Structural Imaging Characteristic, Clinical Features and Risk Factors of Cerebral Venous Sinus Thrombosis: A Prospective Cross-Sectional Analysis from a Tertiary Care Hospital in Pakistan.
26 May 2021-Vol. 11, Iss: 6, pp 958
TL;DR: In this paper, a prospective study aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan.
Abstract: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that accounts for 05–10% of all strokes Clinical presentation, predisposing factors, neuroimaging findings, and outcomes of CVST are extremely diverse, which causes a high index of suspicion in diagnosis Therefore, early diagnosis of CVST is crucial for prompt treatment to prevent morbidity and mortality Objective: The purpose of this prospective study is aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan Material and Methods: Consecutive patients enrolled in this study had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) along with a clinical presentation to confirm the diagnosis of CVST Categorical data were presented as percentages Continuous variable and categorical data were compared (parenchymal lesions vs non-parenchymal lesions) using the Student’s t-test and Chi-square test, respectively Results: A total of 3261 patients with stroke were presented during the study period Out of all patients, 53 confirmed patients with CVST (16%) were recruited; the predominant population was female (8491%), having a male to female ratio of 1:4 Mean age of the cohort was 2839 ± 719 years Most frequent symptoms observed were headache (9245%) followed by vomiting (7547%), seizures (6226%), papilledema (5472%), visual impairment (4151%), and altered consciousness disturbance (5283%) The presumed risk factors associated with CVST were puerperium (5283%), use of oral contraceptives (1321%), antiphospholipid syndrome (755%), elevated serum levels of protein C and S (566%), and CNS infection (377%) On cranial CT scans, 50 patients (9433%) showed abnormalities while 32 patients exhibited various parenchymal lesions Seizures were more frequent in CVST patients with parenchymal lesions compared with subjects lacking parenchymal lesions Seventy-two sinuses, either single or in combination, were involved in CVST patients, being more common in patients with parenchymal lesions than those without parenchymal lesions The most frequent locations of CVST were the superior sagittal and transverse sinus Conclusion: In short, non-contrast CT brain may be used as a first line investigation in suspected cases of CVST Our study also demonstrates some regional differences in the clinical features, risk factors, and neuroimaging details of CVST as described by some other studies Therefore, care must be taken while diagnosing and predicting the outcome of the CVST
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TL;DR: The case study describes the data and the treatment of two patients with confirmed cerebral venous thrombosis with various localizations and associated risk factors, who were admitted to the neurology department of the Sf.
Abstract: Cerebral venous thrombosis accounts for 0.5–1% of all cerebrovascular events and is one type of stroke that affects the veins and cerebral sinuses. Females are more affected than males, as they may have risk factors, such as pregnancy, first period after pregnancy, treatment with oral contraceptives treatment with hormonal replacement, or hereditary thrombophilia. This neurological pathology may endanger a patient’s life. However, it must be suspected in its acute phase, when it presents with variable clinical characteristics, so that special treatment can be initiated to achieve a favorable outcome with partial or complete functional recovery. The case study describes the data and the treatment of two patients with confirmed cerebral venous thrombosis with various localizations and associated risk factors, who were admitted to the neurology department of the Sf. Apostol Andrei Emergency Hospital in Constanta. The first patient was 40 years old and affected by sigmoid sinus and right lateral sinus thrombosis, inferior sagittal sinus, and right sinus thrombosis, associated with right temporal subacute cortical and subcortical hemorrhage, which appeared following a voluntary abortion. The second case was a patient aged 25 who was affected by left parietal cortical vein thrombosis, associated with ipsilateral superior parietal subcortical venous infarction, which appeared following labor. The data are strictly observational and offer a perspective on clinical manifestations and clinical and paraclinical investigations, including the treatment of young patients who had been diagnosed with cerebral venous thrombosis and admitted to the neurology department.
2 citations
TL;DR: In this article , the role of high altitude exposure in the etiology of aggravating predisposition toward cerebral venous sinus thrombosis (CVST) was investigated.
Abstract: Cerebral venous sinus thrombosis (CVST) is believed to be associated with high‐altitude exposure and has worse clinical prognosis in plateau areas than in plain areas, although this needs to be further verified. This retrospective study aims to compare the clinical differences of patients with CVST in plateau and plain areas and further ascertain the role of high‐altitude exposure in the etiology of aggravating predisposition toward CVST.
1 citations
TL;DR: In this article, the authors attributed hypercoagulability, a common complication of COVID-19, disregarding the severity of the infection, to direct activation of platelets, enhancing coagulation, by direct infection and indirect activation of endothelial cells by SARS-CoV-2.
Abstract: Sinus venous thrombosis (SVT) is an increasingly recognised complication of not only SARS-CoV-2 infections, but also of SARS-CoV-2 vaccinations. SVT is attributed to hypercoagulability, a common complication of COVID-19, disregarding the severity of the infection. Hypercoagulability in COVID-19 is explained by direct activation of platelets, enhancing coagulation, by direct infection and indirect activation of endothelial cells by SARS-CoV-2, shifting endothelial cells from an anti-thrombotic to a pro-thrombotic state, by direct activation of complement pathways, promoting thrombin generation, or by immune thrombocytopenia, which also generates a thrombogenic state. Since SVT may occur even in anticoagulated COVID-19 patients and may have an unfavourable outcome, all efforts must be made to prevent this complication or to treat it accurately.
1 citations
TL;DR: In this paper , a review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsias, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications.
Abstract: Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common “red flag symptoms” attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.
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TL;DR: A subgroup of clinically identifiable CVT patients is at increased risk of bad outcome and may benefit from more aggressive therapeutic interventions, to be studied in randomized clinical trials.
Abstract: Background and Purpose— The natural history and long-term prognosis of cerebral vein and dural sinus thrombosis (CVT) have not been examined previously by adequately powered prospective studies. Methods— We performed a multinational (21 countries), multicenter (89 centers), prospective observational study. Patients were followed up at 6 months and yearly thereafter. Primary outcome was death or dependence as assessed by modified Rankin Scale (mRS) score >2 at the end of follow-up. Results— From May 1998 to May 2001, 624 adult patients with CVT were registered. At the end of follow-up (median 16 months), 356 patients (57.1%) had no symptom or signs (mRS=0), 137 (22%) had minor residual symptoms (mRS=1), and 47 (7.5%) had mild impairments (mRS=2). Eighteen (2.9%) were moderately impaired (mRS=3), 14 (2.2%) were severely handicapped (mRS=4 or 5), and 52 (8.3%) had died. Multivariate predictors of death or dependence were age >37 years (hazard ratio [HR]=2.0), male sex (HR=1.6), coma (HR=2.7), mental status disorder (HR=2.0), hemorrhage on admission CT scan (HR=1.9), thrombosis of the deep cerebral venous system (HR=2.9), central nervous system infection (HR=3.3), and cancer (HR=2.9). Fourteen patients (2.2%) had a recurrent sinus thrombosis, 27 (4.3%) had other thrombotic events, and 66 (10.6%) had seizures. Conclusions— The prognosis of CVT is better than reported previously. A subgroup (13%) of clinically identifiable CVT patients is at increased risk of bad outcome. These high-risk patients may benefit from more aggressive therapeutic interventions, to be studied in randomized clinical trials.
1,903 citations
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: Cerebral venous and sinus thrombosis is a rather rare disease which accounts for <1% of all strokes and current therapeutic measures include the use of anticoagulants such as dose‐adjusted intravenous heparin or body weight‐adjusted subcutaneous low‐molecular‐weightHeparin (LMWH).
Abstract: Background: Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed as a result of the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis and symptomatic therapy including control of seizures and elevated intracranial pressure. Methods: We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence but consensus was clear we stated our opinion as good practice points. Results and conclusions: Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous LMWH or with dose-adjusted intravenous heparin (level B recommendation). Concomitant intracranial haemorrhage (ICH) related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulant therapy after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6–12 months in patients with idiopathic CVST and in those with ‘‘mild’’ thrombophilia, such as heterozygous factor V Leiden or prothrombin G20210A mutation and high plasma levels of factor VIII. Indefinite AC should be considered in patients with recurrent episodes of CVST and in those with one episode of CVST andsevere thrombophilia, such as antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without large ICH and threatening herniation (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. However, in severe cases with impending herniation craniectomy can be used as a life-saving intervention (good practice point).
446 citations
TL;DR: D diagnosis and treatment of CVT should be considered as an emergency because of the considerable potential for full recovery in this condition.
Abstract: In contrast to arterial stroke, cerebral venous thrombosis (CVT) is an infrequent condition which presents with a wide spectrum of signs and with a highly variable mode of onset. The clinician must therefore consider it systematically in all brain syndromes and perform the appropriate neuroimaging investigations: computed tomography (CT) with computed tomography angiography and/or magnetic resonance imaging with magnetic resonance angiography and, if necessary intra-arterial angiography. Once the diagnosis is established, a wide investigation for should be carried out in search of the cause, and treatment started as soon as possible. Treatment is based on the combination of intravenous heparin (followed by oral anticoagulants for 3-6 months), symptomatic treatment (anticonvulsants, analgesics, treatment of increased intracranial pressure) and treatment of the cause. Local thrombolysis is indicated if there is deterioration due to thrombosis extension despite adequate anticoagulation. Diagnosis and treatment of CVT should be considered as an emergency because of the considerable potential for full recovery in this condition.
300 citations
TL;DR: If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point).
Abstract: Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed due to the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence, but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation should be treated either with body weight-adjusted subcutaneous LMWH or dose-adjusted intravenous heparin (good practice point). Concomitant intracranial haemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulation after the acute phase is unclear. Oral anticoagulation may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with 'mild' hereditary thrombophilia. Indefinite anticoagulation (AC) should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and 'severe' hereditary thrombophilia (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Antioedema treatment (including hyperventilation, osmotic diuretics and craniectomy) should be used as life saving interventions (good practice point).
278 citations