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Abstract
PURPOSE OF REVIEW The aim of this study is to discuss the symptoms, diagnosis, and management of the neurologic complications of acute and chronic otitis media. RECENT FINDINGS Antibiotic therapy has greatly reduced the frequency of complications of otitis media. However, it is of vital importance to remain aware of the possible development of neurologic complications. There is a trend toward less severe presenting symptoms including otorrhea, headache, nausea, and fever, with altered mental status and focal neurologic deficits presenting later. In order to reduce morbidity, early deployment of a multidisciplinary approach with prompt imaging and laboratory studies is imperative to guide appropriate management. Complications of acute and chronic otitis media may present with neurologic signs and symptoms. It is important to recognize the possible otitic origin of such complications to ensure proper management and to decrease overall morbidity and mortality.
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Affiliation(s)
- Michael J Hutz
- Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153, USA.
| | - Dennis M Moore
- Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153, USA
- Division of Otolaryngology - Head and Neck Surgery, Hines VA Medical Center, Hines, IL, USA
| | - Andrew J Hotaling
- Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153, USA
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52
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Abstract
Cerebral venous thrombosis (CVT) is rare and accounts for 0.5% of all strokes. Its clinical presentation is variable and diagnosis requires a high index of clinical suspicion in conjunction with neuroradiological diagnostic support. Treatment options are limited and are mostly based on consensus. Therefore, familiarity with international guidelines is important. Outcome is often good and most patients make a full recovery, although a small proportion suffers death or disability. Here, we describe the clinical features, risk factors, acute imaging features, management and complications of CVT.
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Affiliation(s)
| | - Martin Punter
- Salford Royal NHS Foundation Trust, and the Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
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53
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Riva N, Ageno W. Approach to thrombosis at unusual sites: Splanchnic and cerebral vein thrombosis. Vasc Med 2017; 22:529-540. [PMID: 29202678 DOI: 10.1177/1358863x17734057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Splanchnic vein thrombosis (SVT) and cerebral vein thrombosis (CVT) are two manifestations of unusual site venous thromboembolism (VTE). SVT includes thrombosis in the portal, mesenteric or splenic veins, and the Budd-Chiari syndrome. CVT encompasses thrombosis of the dural venous sinuses and thrombosis of the cerebral veins. Unusual site VTE often represents a diagnostic and therapeutic challenge because of the heterogeneity in clinical presentation, the limited evidence available in the literature on the acute and long-term prognosis of these diseases, and the lack of large randomized controlled trials evaluating different treatment options. This narrative review describes the approach to patients with SVT or CVT by examining the diagnostic process, the assessment of potential risk factors and the appropriate anticoagulant treatment.
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Affiliation(s)
- Nicoletta Riva
- 1 Department of Pathology, University of Malta, Msida, Malta
| | - Walter Ageno
- 2 Department of Medicine and Surgery, University of Insubria, Varese, Italy
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54
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Lamotte G, Farzal Z, Zimmerman WD, Han S, de Brito P, Mayson D. Clinical Reasoning: Monocular vision loss, ophthalmoplegia, and strokes in a 61-year-old man with diabetes mellitus. Neurology 2017; 89:e276-e281. [PMID: 29229690 DOI: 10.1212/wnl.0000000000004742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Guillaume Lamotte
- From the Departments of Neurology (G.L., Z.F., W.D.Z., D.M.) and Pathology (S.H., P.d.B.), Medstar Georgetown University Hospital, Washington, DC.
| | - Zehra Farzal
- From the Departments of Neurology (G.L., Z.F., W.D.Z., D.M.) and Pathology (S.H., P.d.B.), Medstar Georgetown University Hospital, Washington, DC
| | - William Denney Zimmerman
- From the Departments of Neurology (G.L., Z.F., W.D.Z., D.M.) and Pathology (S.H., P.d.B.), Medstar Georgetown University Hospital, Washington, DC
| | - Suhua Han
- From the Departments of Neurology (G.L., Z.F., W.D.Z., D.M.) and Pathology (S.H., P.d.B.), Medstar Georgetown University Hospital, Washington, DC
| | - Pedro de Brito
- From the Departments of Neurology (G.L., Z.F., W.D.Z., D.M.) and Pathology (S.H., P.d.B.), Medstar Georgetown University Hospital, Washington, DC
| | - Douglas Mayson
- From the Departments of Neurology (G.L., Z.F., W.D.Z., D.M.) and Pathology (S.H., P.d.B.), Medstar Georgetown University Hospital, Washington, DC
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55
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Nyberg EM, Case D, Nagae LM, Honce JM, Reyenga W, Seinfeld J, Poisson S, Leppert MH. The Addition of Endovascular Intervention for Dural Venous Sinus Thrombosis: Single-Center Experience and Review of Literature. J Stroke Cerebrovasc Dis 2017; 26:2240-2247. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/23/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022] Open
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56
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Abstract
Cerebral venous thrombosis (CVT) is an important cause of stroke in young adults. Data from large international registries published in the past two decades have greatly improved our knowledge about the epidemiology, clinical manifestations and prognosis of CVT. The presentation of symptoms is highly variable in this disease, and can range from a patient seen at the clinic with a 1-month history of headache, to a comatose patient admitted to the emergency room. Consequently, the diagnosis of CVT is often delayed or overlooked. A variety of therapies for CVT are available, and each should be used in the appropriate setting, preferably guided by data from randomized trials and well-designed cohort studies. Although deaths from CVT have decreased in the past few decades, mortality remains ∼5-10%. In this Review, we provide a comprehensive and contemporary overview of CVT in adults, with emphasis on advancements made in the past decade on the epidemiology and treatment of this multifaceted condition.
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Affiliation(s)
- Suzanne M Silvis
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, University of Lisbon, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
| | - José M Ferro
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, University of Lisbon, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
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57
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How I treat pediatric venous thromboembolism. Blood 2017; 130:1402-1408. [PMID: 28774877 DOI: 10.1182/blood-2017-04-742320] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023] Open
Abstract
The incidence of pediatric venous thromboembolism (VTE) has been increasing significantly over the past decade in part as a result of increased recognition of this serious disorder but more so because of the increased use of central venous catheters and other technological advancements involved in the care of ill children. Management of pediatric VTE is a complex undertaking, considering that the vast majority of children who develop this complication have serious underlying medical disorders. Although the incidence is rising, in comparison with adults, this remains a relatively rare disorder, and as such, large-scale clinical trials have not been completed, rendering management decisions to be based on extrapolation from adult data and the experience of the treating physician. Clearly, both are fraught with problems. Thus, day-to-day management remains more art than science until such time that the results from clinical trials (many of which are under way) become available. This edition of "How I Treat" describes the author's experience in managing 3 common scenarios that one may encounter in pediatric thrombosis and suggests a logical approach to such situations. Furthermore, the author provides 3 algorithms to help guide management decisions.
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58
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Paniagua JA, Bahamondes R, Cano‐Sánchez A, Velasco F. Unexpected papilledema in a young male with Type 1 diabetes. Clin Case Rep 2017; 5:1333-1338. [PMID: 28781853 PMCID: PMC5538076 DOI: 10.1002/ccr3.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/21/2017] [Accepted: 05/30/2017] [Indexed: 11/08/2022] Open
Abstract
In young patients with T1D, neurological manifestations of cerebral hypertension should suggest the possibility of a cerebral venous sinus thrombosis (CVST). In these patients an inherited prothrombotic risk factor, including factor V Leiden G1691A gene mutation, should be considered during an event of thrombosis. Improving the glycemic control is the first factor that should be controlled in a patient who carries a genetic prothrombotic risk factor. Anticoagulant treatment should be started as son as CVST has been diagnosed. Long-term antithrombotic treatment with tinzaparin 175 IU/kg/day, a low-molecular weight heparin (LMWH), could be reliable and well tolerated, although an indefinite special follow-up, including neurological controls, is advisable even in asymptomatic patients.
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Affiliation(s)
- Juan A. Paniagua
- Physician of Endocrinology and Nutrition ServiceUniversitary Hospital Reina Sofia (UHRS)CórdobaSpain
- Maimonides Institute of Biomedical Research (IMIBIC)CórdobaSpain
| | - Rodrigo Bahamondes
- Physician of Endocrinology and Nutrition ServiceUniversitary Hospital Reina Sofia (UHRS)CórdobaSpain
| | - Antonio Cano‐Sánchez
- Maimonides Institute of Biomedical Research (IMIBIC)CórdobaSpain
- Physician of Radiology ServiceUHRS, IMIBICCórdobaSpain
| | - Francisco Velasco
- Maimonides Institute of Biomedical Research (IMIBIC)CórdobaSpain
- Physician of Hematology ServiceUHRS, IMIBICCordobaSpain
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59
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Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, de Sousa DA, Stam J. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology. Eur Stroke J 2017; 2:195-221. [PMID: 31008314 DOI: 10.1177/2396987317719364] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/13/2017] [Indexed: 12/21/2022] Open
Abstract
The current proposal for cerebral venous thrombosis guideline followed the Grading of Recommendations, Assessment, Development, and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews of all available evidence and writing recommendations and deciding on their strength on an explicit and transparent manner, based on the quality of available scientific evidence. The guideline addresses both diagnostic and therapeutic topics. We suggest using magnetic resonance or computed tomography angiography for confirming the diagnosis of cerebral venous thrombosis and not screening patients with cerebral venous thrombosis routinely for thrombophilia or cancer. We recommend parenteral anticoagulation in acute cerebral venous thrombosis and decompressive surgery to prevent death due to brain herniation. We suggest to use preferentially low-molecular weight heparin in the acute phase and not using direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations due to very poor quality of evidence concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that in women who suffered a previous cerebral venous thrombosis, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular weight heparin should be considered throughout pregnancy and puerperium. Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of cerebral venous thrombosis.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | | | - Patrícia Canhão
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Matteo di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University, Naples, Italy.,Unit of Cell and Molecular Biology in Cardiovascular Diseases, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Alberto Maino
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Florian Masuhr
- Department of Neurology, Bundeswehrkrankenhaus, Berlin, Germany
| | - Diana Aguiar de Sousa
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
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60
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Verhagen MJ, van Es AC, Lycklama À Nijeholt GJ, Jellema K, Coutinho J, van den Wijngaard IR. Successful mechanical thrombectomy in a comatose patient with cerebral venous sinus thrombosis: A case report. Interv Neuroradiol 2017; 23:437-440. [PMID: 28513255 DOI: 10.1177/1591019917706051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cerebral venous sinus thrombosis is a rare cause of stroke, which is routinely treated with systemic heparin. Unfavourable outcome is often seen in severe cases. Therefore alternative treatment methods should be explored in these patients. Due to the risk of haemorrhagic complications, treatment without administration of thrombolytics is of particular interest. This report presents a case of successful mechanical thrombectomy, without the use of thrombolytics, in a comatose patient with cerebral venous sinus thrombosis.
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Affiliation(s)
| | | | | | - Korné Jellema
- 1 Haaglanden Medical Center, The Hague, The Netherlands
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61
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Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare but serious cerebrovascular disorder affecting children from the newborn period through childhood and adolescence. The incidence is estimated at 0.6/100,000/year, with 30-50% occurring in newborns. Causes are diverse and are highly age dependent. Acute systemic illness is the dominant risk factor among newborns. In childhood CSVT, acute infections of the head and neck such as mastoiditis are most common, followed by chronic underlying diseases such as nephrotic syndrome, cancer, and inflammatory bowel disease. Signs and symptoms are also age related. Seizures and altered mental status are the commonest manifestations in newborns. Headache, vomiting, and lethargy, sometimes with 6th nerve palsy, are the most common symptoms in children and adolescents. Recent multicenter cohort studies from North America and Europe have provided updated information on risk factors, clinical presentations, treatment practices, and outcomes. While systemic anticoagulation is the most common specific treatment used, there are wide variations and many uncertainties even among experts concerning best practice. The treatment dilemma is especially pronounced for neonatal CSVT. This is due in part to the higher prevalence of intracranial hemorrhage among newborns on the one hand, and the clear evidence that newborns suffer greater long-term neurologic morbidity on the other hand. With the advent of widespread availability and acceptance of acute endovascular therapy for arterial ischemic stroke, there is renewed interest in this therapy for children with CSVT. Limited published evidence exists regarding the benefits and risks of these invasive therapies. Therefore, the authors of current guidelines advise reserving this therapy for children with progressive and severe disease who have failed optimal medical management. As research focused on childhood cerebrovascular disease continues to grow rapidly, the future prospects for improving knowledge about this disorder should be good.
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Affiliation(s)
- Rebecca Ichord
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States
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62
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Bhogal P, AlMatter M, Aguilar M, Nakagawa I, Ganslandt O, Bäzner H, Henkes H. Cerebral Venous Sinus Thrombosis : Endovascular Treatment with Rheolysis and Aspiration thrombectomy. Clin Neuroradiol 2016; 27:235-240. [PMID: 27622246 DOI: 10.1007/s00062-016-0540-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
Affiliation(s)
- P Bhogal
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Katharinenhospital, Kriegsbergstraße 60, 70172, Stuttgart, Germany.
| | - M AlMatter
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Katharinenhospital, Kriegsbergstraße 60, 70172, Stuttgart, Germany
| | - M Aguilar
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Katharinenhospital, Kriegsbergstraße 60, 70172, Stuttgart, Germany
| | - I Nakagawa
- Department of Neurosurgery, Kashihara, Nara, Japan
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Katharinenhospital, Kriegsbergstraße 60, 70172, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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63
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Suction thrombectomy after balloon maceration for dural venous sinus thrombosis. J Neurol Sci 2016; 365:76-81. [PMID: 27206880 DOI: 10.1016/j.jns.2016.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/17/2016] [Accepted: 03/31/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To introduce the combination of suction thrombectomy (ST) and balloon maceration (BM) for the management of dural venous sinus thrombosis (DVST). MATERIALS AND METHODS Ten consecutive patients (average age, 53±15years; range, 30 to 73years) with DVST treated by ST after BM were evaluated including location of DVST, imaging presentation, procedural findings, and 3-month modified Rankin scale (mRS). RESULTS All 10 patients had evidence of venous infarct on MR or CT. In addition, seven patients had intracerebral hemorrhage (ICH), one had subarachnoid hemorrhage (SAH), and one had both ICH and SAH. More than one sinus was involved in nine patients. ST after BM was technically successful in all patients, and angiographic relief of venous congestion and good outcome (3-month mRS 0 or 1) was achieved in eight patients (80%). The average procedural time was 73.5±24.7min. Two patients who were in coma status had negative outcomes, and one had a known chronic thrombotic segment refractory to treatment. No recurrent thrombosis of recanalized sinus was found on follow-up MR venography in six patients and CT venography in two patients. CONCLUSION BM followed by ST is a promising technique for the treatment of acute DVST.
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64
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Lee EJ, Noh SM, Kang DW, Kim JS, Kwon SU. Impact of Provoking Risk Factors on the Prognosis of Cerebral Venous Thrombosis in Korean Patients. J Stroke 2016; 18:187-94. [PMID: 27165266 PMCID: PMC4901946 DOI: 10.5853/jos.2015.01669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/10/2015] [Accepted: 02/15/2016] [Indexed: 02/02/2023] Open
Abstract
Background and Purpose Little is known about the relationships between provoking risk factors, prognosis, and optimal duration of anticoagulation in patients with cerebral venous thrombosis (CVT), especially in Asians. We aimed to investigate whether the prognosis and required duration of anticoagulation in CVT patients differ according to the provoking risk factors. Methods Prospectively recorded data from a tertiary medical center in South Korea were retrospectively reviewed. CVTs were categorized into three groups: unprovoked, those with possibly resolved provoking factors (PR), and those with persistent provoking factors (PP). The baseline characteristics, treatment, and prognosis of patients in these three groups were analyzed. Results From 2000 to 2015, 61 patients presented with CVT: 19 (31.1%) unprovoked, 11 (18.0%) with PR, and 31 (50.9%) with PP. The patients in our cohort had a slight female predominance and lower frequency of oral contraceptive use compared to Western cohorts. Median follow-up and duration of anticoagulation were 35 and 8 months, respectively. Despite the similarities in baseline characteristics, deaths (n=3; P=0.256) and recurrences (n=7; P=0.020) were observed only in the PP group. The median intervals to death and recurrence were 9 and 13 months, respectively. Death was associated with underlying disease activity, not with CVT progression. Recurrences in the PP group were associated with lack of anticoagulation (P=0.012). Conclusions Although the prognosis of CVT is generally benign in Koreans, recurrence and death were observed in patients with persistent risk factors, suggesting their need for long-term treatment with anticoagulants.
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Affiliation(s)
- Eun-Jae Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Sang-Mi Noh
- Department of Neurology, St. Vincent's Hospital, Suwon, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
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65
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Price M, Günther A, Kwan JSK. Antiepileptic drugs for the primary and secondary prevention of seizures after intracranial venous thrombosis. Cochrane Database Syst Rev 2016; 4:CD005501. [PMID: 27098266 PMCID: PMC7265129 DOI: 10.1002/14651858.cd005501.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intracranial venous thrombosis (ICVT) commonly presents with seizures in the acute period, and some people may develop recurrent seizures in the long term. The prophylactic use of antiepileptic drugs (AEDs) for the management of post-ICVT seizures is controversial, and there is currently no consensus on the optimal management of post-ICVT seizures. This is an updated version of the Cochrane review first published in theCochrane Database of Systematic Reviews 2006, Issue 3. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures related to ICVT.(1) For the question of primary prevention, we aimed to examine whether AEDs reduce the likelihood of seizures in people who have had an ICVT but have not had a seizure.(2) For the question of secondary prevention, we aimed to examine whether AEDs reduce the likelihood of further seizures in people who have had an ICVT and at least one seizure. SEARCH METHODS For the latest update, we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), and MEDLINE (Ovid 1946 onwards) to 20 April 2015, and we checked the reference lists of articles retrieved from the searches. SELECTION CRITERIA We planned to include all randomised and quasi-randomised controlled trials in which participants with a diagnosis of ICVT were assigned to a treatment group (that is, receiving at least one AED) or control group (receiving placebo or no drug). DATA COLLECTION AND ANALYSIS Both review authors independently screened and assessed the methodological quality of the studies. If studies had been included in the review, one review author would have extracted the data and another would have checked the extracted data. MAIN RESULTS No relevant studies were found. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of antiepileptic drugs for the primary or secondary prevention of seizures related to intracranial venous thrombosis. Well-designed randomised controlled trials are urgently needed to inform practice. Since the last version of this review no new studies have been found.
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Affiliation(s)
| | - Albrecht Günther
- Jena University HospitalDepartment of NeurologyErlanger Allee 101JenaGermany07747
| | - Joseph SK Kwan
- The University of Hong Kong, Queen Mary HospitalDepartment of Medicine102 Pok Fu Lam RoadHong KongChina
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66
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Shrestha GS, Poudyal BS, Sedain G, Mahmud KI, Acharya N. Cerebral venous thrombosis presenting with intracerebral hemorrhage in a patient with paroxysmal nocturnal hemoglobinuria. Indian J Crit Care Med 2016; 20:117-9. [PMID: 27076714 PMCID: PMC4810925 DOI: 10.4103/0972-5229.175948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cerebral venous thrombosis (CVT) is an uncommon cause of stroke. Paroxysmal nocturnal hemoglobinuria (PNH) is a rare type of hemolytic anemia, frequently associated with thrombophilia. PNH may rarely present with CVT. Approximately, one-third of the patients with CVT develop cerebral hemorrhage. Here, we present a rare combination of CVT presenting with intracerebral hemorrhage in a patient with PNH. High index of suspicion is needed to avoid misdiagnosis. Patient was successfully managed with anticoagulation therapy.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Gopal Sedain
- Department of General Surgery, Neurosurgery Unit, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Khandokar Imran Mahmud
- Department of Internal Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, England
| | - Niranja Acharya
- Department of Internal Medicine, Civil Service Hospital, Kathmandu, Nepal
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67
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Soyer B, Rusca M, Lukaszewicz AC, Crassard I, Guichard JP, Bresson D, Mateo J, Payen D. Outcome of a cohort of severe cerebral venous thrombosis in intensive care. Ann Intensive Care 2016; 6:29. [PMID: 27068929 PMCID: PMC4828343 DOI: 10.1186/s13613-016-0135-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severity of cerebral venous thrombosis (CVT) may require the transfer to intensive care unit (ICU). This report described the context for CVT transfer to ICU, the strategy of care and the outcome after 1 year. METHODS Monocentric cohort of 41 consecutive CVT admitted in a French ICU tertiary hospital (National Referent Center for CVT). Data collected are as follows: demographic data, clinical course, incidence of craniectomy and/or endovascular procedures and outcome in ICU, after 3 and 12 months. RESULTS 47 years old (IQ 26-53), with 73.2 % were female, having a SAPS II 41 (32-45), GCS 7 (5-8), and at least one episode of mydriasis in 48.8 %. Thrombosis location was 80.5 % in lateral sinus and 53.7 % in superior sagittal sinus; intracranial hematoma was present in 78.0 %, signs of intracranial hypertension in 60.9 %, cerebral edema in 58.5 % and venous ischemia in 43.9 %. All patients received heparin therapy, and 9 cases had endovascular treatment (21.9 %); osmotherapy (53.7 %) and decompressive craniectomy (16 cases, 39 %) necessary to control intracranial hypertension. Ten patients/41 (24.4 %) died in ICU and 18/31 (58.1 %) were discharged from ICU with outcome 0-3 of mRS. After 12 months, 92 % of survivors (23/25) had a mRS between 0 and 3. The proportion of death was 31.7 % at 1 year. CONCLUSIONS The large proportion of acceptable outcome in survivors, which continue to functionally improve after 1 year, motivates the hospitalization in ICU for severe CVT. For similar CVT severity, craniectomy did not improve outcome in comparison with the absence of craniectomy.
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Affiliation(s)
- Benjamin Soyer
- Department of Anesthesiology and Critical Care and SMUR, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.,Université Diderot Sorbonne Paris Cité, Paris, France.,Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France
| | - Marco Rusca
- Department of Anesthesiology and Critical Care and SMUR, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.,Université Diderot Sorbonne Paris Cité, Paris, France.,Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France
| | - Anne-Claire Lukaszewicz
- Department of Anesthesiology and Critical Care and SMUR, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.,Université Diderot Sorbonne Paris Cité, Paris, France.,Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France
| | - Isabelle Crassard
- Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France.,Service of Neurology, Hôpital Lariboisière, AP-HP, Université Paris 7 Denis Diderot, Paris, France
| | - Jean-Pierre Guichard
- Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France.,Department of Neurovascular Imaging, Hôpital Lariboisière, AP-HP, Université Paris 7 Denis Diderot, Paris, France
| | - Damien Bresson
- Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France.,Service of Neurosurgery, Hôpital Lariboisière, AP-HP, Université Paris 7 Denis Diderot, Paris, France
| | - Joaquim Mateo
- Department of Anesthesiology and Critical Care and SMUR, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.,Université Diderot Sorbonne Paris Cité, Paris, France.,Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France
| | - Didier Payen
- Department of Anesthesiology and Critical Care and SMUR, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France. .,Université Diderot Sorbonne Paris Cité, Paris, France. .,Département Hospitalo-Universitaire (DHU) Neuro-Vasculaire, P R E S Paris Sorbonne Cité, Paris, France.
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68
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Jensen PVF, Hansen MS, Møller MN, Saunte JP. The Forgotten Syndrome? Four Cases of Gradenigo’s Syndrome and a Review of the Literature. Strabismus 2016; 24:21-7. [DOI: 10.3109/09273972.2015.1130067] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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69
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Cerebral Venous Thrombosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:183-193. [DOI: 10.1007/5584_2016_115] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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70
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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71
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Syed A, Bell B, Hise J, Philip J, Spak C, Opatowsky MJ. Bilateral cavernous sinus and superior ophthalmic vein thrombosis in the setting of facial cellulitis. Proc (Bayl Univ Med Cent) 2016; 29:36-8. [PMID: 26722163 DOI: 10.1080/08998280.2016.11929349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Cavernous sinus thrombosis is a rare, potentially fatal cause of cerebral venous thrombosis. Infectious causes typically arise from the mid face, orbit, or sinonasal region. We present a case of bilateral cavernous sinus and superior ophthalmic thrombosis secondary to an extreme case of facial cellulitis.
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Affiliation(s)
- Almas Syed
- Department of Radiology (Syed, Bell, Hise, Philip, Opatowsky) and the Division of Infectious Diseases (Spak), Baylor University Medical Center at Dallas
| | - Bruce Bell
- Department of Radiology (Syed, Bell, Hise, Philip, Opatowsky) and the Division of Infectious Diseases (Spak), Baylor University Medical Center at Dallas
| | - Joseph Hise
- Department of Radiology (Syed, Bell, Hise, Philip, Opatowsky) and the Division of Infectious Diseases (Spak), Baylor University Medical Center at Dallas
| | - Joseph Philip
- Department of Radiology (Syed, Bell, Hise, Philip, Opatowsky) and the Division of Infectious Diseases (Spak), Baylor University Medical Center at Dallas
| | - Cedric Spak
- Department of Radiology (Syed, Bell, Hise, Philip, Opatowsky) and the Division of Infectious Diseases (Spak), Baylor University Medical Center at Dallas
| | - Michael J Opatowsky
- Department of Radiology (Syed, Bell, Hise, Philip, Opatowsky) and the Division of Infectious Diseases (Spak), Baylor University Medical Center at Dallas
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72
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Abstract
With 16.9 million people who suffered a first-ever stroke in 2010 worldwide, stroke is a very common vascular disease. Epidemiologic studies have played an essential role in assessing this burden and in detecting the risk factors for stroke. Primary prevention of these risk factors, primarily hypertension, smoking, diabetes, and atrial fibrillation, has reduced the incidence in high-income countries. However, stroke remains a major cause of death and disability, and therefore research should be continued. Subarachnoid hemorrhages are less prevalent than strokes but have an even higher risk of death. Similar to stroke, epidemiologic studies identified smoking and hypertension as its most important risk factors, together with excessive alcohol intake. Although rare, arterial dissections, CADASIL, arteriovenous malformations, venous sinus thrombosis, moyamoya disease, and vasculitis can lead to serious symptoms. The burden and risk factors of those rare diseases are more challenging to assess. Whenever possible, they should be recognized in a timely manner for their increased risk of stroke, but most often they are diagnosed only at the time of stroke. Some cerebrovascular abnormalities do not result in immediate symptoms. This subclinical cerebrovascular disease includes silent infarcts, white-matter lesions, and microbleeds, and is incidentally found by neuroimaging. These lesions are not innocent, as several epidemiologic studies have associated subclinical cerebrovascular disease with an increased risk of stroke, cognitive decline, dementia, and death.
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Affiliation(s)
- M L P Portegies
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - P J Koudstaal
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - M A Ikram
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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73
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Afshari D, Moradian N, Nasiri F, Razazian N, Bostani A, Sariaslani P. The efficacy and safety of low-molecular-weight heparin and unfractionated heparin in the treatment of cerebral venous sinus thrombosis. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2015; 20:357-61. [PMID: 26492115 PMCID: PMC4727621 DOI: 10.17712/nsj.2015.4.20150375] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in the treatment of patients with cerebral venous sinus thrombosis (CVST), and to provide an appropriate treatment option in these patients. METHODS This is a randomized double blind clinical trial conducted between December 2013 and December 2014. The subjects were selected among patients referred to Neurology Department, Imam Reza Hospital; affiliated to Kermanshah University of Medical Sciences, Kermanshah, Iran. Fifty-two cases of CVST were included in this study and randomly divided into 2 groups. Twenty-six cases received LMWH and the other 26 cases received UFH. The primary outcomes include hospital mortality rate and neurologic deficits as assessed by the National Institutes of Health Stroke Scale (NIHSS). The secondary end point was disability as measured by the Modified Rankin Scale (MRS). RESULTS We observed the rate of mortality and neurological deficits and disability based on NIHSS, and the MRS did not differ between the 2 groups. CONCLUSION The efficacy of LMWH and UFH in reduction of neurologic deficit and functional disability in patients with CVST are similar.
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Affiliation(s)
- Daryoush Afshari
- From the Department of Neurology, College of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nasrin Moradian
- From the Department of Neurology, College of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran,Address correspondence and reprint request to: Dr. Nasrin Moradian, Department of Neurology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran. E-mail:
| | - Freshteh Nasiri
- From the Department of Neurology, College of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nazanin Razazian
- From the Department of Neurology, College of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Arash Bostani
- From the Department of Neurology, College of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Payam Sariaslani
- From the Department of Neurology, College of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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74
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King AB, O'Duffy AE, Kumar AB. Heparin Resistance and Anticoagulation Failure in a Challenging Case of Cerebral Venous Sinus Thrombosis. Neurohospitalist 2015; 6:118-21. [PMID: 27366296 DOI: 10.1177/1941874415591500] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus. She was started on systemic anticoagulation and underwent mechanical clot removal and catheter-directed endovascular thrombolysis with limited success. Complicating the intensive care unit care was the development of heparin resistance, with an inability to reach the target partial thomboplastin time (PTT) of 60 to 80 seconds. At her peak heparin dose, she was receiving >35 000 units/24 h, and her PTT was subtherapeutic at <50 seconds. Deficiency of ATIII was suspected as a possible etiology of her heparin resistance. Fresh frozen plasma was administered for ATIII level repletion. Given her high thrombogenic risk and challenges with conventional anticoagulation regimens, we transitioned to argatroban for systemic anticoagulation. Heparin produces its major anticoagulant effect by inactivating thrombin and factor X through an AT-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and the AT. A deficiency of AT leads to a hypercoagulable state and decreased efficacy of heparin that places patients at high risk of thromboembolism. Heparin resistance, especially in the setting of critical illness, should raise the index of suspicion for AT deficiency. Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.
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Affiliation(s)
- Adam B King
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
| | - Anne E O'Duffy
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Avinash B Kumar
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
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75
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Cerebral Venous Sinus Thrombosis, a Nonenhanced CT Diagnosis? Radiol Res Pract 2015; 2015:581437. [PMID: 26064682 PMCID: PMC4433705 DOI: 10.1155/2015/581437] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 04/02/2015] [Accepted: 04/04/2015] [Indexed: 11/17/2022] Open
Abstract
Purpose. Retrospectively evaluate the density of cerebral venous sinuses in nonenhanced head CTs (NCTs) and correlate these with the presence or absence of a cerebral venous sinus thrombus (CVST). Materials and Methods. Institutional review board approval was obtained and informed consent waived prior to commencing this retrospective study. Over a two-year period, all CT venograms (CTVs) performed at our institution were retrieved and the preceding/subsequent NCTs evaluated. Hounsfield Units (HUs) of thrombus when present as well as that of normal superior sagittal and sigmoid sinuses were measured. HU of thrombus was compared to that of normal vessels with and without standardisation to the average HU of the internal carotid arteries. Results. 299 CTVs were retrieved, 26 with a thrombus. Both raw and standardised HU measurements were significantly higher in CVST (p < 0.0001) compared to normal vessels. Both raw and standardised HUs are good predictors of CVST. A HU of ≥67 and a standardised measurement of ≥1.5 are associated with high probability of CVST on NCT. Conclusion. Cerebral venous sinus HU measurements may help improve sensitivity and specificity of NCT for venous sinus thrombosis and avoid potentially unnecessary follow-up examinations.
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76
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Mallick A, Pathak SD, Shankar S, Sati A. Early cavernous sinus thrombosis following unilateral pansinusitis in a child. BMJ Case Rep 2015; 2015:bcr2014208441. [PMID: 25917067 PMCID: PMC4422932 DOI: 10.1136/bcr-2014-208441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2015] [Indexed: 11/04/2022] Open
Abstract
Cavernous sinus thrombosis (CST) is a life-threatening entity with a high rate of mortality and lifelong morbidity. A strong clinical suspicion of the complication, early radiological detection and institution of timely, aggressive treatment are required to prevent permanent neurological disability. We present a 12-year-old girl with bilateral CST following unilateral pansinusitis. Clinical symptoms of headache and retro-orbital pain out of proportion to clinical signs on presentation prompted a suspicion of something beyond sinusitis and raised the clinical suspicion of cavernous sinus involvement. In spite of institution of an early medical treatment, she progressed to develop bilateral cranial nerve paresis. However, with the persistence of antibiotics and anticoagulation therapy, she was successfully managed with no residual neurological sequelae. The aim of this presentation is to highlight the grave consequences of cavernous sinus involvement following infections of paranasal sinus and the rare complete recovery from disability in this case.
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Affiliation(s)
- Ajay Mallick
- Department of ENT, Command Hospital, Kolkata, West Bengal, India
| | - Som Dutt Pathak
- Department of ENT, Command Hospital, Kolkata, West Bengal, India
| | - Sandeep Shankar
- Department of Ophthalmology, Command Hospital, Kolkata, West Bengal, India
| | - Alok Sati
- Department of Ophthalmology, Command Hospital, Kolkata, West Bengal, India
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77
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Razmara A, Bakhadirov K, Batra A, Feske SK. Cerebrovascular complications of pregnancy and the postpartum period. Curr Cardiol Rep 2015; 16:532. [PMID: 25239155 DOI: 10.1007/s11886-014-0532-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Cerebrovascular complications of pregnancy, though uncommon, threaten women with severe morbidity or death, and they are the main causes of major long-term disability associated with pregnancy. In this review, we discuss the epidemiology, pathophysiology, presentation and diagnosis, and management and outcomes of ischemic and hemorrhagic stroke and cerebral venous thrombosis. We also discuss the posterior reversible encephalopathy syndrome, the reversible cerebral vasoconstriction syndrome including postpartum cerebral angiopathy, and their relationship as overlapping manifestations of pre-eclampsia-eclampsia.
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Affiliation(s)
- Ali Razmara
- Fellow in Vascular Neurology, Massachusetts General and Brigham and Women's Hospitals, Boston, MA, USA,
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78
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Abstract
Cerebral venous thrombosis (CVT) is less frequent than ischemic stroke or intracerebral haemorrhage. Its incidence is comparable to that of acute bacterial meningitis in adults. Because of the increased use of magnetic resonance imaging (MR) for investigating patients with acute and subacute headaches and new onset seizures, CVT are now being diagnosed with increasing frequency. CVT have a more varied clinical presentation than other stroke types as they rarely present as a stroke syndrome. Their most frequent presentations are isolated headache, intracranial hypertension syndrome, seizures, a focal lobar syndrome and encephalopathy. The confirmation of the diagnosis of CVT relies on the demonstration of thrombi in the cerebral veins and/or sinuses by MR/MR venography or veno CT. The more frequent risk factors for CVT are prothrombotic conditions, either genetic or acquired, oral contraceptives, puerperium and pregnancy, infection and malignancy. The prognosis of CVT is in general favourable, as only around 15% of the patients remain dependent or die. The main intervention in the acute is anticoagulation with either low molecular weight or unfractionated heparin. In patients in severe condition on admission or who deteriorate despite anticoagulation, local thrombolysis or thrombectomy is an option. Decompressive surgery is life-saving in patients with large venous infarcts or haemorrhage. After the acute phase patients remain anticoagulated for a variable period of time, depending on their inherent thrombotic risk. CVT patients may experience recurrent seizures. Prophylaxis with antiepileptics is recommended after the first seizures, in particular in those with hemispheric lesions. There are several ongoing multicentre registries sand trials which will improve evidence-based management of CVT in the near future.
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79
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Abstract
BACKGROUND Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Clot prevention with anticoagulants might improve outcomes if bleeding risks are low. This is an update of a Cochrane review first published in 1995, with recent updates in 2004 and 2008. OBJECTIVES To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) in people with acute presumed or confirmed ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA) (The Cochrane Library 2014 Issue 6), MEDLINE (2008 to June 2014) and EMBASE (2008 to June 2014). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies. SELECTION CRITERIA Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data. MAIN RESULTS We included 24 trials involving 23,748 participants. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence relates to the effects of anticoagulant therapy initiated within the first 48 hours of onset. Based on 11 trials (22,776 participants) there was no evidence that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.98 to 1.12) at the end of follow-up. Similarly, based on eight trials (22,125 participants), there was no evidence that early anticoagulation reduced the odds of being dead or dependent at the end of follow-up (OR 0.99; 95% CI 0.93 to 1.04). Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.76; 95% CI 0.65 to 0.88), it was also associated with an increase in symptomatic intracranial haemorrhages (OR 2.55; 95% CI 1.95 to 3.33). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60; 95% CI 0.44 to 0.81), but this benefit was offset by an increase in extracranial haemorrhages (OR 2.99; 95% CI 2.24 to 3.99). AUTHORS' CONCLUSIONS Since the last version of the review, no new relevant studies have been published and so there is no additional information to change the conclusions. Early anticoagulant therapy is not associated with net short- or long-term benefit in people with acute ischaemic stroke. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any of the currently available anticoagulants in acute ischaemic stroke.
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Affiliation(s)
- Peter AG Sandercock
- University of EdinburghCentre for Clinical Brain Sciences (CCBS)The Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Carl Counsell
- University of AberdeenDivision of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
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80
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Lin N, Wong AK, Lipinski LJ, Mokin M, Siddiqui AH. Reversible changes in diffusion- and perfusion-based imaging in cerebral venous sinus thrombosis. BMJ Case Rep 2015; 2015:bcr-2014-011447. [PMID: 25678607 DOI: 10.1136/bcr-2014-011447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Diffusion- and perfusion-based imaging studies are regularly used in patients with ischemic stroke. Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is primarily treated by systemic anticoagulation. Endovascular intervention can be considered in cases of failed medical therapy, yet the prognostic value of diffusion- and perfusion-based imaging for CVST has not been clearly established. We present a patient with CVST whose abnormal findings on MRI and CT perfusion images were largely reversed after endovascular treatment.
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Affiliation(s)
- Ning Lin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Andrew K Wong
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Lindsay J Lipinski
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Maxim Mokin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA
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81
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Yoon H, Jeon SB, Kim HA, Kwon BS, Kim SH, Kang JK. Rhinocerebral Mucormycosis Manifested as Pott’s Puffy Tumor. JOURNAL OF NEUROCRITICAL CARE 2014. [DOI: 10.18700/jnc.2014.7.2.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Sharma KM, Ahn J. Cerebral venous sinus thrombophlebitis as a complication of acute otitis media. J Emerg Med 2014; 48:e9-e13. [PMID: 25440866 DOI: 10.1016/j.jemermed.2014.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 08/04/2014] [Accepted: 09/02/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND While headache is a common emergency department chief complaint, cerebral venous sinus thrombosis (CVST) is an infrequently encountered cause of headache and is often not included in emergency physicians' differential diagnoses for headache. Our objective is to review the latest data on epidemiology, presenting symptoms, diagnosis, and treatment of CVST. CASE REPORT A 27-year-old female presented to our emergency department with headache, blurred vision, and vomiting a day after being diagnosed with acute otitis media. Computed tomography scan of the brain without contrast in the emergency department was suggestive of CVST. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although a rare cause of headache, CVST should be considered for a subset of patients presenting to the emergency department with the common complaint of headache. CVST is diagnosed by magnetic resonance venogram or computed tomography venogram of the brain. Anticoagulation with close monitoring in consultation with appropriate experts is a safe first-line therapy for CVST, even in patients with hemorrhage on initial imaging.
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Affiliation(s)
- Kunal M Sharma
- Department of Emergency Medicine, University of Texas Health Science Center, Houston, Texas
| | - James Ahn
- Section of Emergency Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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83
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Anticoagulation for noncardiac indications in neurologic patients: comparative use of non-vitamin k oral anticoagulants, low-molecular-weight heparins, and warfarin. Curr Treat Options Neurol 2014; 16:309. [PMID: 25038005 DOI: 10.1007/s11940-014-0309-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Patients with neurologic disorders may develop a wide variety of thromboembolic events, both as a primary manifestation and as a consequence of their underlying neurologic condition. There are many available options for anticoagulation, ranging from warfarin to the parenteral subcutaneously administered anticoagulants to the non-vitamin K oral anticoagulants (NOACs). Warfarin is orally available, well-studied, and easily reversible in the setting of bleeding, but has a prolonged onset of action, measured in days, and equally slow offset; requires frequent monitoring for dose titration; and has multiple drug-drug and food-drug interactions. Parenteral heparin-based anticoagulants are well-studied and have more predictable pharmacokinetics but are often more expensive, only partially reversible, and require daily injections, which can be difficult for patients to tolerate over long periods of time. The NOACs are easy to administer and have predictable pharmacokinetics but are expensive, not easily reversible, and are not as extensively studied. Specific agents are preferable in some defined neurologic conditions. For acute ischemic stroke, we do not recommend immediate anticoagulation with any agent. For patients with intracranial malignancy (either primary or metastatic), we recommend a low-molecular-weight heparin (LMWH) rather than warfarin or a NOAC. For thromboembolic disease in the setting of spinal cord injury, warfarin, LMWH, or the NOACs are reasonable options. In the setting of VTE or stroke related to antiphospholipid antibody syndrome (APS), we recommend long-term warfarin anticoagulation with an INR goal of 2-3, pending the results of ongoing research involving the NOACs. For cerebral venous sinus thrombosis not related to malignancy or APS, we recommend the use of LMWH in the acute setting, followed by at least three months of warfarin. In this article, we discuss the pharmacology, pathophysiology, and comparative research that served as a basis for our recommendations.
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Alvis-Miranda HR, Milena Castellar-Leones S, Alcala-Cerra G, Rafael Moscote-Salazar L. Cerebral sinus venous thrombosis. J Neurosci Rural Pract 2014; 4:427-38. [PMID: 24347950 PMCID: PMC3858762 DOI: 10.4103/0976-3147.120236] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cerebral sinus venous thrombosis (CSVT) is a rare phenomenon that can be seen with some frequency in young patients. CSVT is a multifactorial condition with gender-related specific causes, with a wide clinical presentation, the leading causes differ between developed and developing countries, converting CSVT in a condition characterized by a highly variable clinical spectra, difficult diagnosis, variable etiologies and prognosis that requires fine medical skills and a high suspicious index. Patients who presents with CSVT should underwent to CT-scan venography (CVT) and to the proper inquiry of the generating cause. This disease can affect the cerebral venous drainage and related anatomical structure. The symptoms may appear in relation to increased intracranial pressure imitating a pseudotumorcerebri. Prognosis depends on the early detection. Correcting the cause, generally the complications can be prevented. Mortality trends have diminished, and with the new technologies, surely it will continue. This work aims to review current knowledge about CSVT including its pathogenesis, etiology, clinical manifestations, diagnosis, and treatment.
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Affiliation(s)
| | | | | | - Luis Rafael Moscote-Salazar
- Department of Neurological Endovascular Therapy, Instituto Nacional de Neurologia y Neurocirugía; Stroke Unit, Hospital Ángeles del Pedregal, Mexico City, Mexico
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Coutinho JM, Middeldorp S, Stam J. Advances in the Treatment of Cerebral Venous Thrombosis. Curr Treat Options Neurol 2014; 16:299. [DOI: 10.1007/s11940-014-0299-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
The aim of this review is to summarize the existing literature on therapy and management of cerebrovascular insults in children and adolescents. As data sources, studies were identified by MEDLINE, PubMed, Cochrane Library, and relevant bibliographies for the topic "pediatric stroke." We also reviewed guidelines for "stroke in adults." As a result, pediatric stroke is underestimated. The annual incidence for all stroke entities (cerebral venous thrombosis and hemorrhagic and arterial ischemic stroke) is as high as for pediatric brain tumors, 3-15/100.000 children per year. A distinct etiology can be determined only in a minority of them. Underlying risk factors are multiple, mainly vasculopathies, congential heart diseases, coagulopathies, lipometabolic disorders, and sickle cell anemia. Current recommendations for therapy are based on adult studies, are preliminary, and discussed controversially. Antithrombotic therapy is uniformly recommended for the acute stage of pediatric stroke; no consensus exists on antiplatelet therapy with acetylsalicylic acid (ASA, aspirin) (5 mg/d), with ultra-fractionated or low-molecular-weight heparin. Thrombolysis using recombinant tissue plasminogen activator is not advised, despite the fact that current practice takes a different approach. None of the guidelines specify the duration of ASA for secondary prevention. Additional supportive therapy measures are osmotherapy and decompressive craniectomy. Oxygen in the absence of hypoxemia, intensive insulin therapy, antiepileptic drugs in the absence of clinical or electrographic seizures, corticosteroids, and GP-IIb/IIIa-receptor antagonists should not be used outside clinical trials. In conclusions, current therapeutic guidelines for pediatric stoke are still based on consensus and expert and society opinions and differ between countries. Consensus prevails on the need for acute anticoagulation using either antiplatelets or heparin. Long-term treatment with acetylsalicylic acid in all or only high-risk patients and for how long remains the subject of debate. Lifelong secondary prevention has never been investigated in children or adults. All guidelines agree that there is no indication for thrombolysis in children outside clinical trials, although clinical practice in large centers differs.
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Riordan MA, Deshaies EM. Two cases of venous sinus thrombosis in women taking the oral contraceptive pill, Yaz (dropirenone/ ethinyl estradiol), and review of the literature. Health (London) 2013. [DOI: 10.4236/health.2013.57a4013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis: a rare combination of complications arising from unilateral frontal sinusitis. The Journal of Laryngology & Otology 2012; 126:1281-3. [DOI: 10.1017/s0022215112002228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractBackground:Subclinical infection of the sinuses can result in delayed diagnosis and unusual presenting complications.Case report:This paper describes the case of a 14-year-old boy with a rare combination of periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis following a late presentation of unilateral frontal sinusitis.Results:Following multiple surgical procedures, and antimicrobial and anticoagulation therapy, the patient made a full recovery.Conclusion:Serious sinusitis complications still occur, and can do so in unusual combinations with minimal clinical signs. Systemic anticoagulation therapy is considered safe practice in the management of cerebral venous sinus thrombosis and may reduce morbidity and mortality.
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