Dural sinus and cerebral venous thrombosis. Incidence in young women receiving oral contraceptives.
TL;DR: Anticoagulant therapy is not advisable for patients with cerebral venous thrombosis after neurologic signs have developed for fear of evoking cerebral hemmorhage.
Abstract: 2 cases are presented of dural sinus and cerebral venous thrombosis in obese but healthy women who were using oral contraceptives. The first was 35-year-old with 5 children and a history of eclampsia and hypertension. She had used Enovid (norethynodrel and mestranol) intermittently for 2 years. She first noted right sided headache then gradually nausea vomiting diarrhea seizures weakness urinary incontinence. On hospitalization 5 days later an echoencephalogram showed shift of midline structures to the left a brain scan showed increased uptake on the right and an angiogram suggested an avascular mass. Craniotomy revealed an intracerbral hematoma and cortical vein thrombosis. She died 1 week later. The autopsy demonstrated thrombi in the superior sagittal sinus and a right frontal hematoma suggesting that the cortical vein thrombi propagated back leading to stasis infarction and hemorrhage. The second case was a 27-year-old mother of 3 who had been taking Ortho-Novum (norethindrone and mestranol) for 12 days. She had 2 days of severe headache then loss of dexterity and visual acuity. No venous pulsation could be seen in the optic fundi. Angiogram showed lack of filling of cortical veins. Spinal fluid had an opening pressure of 400 mm 320 red cells /ml and 80 mg protein/ml. On the fifth day she had Jacksonina seizures and on the eleventh day maximal shift of midline structures 8 cm to the left was measured. Except for thrombophlebitis of right leg and pulmonary embolism she gradually improved. Anticoagulant therapy is not advisable for patients with cerebral venous thrombosis after neurologic signs have developed for fear of evoking cerebral hemmorhage.
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TL;DR: Cerebral venous thrombosis is an infrequent condition characterized by extreme variability in its clinical presentation and mode of onset and the combination of magnetic resonance imaging and magnetic resonance angiography is currently the best method for diagnosis.
711 citations
TL;DR: This study shows that CVT is not rare, that the clinical diagnosis is extremely difficult because of the variable modes of onset and groupings of symptoms, that most CT findings are non specific and that angiography remains the best diagnostic tool.
Abstract: A series of 38 patients with angiographically proven cerebral venous thrombosis (CVT) affecting dural sinuses is reported. This study shows that CVT is not rare, that the clinical diagnosis is extremely difficult because of the variable modes of onset and groupings of symptoms, that most CT findings are non specific and that angiography remains the best diagnostic tool. Only 4 patients died, which suggests a more benign outcome than classically described. None of the 23 heparin treated patients died, which indicates that anticoagulants were not harmful in this series.
709 citations
TL;DR: Treatment data from controlled trials favour the use of anticoagulation (AC) as the first-line therapy of CVST because it may reduce the risk of a fatal outcome and severe disability and does not promote ICH.
Abstract: Cerebral venous and sinus thrombosis (CVST) can present with a variety of clinical symptoms ranging from isolated headache to deep coma. Prognosis is better than previously thought and prospective studies have reported an independent survival of more than 80% of patients. Although it may be difficult to predict recovery in an individual patient, clinical presentation on hospital admission and the results of neuroimaging investigations are--apart from the underlying condition--the most important prognostic factors. Comatose patients with intracranial haemorrhage (ICH) on admission brain scan carry the highest risk of a fatal outcome. Available treatment data from controlled trials favour the use of anticoagulation (AC) as the first-line therapy of CVST because it may reduce the risk of a fatal outcome and severe disability and does not promote ICH. A few patients deteriorate despise adequate AC which may warrant the use of more aggressive treatment modalities such as local thrombolysis. The risk of recurrence is low (< 10%) and most relapses occur within the first 12 months. Analogous to patients with extracerebral venous thrombosis, oral AC is usually continued for 3 months after idiopathic CVST and for 6-12 months in patients with inherited or acquired thrombophilia but controlled data proving the benefit of long-term AC in patients with CVST are not available.
300 citations
Book•
15 Jul 1997
TL;DR: In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation even when the clinical situation seems desperate as mentioned in this paper.
Abstract: Cerebral venous thrombosis is a rare disorder with highly variable and nonspecific clinical presentations. For these reasons, specific treatment should be given only when the diagnosis has been firmly established. Etiologic diagnosis should begin in the emergency department to identify underlying conditions that require specific treatment.
The mainstay of treatment is anticoagulation with heparin, even in the case of cerebral hemorrhage, followed as soon as possible by oral anticoagulant administration. The optimal duration of oral anticoagulation has not been established. By analogy with systemic venous thrombosis, it should be prolonged 3 to 6 months. When a high risk of recurrence is present, treatment should be continued until the risk disappears.
In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation even when the clinical situation seems desperate. For the same reason, aggressive treatment of intracranial hypertension and seizures or status epilepticus is warranted.
Screening for extraneurologic venous thrombosis should be done by means of clinical examination and, if necessary, specific imaging procedures.
Local thrombolysis is not yet of proven efficacy and safety. It can be used in patients with clinical worsening related to documented extension of the venous thrombosis despite anticoagulation and in the absence of cerebral hematoma.
Surgical treatment is limited to external ventricular drainage and suboccipital craniotomy in the very rare cases of cerebellar vein thrombosis with edematous cerebellar infarct.
299 citations
TL;DR: Cerebral venous thrombosis in adults is not uncommon in Saudi Arabia, and Behçet's disease is the single most common etiology.
Abstract: Background and Purpose We undertook this study to determine the frequency, clinical patterns, and etiologies of cerebral venous thrombosis in a Middle Eastern country. Methods Records of all adult patients admitted with an angiographically documented diagnosis of cerebral venous thrombosis from 1985 through 1994 in two major hospitals of Riyadh, Saudi Arabia, were reviewed. Results Forty patients (20 men, 20 women) aged 16 to 40 years were identified. Hospital frequency was 7 per 100 000 patients, and the relative frequency against arterial strokes was 1:62.5. Nineteen cases (47%) had a clinical picture of pseudotumor cerebri. Behcet’s disease was the cause in 10 cases (25%). Other causes included antiphospholipid antibodies in 4, protein S deficiency in 3, intracranial tumors in 3, systemic lupus erythematosus in 3, infections in 3, antithrombin III deficiency in 2, postpartum in 1, and oral contraceptives in 1. Conclusions Cerebral venous thrombosis in adults is not uncommon in Saudi Arabia. Behcet’s ...
268 citations
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Journal Article•
112 citations
TL;DR: This is a report of an investigation into the possible untoward effects of papilledema occurring in a woman who had been using an oral contraceptive, for which the present authors are responsible.
Abstract: At the October 1964, meeting of the Academy of Ophthalmology and Otolaryngology, during a teaching session, one of us (F.W.) remarked on papilledema occurring in a woman who had been using an oral contraceptive, and that he was not aware of any such case having been reported. Other members of the panel (Drs. Thomas Hedges, Donald Lyle, and Lawton Smith) and a colleague in the assembled group had also pondered the possible untoward effects of such substances on the basis of personal experiences or communications with their colleagues. The panel associates agreed that we were obligated to investigate the problem in our respective areas and to put together a report. This is a report of such an investigation, for which the present authors are responsible. After having talked with Dr. David Cogan it seemed expedient to place an editorial in theArchives of Ophthalmologywith a single purpose: to uncover
104 citations
TL;DR: It is concluded that there is not enough evidence to demonstrate a specific correlation between neurological disorders and progestational steroids, and it is recommended that oral contraceptives be administered with caution under these conditions.
Abstract: Case studies of 34 women with neurological syndromes associated with oral contraceptive use are discussed with a view to identifying contraindications of progestational steroid use. The patients were classified by occlusive cerebral arterial disease (5 patients) cortical vein thrombosis (1 patient) and vascular headaches (28 patients). Studies are cited reporting the relationship of oral contraceptives to arterial thrombosis coronary artery thrombosis cerebralvascular disorders and intravascular thrombosis. The possible relation of vascular disorders to thrombosis is mentioned. It is concluded that there is not enough evidence to demonstrate a specific correlation between neurological disorders and progestational steroids. It is recommended that oral contraceptives be administered with caution under these conditions: 1) hypertension 2) history of recurrent vascular headaches 3) history of Raynauds or other vasospastic phenomena 4) history of occlusive arterial disease and 5) epilepsy.
61 citations
TL;DR: It is suggested that there is an apparent association between the use of oral contraceptives and the increased number of episodes of cerebral arterial insufficiency and care should be taken in prescribing oral contraceptives to patients with a family history or past history of such events as toxemia of pregnancy venous thrombosis hypertension or hemiparetic migrainous attacks.
Abstract: Previously when an association between oral contraceptives and cerebrovascular accidents was investigated findings were based on deaths or upon arteriographically proved vascular occlusions. It has been the authors experience that there are many more cases of women taking or not taking the pill who present the clinical picture of abrupt cerebrovascular insufficiency but who recover and who may show very little on arteriographic study. The clinical experience of 2 neurologists in the Birmingham England area with nonfatal cases of incomplete hemiplegia of arterial type is reported in women under 45. In 1954-1963 inclusive 25 such cases were seen. None were on any drug or preparation known to influence vascular thrombosis. During 1964-1966 the total number of new neurological patients referred each year remained constant but the number of arterial episodes of this type was 25 compared to the 6-8 expected. 18 of the 25 were taking oral contraceptives. Case histories of the oral contraceptive users are given in the report. It is suggested that there is an apparent association between the use of oral contraceptives and the increased number of episodes of cerebral arterial insufficiency. Care should be taken in prescribing oral contraceptives to patients with a family history or past history of such events as toxemia of pregnancy venous thrombosis hypertension or hemiparetic migrainous attacks. If a patient taking an oral contraceptive begins to have episodes of loss of motor or sensory function corresponding to the supply of a cerebral artery these should be regarded as danger signals and the authors suggest that that method of contraception be discontinued.
53 citations
TL;DR: Five young women have seen five young women in the course of the past year, each of whom had a stroke in the absence of any of the predisposing medical conditions mentioned above, and each patient had been using an oral contraceptive drug when the stroke occurred.
Abstract: A STROKE in a young woman is an uncommon clinical event When it does occur, an etiology other than atherosclerosis is often found if diligently sought for Pregnancy, atrial fibrillation, rheumatic heart disease, endocarditis, vasculitis, trauma, or blood dyscrasias are the associated conditions usually thought of, and it is only the unusual case in which no cause can be ascertained We have seen five young women in the course of the past year, each of whom had a stroke in the absence of any of the predisposing medical conditions mentioned above Each patient had been using an oral contraceptive drug when the stroke occurred Because of the possibility that oral contraceptives may play a causative role in the genesis of brain infarction, we are prompted to record these cases Report of Cases Case 1 (NCBH 41 57 73) —A 24-year-old white woman, gravida 3, para 3, with a family
35 citations