Early cerebral sinovenous thrombosis in a child with acute lymphoblastic leukemia carrying the prothrombin G20210A variant: a case report and review of the literature

This paper describes the case of a male child with acute lymphoblastic leukemia who developed cerebral sinovenous thrombosis on day 6 of induction therapy with intrathecal methotrexate and methylprednisolone. A central venous catheter had been implanted the day before. The heterozygous prothrombin G20210A variant was found together with acquired activated protein C resistance and a reduced activated partial thromboplastin time. Clinical course and magnetic resonance imaging with magnetic resonance venography gradually improved over the following days after starting anticoagulant therapy (heparin and nadroparin). Cerebral sinovenous thrombosis is a serious disease in leukemic children, occurring in up to 6% of these patients. Data from the literature are in favor of anti-coagulant treatment, even though the efficacy and safety of thromboprophylaxis during chemotherapy in leukemic children with inherited thrombophilic conditions remain to be demonstrated.

Lumbar Puncture and Dural Sinus Thrombosis – A Causal or Casual Association?

BACKGROUND

A few cases of cerebral venous thrombosis (CVT) were reported after a lumbar puncture (LP), suggesting a causal association. The purpose of our study was to document that LP might predispose to CVT by decreasing blood flow velocities (BFV) in veins or dural sinus.

METHODS

We performed a transcranial Doppler ultrasound study to register the mean BFV of the straight sinus (SS) before, during and after LP.

RESULTS

Thirteen patients were studied. LP induced a decrease of 47% of mean BFV in the SS. The mean decrease of BFV was significant immediately at the end (p = 0.003), 30 min after (p = 0.015) and more than 6 h after LP (p = 0.008).

CONCLUSIONS

LP induced a sustained decrease of mean BFV in the SS. The decrease of venous blood flow is a possible mechanism contributing to the occurrence of CVT.

Rheolytic catheter thrombectomy, balloon angioplasty, and direct recombinant tissue plasminogen activator thrombolysis of dural sinus thrombosis with preexisting hemorrhagic infarctions

We describe the case of a 28-year-old obtunded woman who presented with bilateral anterior parietal lobe cortical hemorrhages associated with thrombosis of the superior sagittal sinus, both transverse and sigmoid sinuses, and multiple cortical veins draining into the sagittal sinus. Initial heparin therapy was not effective. A combination of AngioJet rheolytic catheter thrombectomy, balloon angioplasty, and continuous direct superior sagittal sinus recombinant tissue plasminogen activator infusion led to venous recanalization with a successful clinical outcome, without worsening of the preexisting intracranial hemorrhages.

[Sinus vein thrombosis. A rare complication of heparin-induced thrombocytopenia type II]

In the past 10 years numerous reports of cases referring to complications and their outcome with heparin-induced thrombocytopenia type II (HIT II) have been published. Clinically these symptoms are manifested as a combination of arterial and venous thromboembolisms. Mostly affected are the vessels of the limbs, the abdomen, kidneys and coronary arteries. We present the most rare initial manifestations of cerebral symptoms with headache, nausea, change of character and generalised convulsion, which have found their origin in sinus vein thrombosis and the treatment with the heparinoid danaparoid.

Sigmoid sinus thrombosis in a child after closed head injury

Sigmoid sinus thrombosis in children following a closed head injury is rare. The authors report such a case with the clinical presentation, radiological findings and current literature.

A transcranial approach for direct mechanical thrombectomy of dural sinus thrombosis

✓ Cerebral venous sinus thrombosis is often difficult to manage. Treatment options include systemically delivered anticoagulation therapy or chemical thrombolysis. Targeted endovascular delivery of thrombolytic agents is currently a popular option, but it carries an increased risk of hemorrhage. These strategies require significant time to produce thrombolysis, often in a patient with a rapidly deteriorating neurological condition. Rapid mechanical recanalization with thrombectomy is therefore very attractive; this procedure provides rapid recanalization with no increased risk of hemorrhage from use of thrombolytic agents. Nevertheless, the rheolytic catheter is large and stiff and may not be able to navigate tortuous intracranial vascular anatomy. The authors present their experience with direct dural sinus mechanical thrombectomy performed using the rheolytic catheter via a transcranial route.

Two patients with dural sinus thrombosis and rapidly deteriorating levels of consciousness underwent unsuccessful attempts at mechanical thrombolysis via the usual transfemoral route. Through a burr hole over the dural sinus, mechanical thrombectomy was subsequently performed using the thrombectomy catheter. Sinus patency was restored following treatment and both patients demonstrated neurological recovery.

Hemorrhage or a rapidly deteriorating neurological condition may preclude the use of systemic or locally delivered thrombolytic agents for the treatment of cerebral venous sinus thrombosis. Mechanical thrombectomy may be the treatment of choice in these circumstances. In patients with limited transfemoral access, a transcranial approach may be used to access the cerebral dural sinuses and thrombectomy may be safely and effectively performed. Further evaluation of this therapy is warranted.

Cerebral venous and dural sinus thrombosis in severe falciparum malaria

Common causes of coma in falciparum malaria are cerebral malaria, hypoglycaemia and electrolyte disturbances. Focal deficits due to arterial infarcts may sometimes occur in children, but are rare in adults. Three adults with falciparum malaria who had fever, altered consciousness and focal neurological deficits (one of whom also had seizures) are being reported here. CT scan of the brain revealed haemorrhagic infarction of the cerebral cortex and subcortical white matter with surrounding oedema suggestive of venous infarction in all three patients. The diagnosis of cerebral venous thrombosis was missed in the first patient, and was detected only at autopsy. In the next two patients, superior sagittal sinus thrombosis was confirmed angiographically. Only one patient survived; the other two died of increased intracranial pressure. Two of the three patients also had Plasmodium vivax co-infection. A hypercoagulable state resulting from severe malaria may be responsible for this rare and potentially fatal complication. Cerebral malaria may be associated with raised intracranial pressure due to cerebral oedema. Cerebral venous thrombosis may worsen this and adversely affect outcome. This diagnosis should be suspected in patients with severe malaria who develop focal neurological deficits and confirmed by appropriate imaging; judicious use of local thrombolytic therapy may help improve outcome.

Sinus pericranii: clinical and imaging findings in two cases of spontaneous partial thrombosis

Sinus pericranii is an unusual venous anomaly characterized by communication of pericranial varicosities with an underlying dural sinus. We report two cases of spontaneous partial thrombosis of sinus pericranii presenting as focally tender, nonreducible mass lesions different in character from the baseline venous abnormality. CT, CT angiography, and CT venography (CTV) were performed in both cases. CTV was essential in depicting thrombi within the varicosities. MR (in one case) demonstrated the anomaly well, but the thrombus was not evident. Conservative therapy was instituted in both cases.

Cerebral sinus venous thrombosis in children

OBJECTIVE

Cerebral sinus venous thrombosis (cerebral SVT) is rare in children. Information on clinical characteristics, radiological findings and outcome is emerging.

METHODS

Cases of cerebral SVT diagnosed between 1995 and 2001 were identified by a computer-assisted search using International Classification of Disease codes. Medical records were reviewed to collect information on clinical presentation, investigations, treatment and outcome.

RESULTS

Sixteen cases of cerebral SVT were identified. All cases presented in association with head and neck pathology. The majority of cases presented with symptoms of raised intracranial pressure and focal neurological signs. Magnetic resonance imaging identified all cases of cerebral SVT whilst CT scanning failed to demonstrate the diagnosis in two cases. Management with anticoagulation was associated with radiological resolution of the thrombosis and normal neurological outcome. Long-term follow up demonstrated neurological deficits in greater than 40% of patients.

CONCLUSION

Cerebral SVT in children is associated with significant residual neurological morbidity. Prospective studies to identify predictors of outcome and effective management interventions are required.

Clinical picture of patients with cerebral venous thrombosis and patterns of dural sinus involvement

BACKGROUND/OBJECTIVES

Cerebral venous thrombosis may cause focal brain lesions or an isolated intracranial hypertension without focal signs. We investigated whether these different clinical pictures correspond to different patterns of dural sinus thrombosis.

METHODS

Forty-eight patients with cerebral venous thrombosis were classified in 2 groups based on the clinical and neuroradiological picture at admission: one group had clinical signs of intracranial hypertension, without focal neurological signs; the other group had focal neurological signs. The extension of thrombosis in dural sinuses was compared between the groups.

RESULTS

The amount of thrombosed sinuses was significantly different in the two groups, the involvement of the dural sinuses being greater in patients with isolated intracranial hypertension.

CONCLUSIONS

The clinical picture of cerebral venous thrombosis is related to the pattern of dural sinus involvement. The presence of isolated intracranial hypertension is more frequent in patients with a more extended thrombosis of the dural sinuses.

Abnormal sagittal sinus blood flow in term infants following a perinatal hypoxic ischaemic insult

Ultrasound is a useful tool for the study of the superior sagittal sinus in neonates. The normal patterns of blood flow have been established, and the technique has been used to diagnose sagittal sinus thrombosis. This report describes the sonographic diagnosis of abnormally sluggish or absent sagittal sinus flow in two term infants. The first was a 2,320-g female infant with postnatal hypoxia. The second was a 5,000-g male infant who developed hypoxic ischaemic encephalopathy after delivery complicated by shoulder dystocia. In both cases the normal pattern of blood flow in the superior sagittal sinus was re-established on follow-up ultrasonography.

Combined diagnostic and therapeutic imaging in the diagnosis of venous sinus thrombosis in postpartum patients

The case of a woman on day four post partum with sensorimotor deficit of the right side and CT evidence of a left temporofrontal hemorrhagic lesion, is presented. Attending physicians requested cerebral angiography. To better evaluate the clinical justification of requested imaging procedure the patient medical history and performed CT examination were carefully revised. According to this analysis and based on a clinicoradiological methodology, the request of a cerebral angiography was considered appropriate. The examination showed several radiological signs but a definitive diagnosis could not be established. Second choice imaging procedures were analyzed and MRI completed with MR-angiography was performed. It allowed to document transverse and sigmoid sinus thrombosis. Therefore, in the diagnosis of venous sinus thrombosis, MRI combined with MR-angiography was shown to be a method of first choice while angiography plays a major role in therapy for intravascular thrombolysis.

Imaging of complications of acute mastoiditis in children

Acute mastoiditis is a serious complication of acute otitis media in children. Suppurative disease in the mastoid region occasionally spreads to the adjacent dura mater of the posterior and middle cranial fossae and the sigmoid sinus by means of thrombophlebitis, osseous erosion, or anatomic pathways, producing intracranial complications. Computed tomography (CT) should be performed early in the course of the disease to classify the mastoiditis as incipient or coalescent and to detect intracranial complications. On the basis of the clinical features and imaging findings, the disease is managed conservatively with intravenously administered antibiotics or treated with mastoidectomy and drainage plus antibiotic therapy. CT is therefore a decisive diagnostic tool in determining the type of therapy. In addition, magnetic resonance imaging is performed in patients with clinical symptoms or CT findings suggestive of intracranial complications because of its higher sensitivity for detection of extraaxial fluid collections and associated vascular problems.

[Non-metastatic thrombosis of the superior sagittal sinus complicating Burkitt's lymphoma. A case report]

We report a case of non-metastatic superior sagittal sinus thrombosis complicating a Burkitt's lymphoma of the small bowel, and review similar cases of this cerebrovascular disorder associated with lymphoma.

Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: an easily misdiagnosed cause of cerebral haemorrhage

Dural sinus thrombosis has protean clinical and radiological manifestations ranging from minimal effacement of sulci with no symptoms to severe haemorrhagic infarcts associated with focal deficits, coma and even death. An uncommon form of presentation is characterized by unilateral lobar haemorrhage associated with extensive oedema and parenchymal distortion. In an acute presentation, this might resemble haemorrhage into a tumour. In delayed presentations, the haematoma, being iso- or hypodense and showing peripheral ring-like enhancement, can mimic aggressive tumours or infective processes. As this is an uncommon condition, misdiagnosis is common with the potential for mismanagement and adverse outcomes. We present five such consecutive cases that were initially misdiagnosed as other entities. Each of these cases on closer inspection show features observed on CT and MRI that should have suggested a diagnosis of dural venous sinus thrombosis. One of these cases progressed to not only extensively involve the superficial sinuses but also the deep veins, with a significant adverse outcome. The imaging features of this interesting variant of dural sinus thrombosis are reviewed. The haemodynamic basis for haemorrhage and anatomical basis for the lateralization of the lesions are discussed.

Cerebral venous thrombosis in childhood

This was a retrospective study to determine different etiologies of cerebral venous thrombosis (CVT) in childhood and to correlate extent and location of thrombosis with the etiology and the age of the child as well as the final outcome. In addition, the radiologic approach is discussed. This was a retrospective analysis of 19 children with CVT. The children were examined by contrast-enhanced dynamic CT. Radiologic findings were correlated with the etiology of CVT. Cerebral venous thrombosis is not as infrequent in children as has been thought. Cerebral venous thrombosis in children can occur due to trauma (n=9), infections (n=7), or coagulation disorders (n=3). Extent and location of thrombosis, as well as complications, final outcome, and therapy, depend on the etiology. Computed tomography remains a valuable primary imaging modality in the diagnosis of CVT in the acutely injured or diseased child.