 47.2% had sigmoid sinus, and 13.9% had internal jugular vein and 5.6% straight sinus. 47.2% had single sinus involvement, and 52.8% had multiple sinus involvement. 94.4% patients were managed conservatively and 5.6% were managed by neurosurgical intervention. 94.4% patients survived and 5.6% had mortality.Conclusions: Cerebral venous sinus thrombosis is most common in young females during peripartum period. Early diagnosis, treatment and if necessary neurosurgical intervention has good outcome.

Preliminary data on utility of subcutaneous unfractionated heparin in patients with deep cerebral venous thrombosis.

Subcutaneous unfractionated heparin (SCUFH) has been proved effective in puerperal cerebral venous thrombosis (CVT), but its efficacy in the more serious form of the disease such as deep CVT patients (DCVT) unreported. We describe the outcomes of 37 (isolated:combined: 11:26) patients of DCVT diagnosed by MRI, treated with SCUFH in a tertiary care stroke unit. It was a prospective observational cohort study using 5000 U of SCUFH every 6 hourly for 10 days with oral Acenocoumarol started on day 7, with monitoring. The outcome was assessed by modified Rankin scale (mRS), National Institute of Health Stroke Scale (NIHSS) and Barthel's activities of daily life (BADL) at 3 months. The mean age of the cohort was 27.9±9.7 years, females (n = 24) outnumbering the males (n = 13). Mean duration of symptoms being 10.2 ± 15.9 days. MRI showed vein of Galen and straight sinus involvement in 36 (97.3%) patients, with sparing of the basal vein of Rosenthal in 28 (75%). Thalamus 27 (73%) basal ganglia 21 (56.7%) were commonly involved areas with hemorrhagic lesions in 18 (48.6%) patients. The median NIHSS score at presentation was 11 (1-21). Mean duration of SCUFH treatment was 9.3±1.3 days and the mean aPTT on day 7 was 49.3±9.8s (control 32-39s), mean PT INR on day 13 was 1.5±0.45. All the patients improved with no mortality in the study group. At 3 months, good functional outcome (mRS: 0-2) was observed in 94.6% (n = 35) of patients. Two patients had mRS-3. The median mRS (3{1-5} to 0{0-3}) and BADL (8{0-20} to 20{8-20}) improved at 3 months. Complications seen were thrombocytopenia-1, infection-6 and deep vein thrombosis of leg-4. Our preliminary data suggests that SCUFH is safe, effective treatment option in patients with DCVT in a stroke unit with minimal monitoring.

Protein Z G79A Polymorphism and Puerperal Cerebral Venous Thrombosis

Protein Z (PZ), a cofactor for PZ-dependent protease inhibitor, is known to play an important role in inhibiting the coagulation cascade. The aim of the study was to investigate whether PZ G79A polymorphism is a risk factor for puerperal cerebral venous thrombosis (CVT). A total of 71 patients with puerperal CVT and 98 healthy controls were genotyped for PZ 79GA polymorphism by polymerase chain reaction-restriction fragment length polymorphism method. In patients, the genotype distribution for GG, GA, and AA genotypes was 22.5%, 43.7%, and 33.8%, and in controls, 25.5%, 40.8%, and 33.7%, respectively. The risk associated with carrying the mutant genotype (GA and AA) versus the wild GG genotype was found to be 1.11 (95% confidence interval: 0.52-2.35; P = .909). There was no significant difference in the clinical features of the patients with and without the polymorphism. We therefore conclude that PZ G79A polymorphism is not a risk factor for puerperal CVT in Indian women.

Postpartum dönemde konvulsiyon ile prezente olan Serebral venöz tromboz olgusu

Objective: Cerebral venous thrombosis is a disease with high mortality. The incidence of the disease increases in pregnancy and puerperium. It may be associated with headache, convulsions, focal deficits, coma and death. Here, we report a case of puerperal cerebral venous thrombosis, presented by convulsions and successfully treated by heparinization despite the concomitant hemorrhagic infarct. Case: Twenty-eight-year-old patient was admitted to Obstetrics and Gynecology emergency service, Gaziantep Maternity Hospital with convulsions, following severe headache. The patient (G2P2) had a cesarean section 10 days ago with the diagnosis of 32 gestational weeks of monochorionic diamniotic twin pregnancy and fetal distress. Cerebral venous thrombosis was detected in transverse and sigmoid sinus with concomitant hemorrhagic infarct at the thalamic region. The patient was successfully treated by heparinization. Conclusion: Cerebral venous thrombosis should be bear in mind, because of pitfalls in the diagnosis, high incidence in the postpartum period and the importance of the differential diagnosis with eclampsia. The mortality is still high, despite the advances in diagnosis and treatment. We report this case, because of its rarity, presentation type and the treatment success.

Coagulation factor VII R353Q polymorphism and the risk of puerperal cerebral venous thrombosis

Puerperal cerebral venous thrombosis (CVT) is a relatively common form of stroke in young women in India. The blood coagulation factor VII (FVII) R353Q polymorphism increases the risk for venous thrombosis. Our aim was to investigate the association of FVII R353Q polymorphism with the risk of puerperal CVT. A total of 100 women with puerperal CVT and 102 age-matched women without postpartum complications were investigated. FVII R353Q genotypes were identified using restriction fragment length polymorphism analysis. Our results showed that the homozygous FVII 353QQ genotype was present in 9% and 8% of patients and controls, respectively; and 42% of patients and 31.4% of controls had the heterozygous 353RQ genotype (odds ratio = 1.55, 95% confidence interval = 0.89–2.70; p = 0.243). Our findings suggest that the FVII R353Q polymorphism is not associated with increased risk for CVT occurring during the puerperal period in Indian women.

FP23-TU-05 Coagulation factor gene polymorphisms in puerperal cerebral venous thrombosis

Purpose: Puerperal cerebral venous thrombosis (PCVT) is a common cause of stroke in young women in India, where it is 10–12 times more common than in the West. The etiology of PCVT is not yet clear. Various thrombophilic gene polymorphisms have been reported to be associated with venous thrombosis in Caucasians. Published literature on their role in the etiology of PCVT is scarce. Hence, our aim was to evaluate the role of common single nucleotide thrombophilic gene polymorphisms such as prothrombin G20210>A, factor V Leiden G1691>A, factor V A4070>G and factor VII R353>Q as risk factors for PCVT. Methods: After approval by the NIMHANS Human Ethics committee, we investigated 100 female patients with a confirmed diagnosis of PCVT and 102 age-matched clinically normal women with no postnatal complications. Restriction length fragment polymorphism (RFLP) technique was used for identifying the presence or absence of the polymorphisms. Results: Factor V Leiden (OR=0.50, 95%CI = 0.09–2.79, p = 0.683), Factor V A4070G (OR=1.17, 95%CI = 0.49–2.75, p = 0.567) and factor VII R353Q (OR=1.55, 95%CI = 0.89–2.70, p = 0.243) polymorphisms were not significantly associated with PCVT. Moreover, coinheritance of these polymorphisms did not confer an increased risk for PCVT (OR=1.17, 95%CI = 0.53–2.61, p = 0.696). Prothrombin G202010A mutation was found to be absent in our population. Conclusion: We conclude that factor V Leiden, factor V A4070G and factor VII R353Q polymorphisms, though present in the Indian population, are not significantly associated with increased risk for PCVT in Indian women.

Homocysteine, folate and vitamin B12 in puerperal cerebral venous thrombosis

Hyperhomocysteinemia (hyper-Hcy) is a known risk factor for venous thrombosis, but few studies document the risk in puerperal cerebral venous thrombosis (CVT). Nutritional folate and vitamin B(12) deficiency can cause hyper-Hcy and pregnancy may contribute to this deficiency. We studied the association of plasma total homocysteine (tHcy), folate and vitamin B(12) levels with puerperal CVT through a case-control study. Sixty women with puerperal CVT and 64 healthy puerperal controls were recruited. Plasma fasting tHcy was estimated by high pressure liquid chromatography using coulometric electrochemical detection. Vitamin B(12) and folate were measured by radioimmunoassay. Risk of puerperal CVT was estimated for each of the three variables. Adjusted odds ratio for the risk of puerperal CVT with hyper-Hcy (>90th percentile) was 10.8 (95% CI: 4.0-29.4; adjusted for vitamin B(12) and folate levels). Low folate and vitamin B(12) levels (<10th percentile) did not increase the risk for puerperal CVT. There was a significant inverse correlation between folate and tHcy levels (rho=-0.471, p<0.001). Hyperhomocysteinemia is associated with an increased risk of puerperal CVT occurring in Indian women and low folate levels contribute significantly to hyper-Hcy. Regular antenatal folate and vitamin B(12) supplementation is likely to lower puerperal tHcy levels, but its clinical benefit needs to be tested by large therapeutic trials.

Uncomplicated pregnancy and puerperium after puerperal cerebral venous thrombosis

In this report we describe an uncomplicated pregnancy and puerperium in a 34 year old patient who had a previous puerperal superior sagittal sinus thrombosis. Heparin was given 3 weeks antepartum and oral anticoagulants 3 months postpartum.

Unusual early presentation of puerperal cerebral venous thrombosis

Hypercoagulability of blood in pregnancy is a well recognised phenomenon. Plasma fibrinogen levels rise from about 200-450 mg% in the non pregnant state to about 400-650 mg% in late pregnancy. Coagulation factors VII, VIII, IX and X are increased and antithrombin III activity and fibrinolytic activity are decreased during pregnancy.’ Deep vein thrombosis and pulmonary embolism are frequently seen and are well recognised. The less common problem of cerebral venous thrombosis is more difficult to recognise and the symptoms may be mistaken for other disorders such as eclampsia, subarachnoid haemorrhage or post dural puncture headache.2*3 Rarely the clinical symptoms may suggest focal intracranial space occupying lesions,4 and the early use of an appropriate CT or MRI scan may avoid diagnostic errors and unnecessary surgery.

Ischemic cerebrovascular disease in the young. Two common causes in India.

Mandurai City is a composite of many villages with a total population not exceeding one million. Undoubtedly more than 95% of the hospital patients come from the rural areas. Our Government Hospital is the largest and reflects the medical assistance provided for people of average and low income. In our experience, 15% of cerebrovascular strokes occur in those below 40 years of age. Meningovascular neurosyphilis in men (10-15%) and puerperal cerebral venous thrombosis in women (20%) were the two commonly proved causes. Haemorrhagic stroke was uncommon. Embolic strokes from rheumatic heart disease formed 10%. In over 50%, the cause of stroke was not clear. Among 150 patients with neurosyphilis, mostly men, 25 had cerebral arterial thrombosis with stroke syndrome. This study reports on 138 patients with cerebral venous thrombosis and 7 patients with arterial thrombosis in puerperium. Mortality was 20% and quality of survival was good. The incidence, clinical picture, and diagnostic investigations are discussed with a review of literature.

Cortical Blindness and Homonymous Hemianopia in the Postpartum Period

CEREBRAL venous thrombosis is a known complication of the puerperium. Cortical blindness has not been reported as a sole manifestation of this syndrome. We describe one patient with cortical blindness and two with homonymous hemianopia attributed to puerperal cerebral venous thrombosis. Report of Cases Case 1.— A 28-year-old woman had development of a severe occipital headache immediately after an uneventful pregnancy and delivery. Four days later, she was unable to see when she awoke from a nap and experienced the first of three typical grand mal seizures. Her history included a severe left-sided throbbing headache five years earlier, which had been preceded by five minutes of partial loss of vision with spots and wavy lines. Findings from general physical examination with special attention to the optic fundi were normal. The pupils reacted briskly and symmetrically to light. There was no perception of light or motion, and opticokinetic nystagmus was absent.

Cortical Blindness and Homonymous Hemianopia in the Postpartum Period

CEREBRAL venous thrombosis is a known complication of the puerperium. Cortical blindness has not been reported as a sole manifestation of this syndrome. We describe one patient with cortical blindness and two with homonymous hemianopia attributed to puerperal cerebral venous thrombosis. Report of Cases Case 1.— A 28-year-old woman had development of a severe occipital headache immediately after an uneventful pregnancy and delivery. Four days later, she was unable to see when she awoke from a nap and experienced the first of three typical grand mal seizures. Her history included a severe left-sided throbbing headache five years earlier, which had been preceded by five minutes of partial loss of vision with spots and wavy lines. Findings from general physical examination with special attention to the optic fundi were normal. The pupils reacted briskly and symmetrically to light. There was no perception of light or motion, and opticokinetic nystagmus was absent.

Puerperal hemiplegia: Case report and review of primary puerperal cerebral venous thrombosis

We have presented a case report which, although lacking operative and pathologic confirmation, appears to fit clearly the rare syndrome, primary puerperal cerebral venous thrombosis. A review of reported cases is analyzed and the symptom complex and clinical findings are discussed in light of presently known pathophysiology.The etiology is presently unknown but possible causes are noted.The differential diagnosis is discussed and the frequent misdiagnosis of puerperal eclampsia is noted.The treatment is as yet not fully agreed upon but the important therapeutic distinction between this syndrome and eclampsia is noted regarding antihypertensive therapy. The use of anticoagulants is indicated in highly selected cases.The prognosis is probably better than the reported cases heretofore indicate. The mortality is 23 per cent in the reviewed cases and 61.6 per cent survive with no residual defect. Symptomatic and supportive care without overtreatment appears to be the wisest course in these patients.