Risk Factor For Cerebral Venous Thrombosis Research Articles

Cerebral Venous Thrombosis in Pregnant and Postpartum Women Presenting to the Emergency Department with Headaches.

Cerebral venous thrombosis (CVT) is a thromboembolic disease of the intracranial venous systems. The disease can be difficult to diagnose as it often requires a high index of suspicion. Risk factors for the disease include pregnancy, oral contraceptive pills, congenital thrombophilia, infection, cancer, polycythemia, head trauma, and recent surgery. However, there have been no studies in the United States that have examined whether pregnancy and the postpartum stage are truly a risk factor for CVT. The aim of this study is to determine whether pregnant and postpartum women presenting to the emergency department with headaches have a higher incidence of CVT to better risk stratify which patients need to have advanced imaging pursued. A retrospective, observational case-control study was performing by querying the electronic medical record at a large county hospital for patients presenting with a headache to the emergency department. Patients were stratified into groups based on whether they were diagnosed with CVT, pregnancy status, and comorbid conditions to determine the risk associated between pregnancy, the puerperium stage, and CVT. A total of 20,955 males and females presented to the emergency department between January 1, 2016 and April 13, 2023, with a chief complaint of headache. There were 19,474 female patients and 9581 male patients. In the case group, there were 793 pregnant women and 53 postpartum women. In the control group, there were 18,628 women who were not pregnant. Of the 22 patients diagnosed with CVT, 1 was in the puerperium stage and no patients were pregnant. Pregnant and postpartum patients were 1.05 (0.14-7.80) times more likely to develop CVT. Pregnant and postpartum patients were 1.73 (0.23-13.52) times more likely to develop CVT when controlled for comorbidities. Patients in the puerperium stage were 26.48 (3.33-210.87) times more likely to develop CVT when controlled for comorbidities. Pregnant patients presenting to the emergency department with headaches do not have a significantly higher risk of CVT; however, puerperium patients have a significantly higher risk of CVT compared to the general population.

Cerebral Venous Thrombosis With Topical Estrogen-Progesterone Use in a Young Heterosexual Male: A Case Report.

Our report sheds light on the risk of topical hormonal use in relation to cerebral venous sinus thrombosis. We diagnosed our patient with cerebral venous thrombosis (CVT) using computed tomography venogram, then detailed history and examination were obtained, and thorough blood tests and imaging were done to exclude other causes of CVT like thrombophilias, infections, and malignancies. Our patient is a 37-year-old heterosexual male, presented with headache only. The computed tomography venogram showed extensive CVT in the right internal jugular vein, sigmoid, transverse, and straight cerebral venous; detailed history and investigations suggest that his use of crushed oral contraceptive pills mixed with water topically on the scalp is the most important predisposing factor. This patient was managed with anticoagulants and is being followed in the clinic. Oral hormonal use in contraceptives is a known risk factor for CVT. This case sheds light on the importance of topical hormonal use concerning CVT in females and males; it stresses the need for more studies in that area, as it is poorly studied.

Cancer-associated stroke in a patient with testicular cancer - case report

Introduction. Cerebral venous thrombosis is a rare cerebrovascular disease that affects about 5 in 1 million people each year and accounts for 0.5% of all strokes. There is significant overlap of many risk factors for cerebral venous thrombosis and venous thromboembolism: cancer, obesity, genetic thrombophilia, trauma, infection, and prior neurosurgery. Testicular cancer is a malignant tumor found in testicular cells and it is generally called testicular germ cell tumor. This case report puts emphasis on the importance of recognizing cerebral venous thrombosis as one of the cancer-associated symptoms that can help set the appropriate diagnosis, which, however, is not very common for this type of disease. Case report. A 58-year-old patient has been examined many times due to recurrent strokes. Lumbar puncture, computed tomography scan, magnetic resonance imaging, magnetic resonance angiography, magnetic resonance venography, immunoserology and electroencephalography have been performed. Apart from the vascular changes in the brain blood vessels, the cause of the stroke was not clear. Further?more, the patient was examined by a hematologist and an urologist. Laboratory testing showed increased levels of alpha fetoprotein and beta-human chorionic gonadotropin, however, no tumor was found in the suspected testis. Eventually, the patient underwent retroperitoneal lymph mass percutaneous core biopsy procedure and was diagnosed with non-seminoma germ cell tumor - Yolk sac tumor. Conclusion. Patients with cerebral venous thrombosis require multidisciplinary approach for the appropriate diagnosis.

Clinicoetiological Profile of Cerebral Venous Sinus Thrombosis Patients at a Tertiary Care Center

Background: Cerebral venous sinus thrombosis (CVST) accounts for 10%–20% of strokes in young persons. In India, CVST accounts for around 30% of all strokes. The majority of CVSTs are caused by procoagulant circumstances, with pregnancy and early puerperium being well-established risk factors. The study aimed to look into the clinical profile, radiological characteristics, etiological variables, and outcome of CVST in venous stroke patients admitted to a tertiary care facility. Methods: We included individuals between the ages of 18 and 75 years who had a cerebral venous thrombosis (CVT) diagnosis confirmed by magnetic resonance imaging (MRI) + magnetic resonance venography computed tomography (CT) plus CT venography. The research included all individuals suspected of having CVST with or without particular neurological deficits and a confirmed imaging diagnosis. Patients were removed in situations of ambiguous neuroimaging, arterial strokes, space-occupying lesions, metabolic encephalopathy, and patient reluctance to participate. Results: This study included 82 patients, 21 (25.6%) males and 61 (74.4%) of whom were females. The most common presenting symptom was headache (79.2%), followed by vomiting (54.8%) and abnormal sensorium (35.3%). In this study, 34/82 (41.4%) patients had evident clinical triggers and were classified as induced CVT. Para infectious disease was recognized as a risk factor for CVT in 13/34 (38.2%) patients. A prothrombotic conditions could be established in 48 (58.5%) of these patients. Conclusion: CVST is a treatable and reversible cause of stroke in adolescents. The clinical presentation varies greatly, and symptoms may appear gradually over weeks or months. Although it is still an uncommon cause of headache and stroke, MRI has allowed for early detection.

Cerebral Venous Thrombosis in COVID-19.

COVID-19 causes a hypercoagulable state leading to thrombosis. Many of these thrombotic complications occur in those with severe disease and late in the disease course. COVID-19 has recently been associated with cerebral venous thrombosis (CVT). To study the onset of CVT in relation to COVID-19 and compare their characteristics and outcomes with non-COVID CVT patients admitted during the same period. This multicentric, retrospective study conducted between April 4 and October 15, 2020, included adult patients with CVT who were positive for the SARS-CoV-2 virus and compared them with CVT patients who were negative for the SARS-CoV-2 virus hospitalized during the same period. We studied their clinical profile, risk factors for CVT, and markers of COVID coagulopathy, imaging characteristics, and factors influencing their outcomes. We included 18 COVID-19-infected patients and compared them with 43 non-COVID-19 CVT patients. Fourteen patients in the COVID-19 group presented with CVT without the other typical features of COVID-19. Thirteen patients had non-severe COVID-19 disease. Twelve patients had a good outcome (mRS ≤2). Mortality and disability outcomes were not significantly different between the two groups. Our study suggests a possible association between COVID-19 and CVT. CVT can be the presenting manifestation of an underlying COVID-19, occurring early in the course of COVID-19 and even in those with mild disease. Patients with worse GCS on admission, abnormal HRCT chest, severe COVID-19, and need for invasive ventilation had a poor outcome.

Clinical and epidemiological profile of cerebral venous thrombosis. A Multicenter retrospective study in Aseer Region Saudi Arabi.

Objectives:To assess the epidemiological pattern and correlates with the clinical outcome of Cerebral venous thrombosis (CVT) in Abha, Kingdom of Saudi Arabia.Methods:A retrospective record-based cohort design was conducted including all patients admitted with diagnosis of CVT in 2 main tertiary hospitals in Aseer Region between 2015 to the end of 2018. The study hospitals were Aseer Central Hospital and Armed Forces Hospitals Southern Region. The data were collected by structured data sheets, including sociodemographic data. Assessment of known risk factors for CVT, clinical presentation, treatment received, and clinical outcome after treatment were extracted.Results:The study included 119 patients with CVT, whose ages ranged from 15 to 97 years, with a mean age of 35.5-+14.1 years. Majority of the patients were females (81.5%). Headache was the most presenting (82.4%) symptom, followed by vomiting (30.3%) and a decreased level of consciousness. Thirty-three cases (27.7%) had complications, and recanalization was recorded among 92 cases (94.8%) based on follow up vascular imaging.Conclusion:The study revealed that most of the cases of CVT had favorable clinical outcome and recanalization, especially those who had a shorter duration untildiagnosis. Young females were the most affected group.

Cerebral Venous Thrombosis: an Update.

The purpose of this update is to summarize the recent advances on the management of cerebral venous thrombosis (CVT). There is a trend in declining frequency of CVT patients presenting with focal deficits or coma and a decrease in mortality over time. Anemia and obesity were identified as risk factors for CVT. During pregnancy and puerperium, the higher risk of CVT occurs in the first months post-delivery. With appropriate management, 1/3 of comatose CVT patients can have a full recovery. The management of CVT patients includes treatment of associated conditions, anticoagulation with parenteral heparin, prevention of recurrent seizures, and decompressive neurosurgery in patients with large venous infarcts/hemorrhages with impending herniation. After the acute phase, patients should be anticoagulated for 3-12months. Results of recently completed randomized controlled trials on endovascular treatment and comparing dabigatran with warfarin will improve the treatment of CVT.

A prospective study of demography, clinical presentation and risk factors of cerebral venous thrombosis in pregnant and postpartum women

Introduction: Cerebral venous thrombosis (CVT) is reported in pregnant and postpartum women showing different characteristic because of specific physiology associated with pregnancy and puerperium. Aims and Objectives: To study sociodemographic features and risk factors of CVT in pregnant and postpartum women. Materials and Methods: A total 100 pregnant and postpartum women having CVT were studied at Kamla Raja Hospital and JA Group of Hospital at GR Medical College, Gwalior Madhya Pradesh for study period of 2016 to 2017. Detailed patient’s history, risk factors, symptoms, booking and referral status, place and mode of delivery was recorded. Results: CVT was most common in women with 2nd decade of life (84%), were 2nd gravida (39%), belonging to rural community (82%) and low socioeconomic status (85%). Maximum women came directly to the centre (58%), were unbooked (96%), presented in postpartum period (95%) and were delivered in hospital (86%). Maximum patients were delivered at various district hospitals (25.5%). Most common risk factor for CVT was anemia (56%) followed by hypertension (30%) and infection (17%) Most common clinical presentation was seizure (65%), headache (48%), paresis (26%) and nausea and vomiting (15%). Conclusion: CVT is associated with varied symptoms in pregnancy and postpartum period. Young age, rural community, low socioeconomic class, caesarean delivery, anemia and preeclampsia were the prevailing risk factors. Keywords: Pregnancy, Postpartum period, Anemia, Caesarean delivery, CVT.

Retinopathy Revealing Cerebral Venous Thrombosis in Sickle Cell Disease in Niger

Cerebral venous thrombosis (CVT) in sickle cell disease has been rarely described in the literature. Some authors consider sickle cell disease as a risk factor for CVT. We report the case of a 20-year-old boy, known as sickle cell, followed at the National Reference Center for Sickle Cell Disease in Niger. Admitted in consultation for a decrease of acuity with the right eye with perception of a black spot evolving since about three (3) days, ophthalmological examination revealed sickle cell retinopathy associated with cerebral venous thrombosis on MRI. The rest of the balance showed normochromic anemia, ionic disturbance and a D-dimer at 1500 μg/l. Rehydration, strict rest, antibiotic therapy and analgesics were started with an internal medicine opinion for further treatment. There was an improvement in visual acuity of 6/10 in 48 hours with disappearance of black spot perception, after three weeks, an ad integrum recovery of retinal lesions to control imaging. Despite the ocular complications of sickle cell disease involving visual prognosis, cerebral venous thrombosis is another complication to be investigated in any sickle cell retinopathy.

Non-genetic and genetic risk factors for adult cerebral venous thrombosis

IntroductionA wide variety of non-genetic and genetic factors have been shown to associate with increased risk for cerebral venous thrombosis (CVT). However, there is a paucity of risk factor data and conclusions about their impact are often conflicting. Herein, we quantified the associations of non-genetic and genetic risk factors for CVT in adults. Materials and methodsElectronic databases were searched up to January 2017. Meta-analyses were performed (RevMan v5.3) to determine pooled odds ratios (ORs and 95% CIs) for risk factors, interstudy heterogeneity and publication bias. ResultsTwenty non-genetic (n = 2314) and 33 genetic (n = 2117) studies up to January 2017 met the selection criteria. For non-genetic factors, CVT risk increased in the presence of glucocorticosteroid therapy by 18.3-fold (3.3–102.6), alcohol consumption 2.7-fold (1.8–3.9), infection 7.5-fold (2.6–21.6), surgery 9.6-fold (1.1–83.5), hypercholesterolaemia 2.4-fold (1.3–4.4), hyperhomocysteinaemia 3.1-fold (2.1–4.6), antiphospholipid antibodies 7.0-fold (2.1–23.6), autoimmune diseases 5.6-fold (2.3–13.6), anaemia 4.0-fold (2.1–7.9), malignancy 3.2-fold (1.4–7.1) and pregnancy/puerperium 11.4-fold (5.7–24.3). Smoking, hypertension and diabetes did not associate with CVT risk. For genetic factors, CVT risk increased in the presence of factor V Leiden (G1691A) by 2.5-fold (1.9–3.3), protein C deficiency 10.7-fold (3.1–37.7), protein S deficiency 5.7-fold (1.4–22.4), antithrombin deficiency 3.8-fold (1.0–13.8), prothrombin (G20210A) 5.5-fold (4.0–7.27) and TAFI gene variant (C1040T) 1.6-fold (1.0–2.4). Prothrombin G20210A and factor V Leiden polymorphisms tended to have higher ORs for CVT than for ischaemic stroke. ConclusionsWe provide quantitative data supporting a strong basis for genetic and non-genetic risk factors in CVT. Its genetic liability seems higher when compared with sporadic ischaemic stroke.

Misdiagnosis of Cerebral Vein Thrombosis in the Emergency Department.

Rates of cerebral venous thrombosis (CVT) misdiagnosis in the emergency department and outcomes associated with misdiagnosis have been underexplored. Using administrative data, we identified adults with CVT at New York, California, and Florida hospitals from 2005 to 2013. Our primary outcome was probable misdiagnosis of CVT, defined as a treat-and-release emergency department visit for headache or seizure within 14 days before CVT. In addition, logistic regression was used to compare rates of clinical outcomes in patients with and without probable CVT misdiagnosis. We performed a confirmatory study at 2 tertiary care centers. We identified 5966 patients with CVT in whom 216 (3.6%; 95% confidence interval [CI], 1.1%-4.1%) had a probable misdiagnosis of CVT. After adjusting for demographics, risk factors for CVT, and the Elixhauser comorbidity index, probable CVT misdiagnosis was not associated with in-hospital mortality (odds ratio, 0.14; 95% CI, 0.02-1.05), intracerebral hemorrhage (odds ratio, 0.97; 95% CI, 0.57-1.65), or unfavorable discharge disposition (odds ratio, 0.90; 95% CI, 0.61-1.32); a longer length of hospital stay was seen among misdiagnosed patients with CVT (odds ratio, 1.62; 95% CI, 1.04-2.50). In our confirmatory cohort, probable CVT misdiagnosis occurred in 8 of 134 patients with CVT (6.0%; 95% CI, 2.6%-11.4%). In a large, heterogeneous multistate cohort, probable misdiagnosis of CVT occurred in 1 of 30 patients but was not associated with the adverse clinical outcomes included in our study.

Should We Screen for Janus Kinase 2 V617F Mutation in Cerebral Venous Thrombosis?

Background: The presence of Janus Kinase 2 (JAK2) V617F mutation represents a major diagnostic criterion for detecting myeloproliferative neoplasms (MPN) and even in the absence of overt MPN, JAK2 V617F mutation is associated with splanchnic vein thrombosis. However, the actual prevalence and diagnostic value of the JAK2 V617F mutation in patients with cerebral venous thrombosis (CVT) are not known. The aims of this study were to assess the prevalence of JAK2 V617F mutation in a large group of consecutive CVT patients, to detect clinical, biological, and radiological features associated with the mutation, and to determine the long-term venous thrombosis recurrence rate in CVT patients with JAK2 mutation but without overt MPN in order to recommend the best preventive treatment. Methods: This was a prospective study conducted on consecutive patients with a first-ever radiologically confirmed CVT. JAK2 V617F mutation analysis was assessed in all the study subjects. JAK2 V617F-positive patients were followed up to detect new venous thrombotic events. Results: Of the 125 included subjects, 7 were found to have JAK2 V617F mutation (5.6%; 95% CI 2.3-11.2). Older age (p = 0.039) and higher platelet count (p = 0.004) were independently associated with JAK2 V617F positivity in patients without overt MPN. During a mean follow-up period of 59 (SD 46) months, 2 JAK2 V617F-positive patients presented with 4 new venous thromboembolic events. Conclusions: Screening for the JAK2 V617F mutation in CVT patients seems to be useful even in the absence of overt MPN and/or in the presence of other risk factors for CVT because of its relatively high prevalence and the risk of thrombosis recurrence.

Facial palsy in cerebral venous thrombosis: An atypical case in a young girl

Cerebral venous thrombosis (CVT) is a rare and potentially life-threating cause of stroke. A number of etiologies and risk factors for CVT have been identified so far. These include head trauma, local and systemic infectious diseases, malignancies, autoimmune diseases, and oral contraceptive use. The most common clinical symptoms are headache and changes in consciousness. Cranial nerve palsy in CVT is uncommon, and there are very few reports of facial nerve palsy. This case report highlights an atypical manifestation in a CVT patient, who presented with peripheral facial palsy. The patient was successfully treated with anticoagulation.

Thrombosis of the cerebral veins in gynecological practice

The review presents literature data on the risk factors of cerebral venous thrombosis (CVT), a rare life threatening disorder. Currently, the diagnosis of CVT is made more often due to the possibility of using neuroimaging methods of cerebral structures. Pregnancy, postpartum period, use of oral contraceptives are risk factors of CVT. A role of thrombophilia, in particular Factor V Leiden mutations and the prothrombin G20210A polymorphism, in the CVT pathogenesis is confirmed. The development of CVT is an example of the interaction between persistent risk factors increasing the likelihood of thrombotic complications and acquired risk factors. A focal neurological deficit during pregnancy, delivery and postpartum period is the best indicator of CVT diagnosis. Possibilities of the use of anticoagulants in treatment and prevention of CVT are analyzed.

Malignant Cerebral Venous Sinus Thrombosis in Polycythemia.

Malignant Cerebral Venous Sinus Thrombosis in Polycythemia.

Association Between Anemia and Cerebral Venous Thrombosis: Case-Control Study.

Anemia is often considered to be a risk factor for cerebral venous thrombosis (CVT), but this assumption is mostly based on case reports. We investigated the association between anemia and CVT in a controlled study. Unmatched case-control study: cases were adult patients with CVT included in a single-center, prospective database between July 2006 and December 2014. Controls were subjects from the control population of the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) study. Anemia was defined according to World Health Organization criteria: nonpregnant women hemoglobin<7.5 mmol/L, pregnant women<6.9 mmol/L, and men<8.1 mmol/L. We used logistic regression analysis, adjusting for age, sex, malignancy, oral contraceptive use, and pregnancy/puerperium. We included 152 cases and 2916 controls. Patients with CVT were younger (mean age, 40 versus 48 years) and more often women (74% versus 53%) than controls. Anemia was more frequent in cases (27.0%) than in controls (6.5%; P<0.001). Anemia was associated with CVT, both in univariate analysis (odds ratio, 5.3; 95% confidence interval [CI], 3.6-7.9) and after adjustment for potential confounders (adjusted odds ratio, 4.4; 95% CI, 2.8-6.9). Hemoglobin as a continuous variable was inversely associated with CVT (adjusted odds ratio per 1 mmol/L change 0.53; 95% CI, 0.42-0.66). Stratification by sex showed a stronger association between anemia and CVT in men (adjusted odds ratio, 9.9; 95% CI, 4.1-23.8) than in women (3.6; 95% CI, 2.1-6.0). Our data suggest that anemia is a risk factor for CVT.

Clinical Course of Cerebral Venous Thrombosis in Adult Acute Lymphoblastic Leukemia

Venous thromboembolism (VTE) is a frequent complication in patients with acute lymphoblastic leukemia (ALL). A significant proportion of patients develop cerebral venous thrombosis (CVT). To investigate risk factors for and the clinical course of CVT in ALL patients, we describe all cases of CVT which occurred in a well-defined cohort of 240 adults, treated for newly diagnosed ALL in the HOVON (Dutch-Belgian Hemato-Oncology Cooperative Group)-37 study. We conducted a nested case-control study to explore the relevance of early symptoms and risk factors for CVT in ALL patients. Nine of 240 patients developed CVT (4%). CVT occurred during or shortly after L-asparaginase therapy (in 8 cases) and shortly after intrathecal methotrexate injections (in all cases) during cycle I of remission induction treatment. CVT was associated with prior headache and seizures. In 5 of 9 patients with CVT, headache before the diagnosis of CVT occurred within 3 days after lumbar puncture and initially had a postural character. CVT is relatively common in adult ALL patients. Our data suggest that CVT in adult ALL patients results from the additive effects of multiple risk factors, with a particular role for asparaginase and the effects of lumbar punctures for intrathecal therapy.

Report of Nineteen Cerebral Vein Thrombosis Referrals to an Emergency Departmenta Case Series and Literature Review

Background: Risk factors, diagnosis, treatment and outcome of patients with cerebral venous thrombosis (CVT) have always been challenging. Objectives: The present study aimed to report on the characteristics of CVT in the patients referring to the emergency unit of a teaching hospital to review and add to the current knowledge on this topic. Patients and Methods: This was a retrospective cross sectional study, which consisted of a series of 19 patients admitted to the emergency department during one year with the diagnosis of CVT. The required data were extracted from existing reports in the case files via manualsearching. All patients were re-evaluated prospectively with the goal of outcome assessment. Results: This study included 19 patients with CVT. Mean age of the cases was 38.7 ± 8.8 years (range 22 to 62 years) and they were predominantly women (84.2%). The most common chief complaint at presentation was headaches, observed in 15 (78.9%) of the patients either solely or accompanied with other symptoms. Use of oral contraceptive pills (OCPs) was reported in more than half of the cases. The outcome was favorable in 18 (94.7%) of the cases and only one patient, despite appropriate five months of remedial measures, still suffered from visual disturbance. Conclusions: Although many risk factors for CVT have been identified thus far, it seems that there are different patterns of frequency among ethnic groups. Thus, an inter racial comparison study is still needed. Likewise, with attention to the lack of proper studies and strong evidence regarding treatment options, conducting a multicenter prolonged study with a large sample size is apparently required.

Cerebral venous thrombosis and Buerger’s disease

In November 2011, a 44-year-old male patient developed progressive and intense headaches accompanied with vomiting and blurred vision. Five years ago, he was diagnosed with severe arteritis attributed to thromboangiitis obliterans (Buerger’s disease), requiring sympatholysis and implantation of a neurostimulator due to severe chronic pain. Despite smoking cessation in March 2010, he had his right leg amputated in August 2010 (panel A) and 1 month later he presented with signs suggestive of acute anterior myocardial infarction. Coronarography disclosed subocclusion of the anterior interventricular artery due to a movable clot, without underlying artery stenosis; the clot was removed by catheter aspiration. Patient was placed under clopidogrel 75 mg and aspirin 80 mg daily from that moment and no either significant event was reported since its admission at the emergency room. Head CT scans (panels B and C) revealed extensive thrombus of the superior longitudinal sinus (arrowheads), the straight sinus and the vein of Galen (arrows), as well as the inferior longitudinal and the right transverse sinuses (not shown). D-dimers and fibrinogen were transiently moderately elevated (0.9 lg ml [normal \0.5] and 591 mg % [normal: 170–400]). Prothrombin time and platelet count were normal. Long-term anticoagulation therapy was started. Further hemostasis testing revealed no coagulation disorder (homocystein was slightly elevated: 16.9 lmol l [normal: 5–15]; antithrombin and activated partial thromboplastin time values were within the normal range; G20210A prothrombin mutation, activated protein C resistance, anticardiolipin antibodies, circulating anticoagulants and anti B2GP1 antibodies were negative). Clinical resolution and radiological improvement were observed after 3 months of treatment and no further complications reported. Cerebral venous thrombosis (CVT) is a rare stroke type, but it is also the only one that can be cured before the pathology of the vessel has led to damage of the brain parenchyma. While headaches are the most common signs of CVT, 60–90 % of patients will develop cerebral— potentially fatal—complications without prompt initiation of anticoagulant therapy [1]. A brain MRI was not available in our patient, due to implanted neurostimulator, so that thrombus was evidenced using CT scan. Interestingly, diagnosis was already suspected based on an unenhanced CT scan of the brain, a routine test available at the emergency department (Fig. 1). Although there are numerous factors predisposing a patient to develop CVT, BD is not listed among them [1]. We found three previous reports presenting associations of CVT and BD [2–4]. Questioning more specifically the link between CVT and BD could therefore bring a new perspective to clinicians studying these conditions. This is particularly true for BD, since the pathogenesis of this disease is still largely unknown [5]. Yet, smoking is known to influence BD activity. In our patient, CVT occurred 20 months after smoking cessation, while the last arterial event was reported 6 months after the cessation. A causal association may thus appear less likely. Conversely, no common risk factor for CVT was found in our patient, J.-M. Raymackers (&) Department of Neurology, Clinique Saint-Pierre, 9 avenue Reine Fabiola, 1340 Ottignies, Belgium e-mail: je.raymackers@clinique-saint-pierre.be

Cerebral Venous Thrombosis in an Elderly Adult Treated with Diethylstilbestrol

To the Editor: Cerebral venous thrombosis (CVT) is rare in elderly adults. Multiple risk factors are known to lead to a CVT, in particular, drugs such as estrogens, cytotoxics (e.g., thalidomide), corticosteroids, and others. Herein is reported the case of an individual with prostate cancer in remission treated with diethylstilbestrol and in whom a CVT was diagnosed during the course of an examination for isolated headache. Isolated headaches due to CVT are rarely seen in elderly adults.1 Thromboembolic complications due to this hormone therapy are well known, but no CVT has been previously reported in the literature. In May 2012, an 81-year-old man was admitted for a 7-month history of right hemicrania and retro-orbital pain without nausea, vomiting, focal neurological signs, visual disorder, or seizure. His past medical history included prostate cancer (2003) treated with diethylstilbestrol since September 2009. He had no history of migraine. His medication consisted of diethylstilbestrol (1 mg/d). He was self-sufficient except for meals, and his cognitive function was intact. He had a dental infection (pericoronitis) a few weeks before admission that was treated with 5 days of spiramycin and metronidazole followed by dental extraction. Clinical examination revealed no fever, no focal neurological signs, impaired consciousness, or changes in mental status. His hemodynamic status was normal, as was his general examination. Laboratory studies revealed normal blood count, electrolytes, serum creatinine, C-reactive protein, coagulation studies, and prostate-specific antigen (PSA). Brain magnetic resonance imaging showed thrombosis in the right lateral sinus without any lesion in the parenchyma (Figure 1). He was admitted to the Geriatric Department and received anticoagulation and analgesics. The diethylstilbestrol was discontinued because it is known to be a potential etiological factor. His clinical course slowly improved, but moderate headaches were still present 9 months after discharge. He had no further thrombotic events. No other treatment was given in place of diethylstilbestrol for his prostate cancer because it appeared to be well controlled. Cerebral venous thrombosis is rare, especially in elderly adults. In a prospective series of 624 individuals with CVT, 51 (8.2%) were aged 65 and older, and only four (0.64%) were aged 80 and older.1 Headache is the earliest and most frequent symptom but is rarely isolated,2 particularly in elderly adults, in whom the prognosis is worse (49% made a complete recovery vs 82% in younger individuals).1 Impaired consciousness and mental changes are more frequent in elderly adults.1 The current case was atypical because the usually observed symptoms were absent, and he had a favorable prognosis (no deficit or dependence). A multitude of conditions have been found to be risk factors for CVT. The most common conditions are hereditary thrombophilia, pregnancy and puerperium, postoperative state, intracranial and local infections, and the use of oral contraceptives. The cause of CVT is frequently multifactorial, and in fewer than 20–35% of cases, no clear risk factor is identified.3 Cancers can lead to CVT and are statistically more significant1 in elderly adults, although the individual described herein was in remission at that time, and this complication is rare. More than 5% of men diagnosed with prostate cancer have a past history of a thromboembolic event even when no traditional risk factors for venous thromboembolism4 are present. A case of CVT was reported in an individual with prostate cancer (with high PSA) without any risk factors.5 In the current case, no other cancer was detected. The dental infection was not sufficient to lead a CVT, and the dental CT scan excluded any deep infection. Prothrombotic screening was normal. In younger individuals, estrogen therapy can lead to CVT. High estrogen levels (≥50 μg) increase the risk of venous and arterial thromboses. Each diethylstilbestrol dose contained 3.33 mg of estrone, but no CVT has been previously described in the literature In France, only five cases of thromboembolic complications that seemed to be related to diethylstilbestrol treatment have been reported, but no case of CVT. In this patient, the chronology of the clinical course strongly suggests that diethylstilbestrol was the etiological factor involved. Cerebral venous thrombosis is rarely found to be the cause of isolated headache, especially in elderly patients. Diethylstilbestrol can provoke venous and arterial thrombosis, but no published report has ever suggested that it can cause CVT. This case report is also atypical because the prognosis was so favorable. We thank Dr. Donald Schwartz for correcting the English version. Conflict of Interest: The editor finds no conflict of interest for any of the authors. Author Contributions: Elodie Ponce took care of the patient and prepared and wrote the paper. Karl Mondon participated in the writing and revised the final version. Jean-Philippe Cottier acquired and interpreted the MRI scan. Yves Gruel explored the coagulation and thrombophilia. Caroline Hommet revised and approved the final version. Sponsor's Role: None.