European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology

Can mechanical thrombectomy be effective in deep cerebral venous thrombosis worsening on anticoagulant? Insight from two cases

OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare condition whose clinical presentation can range from simple headaches to severe impairment of alertness. Some clinical forms, such as involvement of the deep venous system, are associated with a poorer clinical prognosis despite well-managed anticoagulation. The role and timing of rescue mechanical thrombectomy for these patients is not well established.

METHOD

Clinical and imaging follow-up are discussed according to our treatment decision.

RESULTS

We describe two cases with deep venous system thrombosis that were treated unsuccessfully with optimal anticoagulation, with a spectacular clinical and radiological response after mechanical thrombectomy (MT).

CONCLUSION

These cases demonstrate that, despite the negative results of the TO-ACT trial, MT could be considered as a rescue treatment in some clinical forms of deteriorating CVT despite optimal anticoagulation.

American Society of Hematology 2023 guidelines for management of venous thromboembolism: thrombophilia testing

Hereditary and acquired thrombophilia are risk factors for venous thromboembolism (VTE). Whether testing helps guide management decisions is controversial. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about thrombophilia testing. ASH formed a multidisciplinary guideline panel covering clinical and methodological expertise and minimizing bias from conflicts of interest. The McMaster University GRADE Centre provided logistical support, performed systematic reviews, and created evidence profiles and evidence-to-decision tables. The Grading of Recommendations Assessment, Development, and Evaluation approach (GRADE) was used. Recommendations were subject to public comment. The panel agreed on 23 recommendations regarding thrombophilia testing and associated management. Nearly all recommendations are based on very low certainty in the evidence due to modeling assumptions. The panel issued a strong recommendation against testing the general population before starting combined oral contraceptives (COCs) and conditional recommendations for thrombophilia testing in the following scenarios: (a) patients with VTE associated with nonsurgical major transient or hormonal risk factors; (b) patients with cerebral or splanchnic venous thrombosis, in settings where anticoagulation would otherwise be discontinued; (c) individuals with a family history of antithrombin, protein C, or protein S deficiency when considering thromboprophylaxis for minor provoking risk factors and for guidance to avoid COCs/hormone replacement therapy; (d) pregnant women with a family history of high-risk thrombophilia types; and (e) patients with cancer at low or intermediate risk of thrombosis and with a family history of VTE. For all other questions, the panel provided conditional recommendations against testing for thrombophilia.

An Exploration of Anti-Inflammatory Therapy in Acute/Subacute Severe Cerebral Venous Thrombosis with Hereditary Protein C/S Deficiency: Case Series

Background

Inflammation was associated with the severity of severe cerebral venous thrombosis (CVT) on admission and poor prognosis at discharge. Hereditary protein C/S deficiency (hereditary PCD/PSD) not only promotes thrombosis but also activates the inflammatory response, further inducing venous thrombosis. However, conventional treatments such as standard anticoagulant/endovascular therapy (EVT) do not seem to improve prognosis. Anti-inflammatory therapy may be a new way to treat the disease.

Methods

We enrolled five patients with acute/subacute severe CVT with hereditary PCD/PSD from January 2020 to July 2022. In addition to standard anticoagulant therapy, all of them were given short-term methylprednisolone pulse therapy. Neurological deficit, increased intracranial pressure, venous recanalization, serum and cerebrospinal fluid (CSF) inflammatory markers and adverse events were retrospectively described before and after treatment and at 6 months after discharge.

Results

Inflammatory indexes of all patients were significantly elevated on admission. After methylprednisolone pulse therapy, serum inflammatory indexes including neutrophil-to-lymphocyte ratio (P=0.043); platelet-to-lymphocyte ratio (P=0.043); systemic immune inflammatory index (P=0.043); interleukin-6 (P=0.043) and hypersensitive C-reactive protein (P=0.022) reduced dramatically compared with baseline. CSF inflammatory indexes had a decreasing trend compared with baseline (P>0.05). In terms of venous recanalization, one patient achieved complete recanalization, four patients obtained partial recanalization. Compared with baseline on admission, the NIH Stroke Scale (NIHSS), modified Rankin Scale (mRS) and intracranial pressure were all considerably lower at discharge (P=0.029, P=0.041 and P=0.017). At 6-month follow-up, NIHSS and mRS further declined. During hospitalization and 6-month follow-up, none of the five patients experienced severe steroid-related adverse effects such as recurrence of venous thrombosis, spontaneous fracture or osteonecrosis, and gastroduodenal ulcer.

Conclusion

Acute/subacute severe CVT with hereditary PCD/PSD has high levels of inflammation. In addition to conventional anticoagulant therapy, early anti-inflammatory therapy using steroids may be necessary. Nevertheless, substantial randomized controlled trials with larger sample sizes are required for further investigation.

Facial pain associated with vein of Trolard thrombosis Case report Neurology

Cerebral venous thrombosis is a rare condition, with identified and described risk factors mainly associated with prothrombotic states, with a wide variety of symptomatology based on the site affected, the most common being intracranial hypertensive syndrome, focal or encephalopathy. Cortical veins of the superficial system are among the least frequently affected veins. The following describes a case of painful facial symptoms progressing to a focal syndrome associated with a history of chronic oral contraceptive use, with thrombosis of vein of Trolard detected and successfully treated with oral anticoagulants.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy

INTRODUCTION

Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC.

MATERIALS AND METHODS

Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed.

RESULTS

Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization.

CONCLUSION

In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

BACKGROUND

Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities.

METHODS

We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.

RESULTS

The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R).

CONCLUSIONS

Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis

BACKGROUND

Emerging data suggest that direct oral anticoagulants may be a suitable choice for anticoagulation for cerebral venous thrombosis (CVT). However, conducting high-quality trials in CVT is challenging as it is a rare disease with low rates of adverse outcomes such as major bleeding and functional dependence. To facilitate the design of future CVT trials, SECRET (Study of Rivaroxaban for Cerebral Venous Thrombosis) assessed (1) the feasibility of recruitment, (2) the safety of rivaroxaban compared with standard-of-care anticoagulation, and (3) patient-centered functional outcomes.

METHODS

This was a phase II, prospective, open-label blinded-end point 1:1 randomized trial conducted at 12 Canadian centers. Participants were aged ≥18 years, within 14 days of a new diagnosis of symptomatic CVT, and suitable for oral anticoagulation; they were randomized to receive rivaroxaban 20 mg daily, or standard-of-care anticoagulation (warfarin, target international normalized ratio, 2.0-3.0, or low-molecular-weight heparin) for 180 days, with optional extension up to 365 days. Primary outcomes were annual rate of recruitment (feasibility); and a composite of symptomatic intracranial hemorrhage, major extracranial hemorrhage, or mortality at 180 days (safety). Secondary outcomes included recurrent venous thromboembolism, recanalization, clinically relevant nonmajor bleeding, and functional and patient-reported outcomes (modified Rankin Scale, quality of life, headache, mood, fatigue, and cognition) at days 180 and 365.

RESULTS

Fifty-five participants were randomized. The rate of recruitment was 21.3 participants/year; 57% of eligible candidates consented. Median age was 48.0 years (interquartile range, 38.5-73.2); 66% were female. There was 1 primary event (symptomatic intracranial hemorrhage), 2 clinically relevant nonmajor bleeding events, and 1 recurrent CVT by day 180, all in the rivaroxaban group. All participants in both arms had at least partial recanalization by day 180. At enrollment, both groups on average reported reduced quality of life, low mood, fatigue, and headache with impaired cognitive performance. All metrics improved markedly by day 180.

CONCLUSIONS

Recruitment targets were reached, but many eligible participants declined randomization. There were numerically more bleeding events in patients taking rivaroxaban compared with control, but rates of bleeding and recurrent venous thromboembolism were low overall and in keeping with previous studies. Participants had symptoms affecting their well-being at enrollment but improved over time.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03178864.

Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers

BACKGROUND

Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19.

AIMS

This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19.

CONCLUSION

A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.

Risk and Prognosis of Cancer in Patients With Cerebral Venous Thrombosis Compared With the Danish General Population

BACKGROUND

Whether cerebral venous thrombosis (CVT) is a marker of cancer in clinical practice remains unknown. Little is known about the prognosis of cancer detected subsequent to CVT.

METHODS

We used Danish nationwide registries (1996-2019) to identify patients with a first-time primary inpatient diagnosis of CVT without a history of cancer (N=811, 65% women, median age 42 years). We assessed the risk of an incident cancer diagnosis using standardized incidence ratios (SIRs). This measure contrasts the number of observed cancers among patients with CVT to the number of expected cancers where patients with CVT have the same cancer risk as the general population. We used Kaplan-Meier survival analysis and Cox regression to compare the survival of patients with both cancer and CVT with the survival of patients with cancer but without CVT, matched on cancer site, sex, age, and year of cancer diagnosis.

RESULTS

Observing 43 incident cancer cases during follow-up, the overall SIR was unity (SIR, 1.04 [95% CI, 0.75-1.40]). However, the risk was ≈7-fold the expected level in the first 3 months following CVT diagnosis (SIR, 7.00 [95% CI, 3.02-13.80]) and ≈2-fold the expected level from 3 to 12 months following CVT diagnosis (SIR, 2.21 [95% CI, 0.89-4.56]). By 12 months following CVT diagnosis, the risk resembled the expected level (SIR, 0.76 [95% CI, 0.50-1.09]). Survival among cancer patients with prior CVT versus cancer patients without prior CVT was 91% versus 87% after 6 months and 65% versus 70% after 5 years. The adjusted hazard ratio of death was 0.78 (95% CI, 0.44-1.38).

CONCLUSIONS

Patients with CVT were not at overall increased risk of a cancer diagnosis, except in the first 3 months after diagnosis during which period the risk was elevated ≈7-fold. The estimate from this early period, however, was based on only a few cancer diagnoses. Unlike other forms of venous thrombosis, a prior diagnosis of CVT did not negatively impact cancer survival.

Characteristics and Outcomes of Children with Cerebral Sinus Venous Thrombosis

BACKGROUND

Cerebral sinus venous thrombosis (CSVT) is an uncommon condition in children with potentially serious outcomes. Large epidemiological studies in children with CSVT are few. The objective of this study is to evaluate the epidemiology and in-hospital outcomes of hospitalized children with CSVT in the United States.

METHODS

We performed a retrospective cross-sectional analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for the combined years 2016 and 2019. The database was queried using the diagnoses for intracranial and intraspinal phlebitis and thrombophlebitis, nonpyogenic thrombosis of the intracranial venous system, and cerebral infarction due to cerebral venous thrombosis. Sample weighting was employed to produce national estimates.

RESULTS

Of 12,165,621 discharges, 3202 had CSVT (in-hospital prevalence 26.3 per 100,000 discharges). Male patients accounted for 57% of CSVT discharges. The median age was 8 years (interquartile range 1-16), with a U-shaped distribution with peaks in patients younger than 4 years and patients aged between 18 and 20 years. A total of 19.3% of children with CSVT had either hemorrhagic or ischemic stroke. Patients with stroke were more likely to require mechanical ventilation (odds ratio [OR] 2.7; 95% confidence interval [CI] 2.1-3.3; p < 0.001) and have higher mortality (OR 2.3; 95% CI 1.6-3.4; p < 0.001). Mechanical ventilation was necessary for 25.2% of patients with CSVT, of whom the majority were neonates and young children. The need for mechanical ventilation was associated with increased mortality (OR 16.6; 95% CI 9.9-27.9; p < 0.001). The overall mortality rate for CSVT was 4.1%, and 16.5% of patients with CSVT were discharged with home health care or to a skilled nursing facility.

CONCLUSIONS

CSVT, which has a U-shaped age distribution, is an uncommon condition in children. Stroke is common in children with CSVT, and it is associated with an increased need for mechanical ventilation and increased mortality. The need for mechanical ventilation is more common in infants, and it is associated with increased mortality across all age groups.

Prognosis and management of acute symptomatic seizures: a prospective, multicenter, observational study

BACKGROUND

Acute symptomatic epileptic seizures are frequently seen in neurocritical care. To prevent subsequent unprovoked seizures, long-term treatments with antiseizure medications are often initiated although supporting evidence is lacking. This study aimed at prospectively assessing the risk of unprovoked seizure relapse with respect to the use of antiseizure medications. It was hypothesized that after a first acute symptomatic seizure of structural etiology, the cumulative 12-month risk of unprovoked seizure relapse is ≤ 25%.

METHODS

Inclusion criteria were age ≥ 18 and acute symptomatic first-ever epileptic seizure; patients with status epilepticus were excluded. Using telephone and mail interviews, participants were followed for 12 months after the acute symptomatic first seizure. Primary endpoint was the occurrence and timing of a first unprovoked seizure relapse. In addition, neuro-intensivists in Germany were interviewed about their antiseizure treatment strategies through an anonymous online survey.

RESULTS

Eleven of 122 participants with structural etiology had an unprovoked seizure relapse, resulting in a cumulative 12-month risk of 10.7% (95%CI, 4.7%-16.7%). None of 19 participants with a non-structural etiology had a subsequent unprovoked seizure. Compared to structural etiology alone, combined infectious and structural etiology was independently associated with unprovoked seizure relapse (OR 11.1; 95%CI, 1.8-69.7). Median duration of antiseizure treatment was 3.4 months (IQR 0-9.3). Seven out of 11 participants had their unprovoked seizure relapse while taking antiseizure medication; longer treatment durations were not associated with decreased risk of unprovoked seizure relapse. Following the non-representative online survey, most neuro-intensivists consider 3 months or less of antiseizure medication to be adequate.

CONCLUSIONS

Even in case of structural etiology, acute symptomatic seizures bear a low risk of subsequent unprovoked seizures. There is still no evidence favoring long-term treatments with antiseizure medications. Hence, individual constellations with an increased risk of unprovoked seizure relapse should be identified, such as central nervous system infections causing structural brain damage. However, in the absence of high-risk features, antiseizure medications should be discontinued early to avoid overtreatment.

Direct oral anticoagulants for the treatment of cerebral venous thrombosis - a protocol of an international phase IV study

Introduction

Current guidelines recommend that patients with cerebral venous thrombosis (CVT) should be treated with vitamin K antagonists (VKAs) for 3-12 months. Direct oral anticoagulants (DOACs), however, are increasingly used in clinical practice. An exploratory randomized controlled trial including 120 patients with CVT suggested that the efficacy and safety profile of dabigatran (a DOAC) is similar to VKAs for the treatment of CVT, but large-scale prospective studies from a real-world setting are lacking.

Methods

DOAC-CVT is an international, prospective, observational cohort study comparing DOACs to VKAs for the prevention of recurrent venous thrombotic events after acute CVT. Patients are eligible if they are 18 years or older, have a radiologically confirmed CVT, and have started oral anticoagulant treatment (DOAC or VKA) within 30 days of CVT diagnosis. Patients with an absolute contra-indication for DOACs, such as pregnancy or severe renal insufficiency, are excluded from the study. We aim to recruit at least 500 patients within a three-year recruitment period. The primary endpoint is a composite of recurrent venous thrombosis and major bleeding at 6 months of follow-up. We will calculate an adjusted odds ratio for the primary endpoint using propensity score inverse probability treatment weighting.

Discussion

DOAC-CVT will provide real-world data on the comparative efficacy and safety of DOACs versus VKAs for the treatment of CVT.

Clinical trial registration

ClinicalTrials.gov, NCT04660747.

High-Altitude Exposure and Cerebral Venous Thrombosis: An Updated Systematic Review

Kharel, Sanjeev, Suraj Shrestha, Samriddha Raj Pant, Suman Acharya, Amit Sharma, Santosh Baniya, and Sanjeeb S. Bhandari. High-altitude exposure and cerebral venous thrombosis: an updated systematic review. High Alt Med Biol. 24:167-174, 2023. Background: High altitude (HA) may increase the risk of cerebral venous thrombosis (CVT). Differentiating it from other HA illnesses is crucial for prompt treatment and better outcomes. We aimed to summarize the clinical data, etiology, and risk factors of this poorly understood entity at an HA. Materials and Methods: A systematic literature search of various databases, including PubMed, Embase, and Google Scholar, was done using relevant keywords; cerebral venous thrombosis; HA, up to May 1, 2022. Results: A total of nine studies, including 75 cases of CVT at HA (3,000-8,848 m), with 66 males and 9 females, were included in this review. Headache and seizure were the most common clinical presentations. Smoking, drinking habits, and the use of oral contraceptive pills (OCP) were the most common risk factors for the development of CVT. Similarly, various underlying hypercoagulable states were also present among cases of CVT associated with HA exposure. Conclusion: Our review concludes that HA exposure can predispose individuals with risk factors such as preexisting hypercoagulable states, smoking, drinking habits, and use of OCP to an increased risk of CVT.

Descriptive Study of Headache as the Most Common Presenting Feature of Cerebral Venous Thrombosis

OBJECTIVE

To study the etiology and clinical characteristics of cerebral venous thrombosis (CVT) patients with a detailed description of headache as a presenting feature.

INTRODUCTION

CVT is an infrequent type of stroke with protean clinical manifestations. The most common presenting symptom in CVT is headache (>85%), followed by seizures and focal neurological deficits.

METHODS

A total of 32 consecutive and confirmed patients of CVT were recruited after obtaining informed consent. CVT was diagnosed based on clinical and imaging parameters. Data regarding etiology, clinical symptoms, and signs with special mention of headache pattern, onset, site, character, severity (based on the visual analog scale), aggravating and relieving factors, as well as sinus involvement were recorded.

RESULTS

A total of 32 patients (16 males and 16 females) with a mean age of 31.56 (SD = 14.31) years were recruited, out of which 31 patients (96.87%) presented with headaches. The mode of onset of headache was acute in 19.35%, sub-acute in 67.75%, and chronic in 12.9% of patients. Location was holocranial in 38.71%, hemicranial in 29.03%, frontal in 22.58%, and occipital in 9.68% of patients. Headache was severe in 38.7% and moderate in 61.3% of patients. Character was throbbing in 67.74%, heaviness in 25.8%, and band-like in 6.46% of patients. Headache was aggravated on bending forward in 58.06%, movement in 35.48%, coughing in 32.26%, straining in 25.8%, and standing in 16.12% of patients. The relieving factors of headache were lying down in 45.16%, sleeping in 45.16%, and sitting quietly in 9.86% of patients.

CONCLUSION

CVT should be suspected in patients presenting with new-onset holocranial or hemicranial headaches of increasing intensity, thereby requiring early imaging and appropriate management.

Nitrous Oxide-Induced Cerebral Venous Thrombosis: A Case Report, Potential Mechanisms, and Literature Review

Cerebral venous thrombosis can result from hypercoagulation, either genetic or acquired. Hyperhomocysteninemia was previously thought to be linked with thrombophilia, although this is still controversial to this present day. In recent years, there has been a notable surge in the recreational use of nitrous oxide, which could potentially lead to hyperhomocysteinemia. We present a case of a 19-year-old female who was diagnosed with cerebral venous thrombosis with intracerebral hemorrhage. She had a history of nitrous oxide abuse, which is known to cause dysfunction of vitamin B12. Additionally, we conducted a literature review of cerebral venous thrombosis following nitrous oxide usage. Investigation showed that her serum vitamin B12 level was <100 pg/mL (reference range 197-771 pg/mL), and homocysteine level was 100.6 µmol/L (reference range 5.0-15.0 µmol/L). After receiving a vitamin B12 supplement, both serum vitamin B12 and homocysteine levels returned to normal. No other risk factors for thrombophilia were detected. Previously reported cases predominantly demonstrated hyperhomocysteinemia. The most likely mechanism of her cerebral venous thrombosis was hyperhomocysteinemia due to vitamin B12 deficiency caused by nitrous oxide abuse. This finding supports the hypothesis that hyperhomocysteinemia can induce cerebral venous thrombosis.

Cerebral Venous Thrombosis in a 17-Year-Old Female Patient: A Case Report

Cerebral venous thrombosis (CVT) is a rare disorder predominantly affecting young women. Clinical presentation is not specific and varies depending on the location of the thrombus. The diagnosis requires clinical suspicion with confirmation by images. Guidelines for treatment recommend heparin during the acute phase even in patients with intraparenchymal hemorrhage. It is associated with a good prognosis when diagnosed and treated promptly. We present a case of CVT and intraparenchymal hemorrhage in a 17-year-old female with severe headache, nausea, vomiting, and altered mental status. The patient was diagnosed with CVT secondary to systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). She showed improvement after anticoagulation and corticosteroids.

Cerebral venous thrombosis in adults: a case series of 35 patients from a tertiary hospital

OBJECTIVE

To describe the baseline characteristics, clinical presentation, imaging tests and outcomes and identify potential prognostic factors in a cohort of patients diagnosed with cerebral venous thrombosis (CVT).

PATIENTS AND METHODS

Retrospective, single-center, observational study that included adult patients diagnosed with CVT from January 2016 to December 2020. The variables were reviewed through electronic medical records.

RESULTS

A total of 35 patients were included and the median age at diagnosis was 50.3 (+/- 17.8) years, the majority being women (74.4%). Almost 95% of the patients presented at least one risk factor for the development of CVT. Heparins were used for the acute phase in 97.1%; among them, 75% were low molecular weight heparins. The compound event (death, intensive care unit admission, National Institute of Health Stroke Scale at discharge >3, CVT recurrence, major bleeding, or the presence of complications) within the first two weeks occurred in 28.6% (10 patients). During the mean follow-up of 3.3 years, 14.3% died (among them, only one patient´s death was caused by CVT), one patient had major bleeding and no patient presented recurrence of CVT.

CONCLUSIONS

In our cohort, CVT affected more frequently young women with at least one risk factor for the development of CVT. The presence of edema on CT and corticosteroid treatment were associated with poor short-term prognosis. A good long-term prognosis was observed in terms of mortality, recurrence, and bleeding.

Imaging Outcomes of Emergency MRI in Patients with Suspected Cerebral Venous Sinus Thrombosis: A Retrospective Cohort Study

Cerebral venous sinus thrombosis (CVST) is a rare neurological emergency condition with non-specific symptoms. Imaging options to rule out CVST are computed tomography (CT) and magnetic resonance imaging (MRI). This study aimed to determine the imaging outcomes of emergency MRI as a first-line imaging method in patients with suspected CVST. In this retrospective cohort study, we analyzed emergency brain MRI referrals from a five-year period in a tertiary hospital for suspicion of CVST. We recorded patient characteristics, risk factors mentioned in the referrals, and imaging outcomes. Altogether 327 patients underwent emergency MRI on the grounds of suspected CVST. MRI showed evidence of CVST among five patients (1.5%). Imaging showed other clinically significant pathology in 15% of the patients and incidental findings in 5% of the patients. Despite clinical suspicion, the diagnostic yield of emergency MRI for CVST is low and similar to that previously reported for CT. MRI is an alternative imaging method devoid of ionizing radiation in patients with suspected CVST.

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

BACKGROUND

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

AIMS

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

SUMMARY OF REVIEW

Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

CONCLUSION

The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Clinical features of patients with cerebral venous sinus thrombosis at plateau areas

OBJECTIVE

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.

METHODS

Twenty-four symptomatic CVST patients occurring at plateau areas (altitude ≥ 4000 m), in corresponding with 24 CVST patients occurring at plain areas (altitude ≤ 1000 m), were recruited according to the inclusion and exclusion criteria from June 2020 to December 2021. The collected data and compared parameters include clinical features, neuroimaging findings, hematology profile, lipid profile, and coagulation profile within 24 h of hospital admission, as well as the treatment method and final outcome.

RESULTS

There were no obvious differences of demographic characteristics, including gender, age, height, and weight between patients with CVST in plateau and plain areas, as well as medical history, neuroimaging findings, treatment protocols, and clinical outcome (all p > .05). Compared to patients with CVST at plain areas, time before hospital admission was longer and heartbeat was slower in patients with CVST at plateau areas (all p < .05). More importantly, elevated red blood cells counts, hemoglobin level, and altered coagulation function were found in patients with CVST at plateau areas (all p < .05).

CONCLUSION

CVST patients in plateau areas presented with altered clinical characteristics, altered coagulation function, and aggravated predisposition toward venous thromboembolism compared with CVST patients in plain areas. Future prospective studies will be needed to further elucidate the influences of a high altitude on the pathogenesis of CVST.

Obstetric and Gynecologic Disorders and the Nervous System

OBJECTIVE

This article discusses obstetric and gynecologic associations with common neurologic disorders.

LATEST DEVELOPMENTS

Neurologic complications of obstetric and gynecologic disorders can arise throughout the lifespan. Caution should be exercised when prescribing fingolimod and natalizumab to patients with multiple sclerosis who are of childbearing potential because of the risk of disease rebound when they are discontinued. OnabotulinumtoxinA is considered safe in pregnancy and lactation based on long-term observational data. Hypertensive disorders of pregnancy are associated with higher subsequent cerebrovascular risk, likely via multiple mechanisms.

ESSENTIAL POINTS

Neurologic disorders may present in a variety of obstetric and gynecologic contexts, with meaningful implications for recognition and treatment. These interactions must be considered when treating women with neurologic conditions.

Safety and clinical outcomes in endovascular treatment for symptomatic cerebral venous thrombosis: a single-center experience with meta-analysis

The role of mechanical thrombectomy (MT) in cerebral venous sinus thrombosis (CVT) is ambiguous. This study aims to share our experience with MT in CVT, supplemented by a meta-analysis on this treatment. All patients who had MT for CVT at our institution, between 2016 and 2021, were retrospectively reviewed for treatment indications, the technique used, success and complication rates, and clinical outcomes. A meta-analysis was performed for clinical and safety outcomes from published literature with > 10 patients. A total of 15 patients were included in this study. All had a venous hemorrhage or deteriorating despite anticoagulation. MT was performed using aspiration (with wide bore catheters) in 7 patients: aspiration with stent retriever in 5 and transjugular Fogarty-balloon thrombectomy in 3 patients. Adjunctive intra-sinus thrombolysis (IST) was used in 4 cases and venoplasty in 3. Technical success (restoring antegrade venous flow on arterial injection) was 100% with no procedure-related major complication. The direct transjugular approach was cheaper and faster. At 3-month follow-up, 86% of patients had good outcomes (MRS < 2). Meta-analysis of clinical and safety outcomes from 22 and 20 studies, respectively, demonstrated a positive association between MT and good outcomes as well as no significant association with hazardous periprocedural events. EVT via mechanical means for CVT is feasible in our series and meta-analysis. From our experience, trans-jugular Fogarty balloon embolectomy seems to be a potential cost-saving option, at least in a certain part of the world.

Clinical Reasoning: A 25-Year-Old Woman With Eye Swelling and Headache

Cerebral venous sinus thrombosis (CVST) is uncommon. Risk factors include inherited and acquired factors. Rapid diagnosis and treatment is essential and can help prevent complications, which can include seizures and visual disturbance. A 25-year-old woman with a background history of CVST and intermittent warfarin use presented to the hospital in 2021 with a 3-month history of progressive eye swelling and headache. Her headache was located in the right frontal region and worsened with movement. Her workup was consistent with recurrent CVST and dural arteriovenous fistula. IR-guided embolization of the fistulas and stenting of her sinuses was performed. She was treated with dual antiplatelet therapy and therapeutic tinzaparin. Her symptoms improved markedly over several days, with improvement in headache and visual acuity. This case illustrates the potential for severe complications including visual disturbance in untreated CVST, as well as the importance of a thorough history and examination in aiding the recognition of the condition.

Identifying the risk factors for intracranial herniation in patients with cerebral venous thrombosis

BACKGROUND

 Cerebral venous sinus thrombosis (CVST) is not as well understood as an ischemic stroke of arterial origin. Although the prognosis of CVST is usually good, parenchymal lesions may occur in some patients, and the development of intracranial herniation may result in death. For this reason, recognizing the risk factors for intracranial herniation and accurately determining those patients who should undergo decompressive craniectomy is important.

OBJECTIVE

 This study aims to determine the risk factors for intracranial herniation in patients with CVST.

METHODS

 A total of 177 patients diagnosed with CVST between 2015 and 2021 in our tertiary center were retrospectively included in this study.

RESULTS

 Of the 177 patients, 124 were female and 53 were male with mean ages of 40.65 ± 13.23 and 44.13 ± 17.09, respectively. Among those, 18 patients had developed intracranial herniation. A significant statistical relationship was observed between superior sagittal sinus thrombosis, sinus rectus thrombosis, venous collateral score, nonhemorrhagic venous infarct, presence of malignancy, small juxtacortical hemorrhage, and cortical vein thrombosis. The binary logistic regression analysis results showed that the most significant variables were the venous collateral score of 0, malignancy, and small juxtacortical hemorrhages.

CONCLUSION

 This study identified small juxtacortical hemorrhages, the presence of malignancy, and a venous collateral score of 0 to be independent risk factors for intracranial herniation in CVST patients. Drawing on these results, we recommend close clinical observation of CVST patients, as they may be candidates for decompressive craniectomy.

Snakebite Induced Cerebral Venous Sinus Thrombosis: A Case Report

Introduction:

Cerebral venous sinus thrombosis (CVST) is a rare but highly fatal neurological condition mostly caused by prothrombotic conditions like antiphospholipid syndrome, factor V Leiden, and G20210A prothrombin polymorphism. Snake bites are a rare cause of cerebral venous sinus thrombosis that must be recognized and treated promptly to improve survival.

Case presentation:

We present a case of a 25-year-old male who developed headaches and seizures following a Viper snake bite. The diagnosis was made based on a magnetic resonance venogram (MRV) showing transverse sinus thrombosis with sigmoid sinus stenosis. Initially, the patient was treated with antivenom and supportive treatment for disseminated intravascular coagulation (DIC). After the diagnosis of CVST, the patient was treated with rivaroxaban and levetiracetam. The patient improved within 1 week of treatment and was advised to follow up in 3 months.

Conclusion:

A high index of suspicion for cerebral venous sinus thrombosis is required if the patient presents with headaches, seizures, or abnormal vision following a snake bite. Early diagnosis and management can prevent further neurological damage.

Diagnosis and Treatment of Cerebral Venous Thrombosis

OBJECTIVE

Cerebral venous thrombosis (CVT), thrombosis of the dural sinus, cerebral veins, or both, is a rare cerebrovascular disease. Although mortality rates after CVT have declined over time, this condition can result in devastating neurologic outcomes. This article reviews the latest literature regarding CVT epidemiology, details new factors associated with the development of CVT, and describes advances in CVT treatment. It also contains a discussion of future directions in the field, including novel diagnostic imaging modalities, and potential strategies to reduce the risks associated with CVT.

LATEST DEVELOPMENTS

The incidence of CVT may be as high as 2 per 100,000 adults per year. It remains a difficult condition to diagnose given its variable clinical manifestations and the necessity of neuroimaging for confirmation. The COVID-19 pandemic has revealed a novel CVT trigger, vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as an association between COVID-19 infection and CVT. Although VITT is a very rare event, timely diagnosis and treatment of CVT due to VITT likely improves patient outcomes. Direct oral anticoagulants are currently being used to treat CVT and emerging data suggest that these agents are as safe and effective as vitamin K antagonists. The role of endovascular therapy to treat CVT, despite a recent clinical trial, remains unproven.

ESSENTIAL POINTS

The incidence of CVT has increased, outcomes have improved, and the use of direct oral anticoagulants to treat CVT represents an important advance in the clinical care of these patients. Rates of CVT as a complication of COVID-19 vaccines using adenoviral vectors are very low (<5 per million vaccine doses administered), with the benefits of COVID-19 vaccination far outweighing the risks.

Cerebral venous thrombosis in patients with Sjögren's syndrome: A case report and literature review

Although cerebral venous thrombosis (CVT) is known to be induced by autoimmune diseases such as systemic lupus erythematosus and antiphospholipid syndrome, CVT caused by Sjögren's syndrome (SS) is scarcely reported in the medical literature. Since the first report of SS-induced CVT in 1994, only five cases have been reported, and the clinicopathological features of the disease are not well documented. We herein present a case report of a 41-year-old woman who was diagnosed with SS-induced CVT and perform a literature review of six cases of SS-induced CVT with a discussion of the pathogenesis, features of clinic symptoms, treatment, and prognosis of SS-associated CVT. We aim to improve the understanding of SS-induced CVT among clinicians and reduce the incidence of missed clinical diagnoses.

Decompressive surgery in cerebral venous thrombosis: A systematic review and meta-analysis

OBJECTIVE

The efficacy of decompressive surgery (DS) in cerebral venous thrombosis (CVT) patients has been reported in several case reports and case series. We aimed at determining the association of DS compared with medical management and timing of surgery with functional outcome and mortality. We also aimed at determining the prevalence of DS in CVT patients.

METHODS

The literature search was conducted till 7 November 2022 in PubMed, Google Scholar, EMBASE and Cochrane Library databases. Risk of bias was examined using Joanna Briggs Institute scale for case series and case reports. Association of DS compared with medical management and timing of surgery with functional outcome and mortality was determined using odds ratio (OR) and 95% confidence interval (CI). Pooled prevalence of DS in CVT patients with 95%CI was calculated. Heterogeneity was explored using outlier, meta-regression, sensitivity and subgroup analyses.

RESULTS

Fifty-one studies consisting of 483 CVT cases with DS were included. The OR of poor outcome with surgery was 0.03; (95%CI: 0.00-0.22) and of mortality with surgery was 0.25; (95%CI: 0.02-2.60) versus that with medical management. Surgery done ≤48 h of admission was significantly associated with less mortality (OR: 0.26; 95%CI: 0.10-0.69). Pooled prevalence of DS in CVT was 12% (95%CI: 8%-17%; I²  = 91%). Revised pooled prevalence after removing outliers was 10% (95%CI: 7%-13%; I²  = 73%).

CONCLUSIONS

Surgery ≤48 h of admission might decrease mortality in CVT patients and may result in improved functional outcome. Further prospective studies with appropriate control arms are required to confirm its efficacy over medical management.

Mechanical Venous Thrombectomy Using Indigo Aspiration System: A Case Report

We present a case of successful endovascular thrombectomy of cerebral venous sinus thrombosis utilizing Penumbra's Indigo Aspiration System (Penumbra Inc., Place Alameda, CA), a minimally invasive system with a large-lumen (Indigo System CAT7, 7F) catheter predominantly used for the removal of thromboembolism involving the peripheral arterial and venous systems. A 30-year-old female presented with a seizure and focal neurological deficits and was found to have a left posterior temporal lobe hemorrhagic infarct secondary to an extensive cerebral venous sinus thrombosis extending from the left transverse sinus to the ipsilateral internal jugular bulb. We considered the combination of seizure, motor deficit, and hemorrhagic infarct high-risk features for poor response to standard medical therapy with therapeutic anticoagulation. Therefore, we performed a mechanical venous thrombectomy with the above device in addition to anticoagulation treatment with heparin infusion. This combination therapy resulted in a technically successful radiographic recanalization of the involved sinuses and an excellent functional outcome at follow-up. This case demonstrates that this trackable, atraumatic, large-bore system was safe and efficacious in the cerebral venous system, permitting near-complete thrombus removal.

Risk factors for the development of secondary intracranial hypertension in acute cerebral venous thrombosis

PURPOSE

Intracranial hypertension (IH) can complicate cerebral venous thrombosis (CVT), potentially causing permanent visual loss. Current knowledge on risk factors for the development of IH following CVT is scarce. We applied a compound classifier (CSF opening pressure > 25 cmH₂O, papilledema, or optic disc protrusion on MRI) as a surrogate for IH and studied the predictive value of thrombus location, the number of thrombosed segments, and thrombus volume.

METHODS

We prospectively included 26 patients with acute CVT and complete MRI data. IH was defined by CSF opening pressure > 25 cmH₂O, papilledema, or optic disc protrusion on MRI. Using high-resolution contrast-enhanced venography, we determined the thrombus location, number of thrombosed segments, and thrombus volume. We analyzed their association with IH by logistic regression, their predictive power by the area under the receiver operating characteristic curve, and their association with CSF opening pressure by linear regression.

RESULTS

IH occurred in 46% of CVT patients and was associated with higher thrombus volume (AUC 0.759, p = 0.025) and superior sagittal sinus thrombosis both alone (OR 2.086, p = 0.049) and combined with transverse sinus thrombosis (OR 2.014, p = 0.028). Effects in patients presenting CSF opening pressure > 25 cm H₂O and the compound classifier were consistent. Thrombus volume > 4 ml was the single most important predictor of higher CSF opening pressure (ß = 0.566, p = 0.035), increasing IH risk.

CONCLUSION

Larger thrombus volume, dominant transverse sinus occlusion, and extensive superior sagittal combined with transverse sinus thrombosis were associated with IH. Thrombus volumetry might identify patients at risk for IH and direct further clinical evaluation.

Dural Venous Sinus Thrombosis and Papilledema Related to JAK2 Mutation: A Case Series

BACKGROUND

Dural venous sinus thrombosis (DVST) is an important cause of papilledema. Patients diagnosed with DVST should undergo work-up for underlying hypercoagulable state, including genetic causes. One important prothrombotic mutation is in the JAK2 gene, which is a driver of myeloproliferative neoplasms including polycythemia vera (PV). We aimed to determine the prevalence of JAK2 mutation in patients in presenting to neuro-ophthalmology clinic with DVST and papilledema.

METHODS

Retrospective case series of patients seen in a tertiary neuro-ophthalmology practice who presented with papilledema due to DVST and were investigated for presence of JAK2 mutation.

RESULTS

Four out of 15 patients with DVST (26%) were found to have JAK2 V617F mutation which led to subsequent diagnosis of PV in 2. One additional patient had a known diagnosis of essential thrombocytosis. We describe the clinical presentation of these four patients with papilledema and JAK2 mutation.

CONCLUSIONS

A significant proportion of patients with papilledema secondary to DVST will harbor mutations in the JAK2 gene. Clinicians should be aware of this mutation as early testing will facilitate timely diagnosis and treatment of myeloproliferative disease to improve prognosis and reduce risk of recurrent thrombotic events.

The Negative Prognostic Role of Inflammatory Biomarkers in Patients With Chronic Cerebrospinal Venous Insufficiency

BACKGROUND

The pathologic consequences of inflammatory responses in chronic cerebrospinal venous insufficiency (CCSVI) remains poorly understood. Hence, this study was aimed to evaluate the peripheral inflammatory biomarkers in patients with intracranial and extracranial CCSVI pathology. In addition, the relationship between inflammatory cytokine profile and CCSVI prognosis was also evaluated.

METHODS

Patients diagnosed with CCSVI between July 2017 and July 2019 were included and subsequently divided into 3 groups based on the location of stenosis. The inflammatory biomarker assay included neutrophil-to-lymphocyte ratios (NLRs), platelet-to-lymphocyte ratios (PLRs), red blood cell distribution widths (RDW), C-reactive protein (CRP) levels, interleukin-6 (IL-6) levels, and neuron-specific enolase levels. Clinical outcomes were assessed using the modified Rankin Scale and Patient Global Impression of Change score. Univariate and multivariate regression analyses were performed to identify significant prognostic factors for poorer outcomes. Finally, we established a nomogram based on the multivariate regression analysis.

RESULTS

We enrolled 248 patients in total, including 102 males and 146 females, with an average age of 57.85±12.28 years. Compared with patients with internal jugular vein stenosis, cerebral venous sinus stenosis (CVSS) patients were mostly younger and had been suffering from headaches and severe papilledema. Higher levels of NLR, RDW, and CRP were also observed in the CVSS group. Multivariate analysis indicated that NLR, PLR, and IL-6 were the independent prognostic factors for poor CCSVI outcomes.

CONCLUSIONS

The clinical presentations and increases in NLR, PLR, IL-6, and CRP levels could be distinctly marked in patients with CVSS-related CCSVI than that in internal jugular vein stenosis-related CCSVI, indicating poor prognostic outcomes in these patients. A proinflammatory state might be associated with CCSVI pathology.

Investigation of Neurological Complications after COVID-19 Vaccination: Report of the Clinical Scenarios and Review of the Literature

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), broke out in 2019 and became a pandemic in 2020. Since then, vaccines have been approved to prevent severe illness. However, vaccines are associated with the risk of neurological complications ranging from mild to severe. Severe complications such as vaccine-induced immune thrombotic thrombocytopenia (VITT) associated with acute ischaemic stroke have been reported as rare complications post-COVID-19 vaccination. During the pandemic era, VITT evaluation is needed in cases with a history of vaccination within the last month prior to the event. Cerebral venous sinus thrombosis (CVST) should be suspected in patients following immunization with persistent headaches who are unresponsive to analgesics. In this article, we investigated neurological complications after COVID-19 vaccination and provided more subsequent related clinical studies of accurate diagnosis, pathophysiological mechanisms, incidence, outcome, and management.

Decompressive surgery in cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia

BACKGROUND AND PURPOSE

Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored.

METHODS

Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included.

RESULTS

Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent.

CONCLUSIONS

Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence.

Diagnostic Sensitivity of Unenhanced CT for Cerebral Venous Thrombosis: Can Clot Density Measurement Replace CT Venogram?

Objectives Cerebral venous sinus thrombosis is an important cause of stroke in young adults. Noncontrast-enhanced CT head (NECT) is almost always the first investigation.

Our objectives were as follows:

1. How accurately does venous sinus density on NECT predict the presence of clot on CT venogram (CTV)?

2. Whether repeated measurements changed the confidence?

3. How many venous sinus thrombus would be missed if we do not do a CTV?

4. Can clot density measurement replace CTV?

Methods Multicenter case–control study was designed with data from seven hospitals. Inclusion criteria: all CT and magnetic resonance imaging venograms with a prior NECT, performed between 1.1.2018 and 31.12.2018 (12 months), were included. Hounsfield unit (HU) values were calculated at the site of highest density on the NECT. Logistic regression analysis was performed using STATA.

Result Two-hundred seventy-seven cases met the criteria with 33 positive cerebral venous thrombosis (density on NECT 60–92 HU) and 244 negative examinations (density on NECT 31–68 HU). Area under the curve for average clot density on NECT was 0.9984.

Conclusion We found a strong relationship between sinus density on NECT and outcome of CTV. Repeating density measurements did not add any predictive value or changed outcome.

Advances in Knowledge Density 70 HU or higher on NECT always resulted in a positive CTV but would miss a fifth of the positives. Cutoff at 60 HU would not miss any but result in significant false positives. An efficient option could be to limit CTV to sinus densities 60 to 70 HU only. However, a larger study would be required for such change in practice.

Deep cerebral venous system involvement in patients with cerebral sinus thrombosis. A proposal of neuroradiological score systems useful for clinical assessment

PURPOSE

To develop a neuroradiological score in patients with deep cerebral venous thrombosis (DCVT), capable of assessing extension of intracranial changes and venous occlusion at diagnosis; to assess the relationship between neuroradiological and clinical features at follow-up.

MATERIAL AND METHODS

In 14 patients with DCVT, we developed 2 score systems on non-enhanced and contrast-enhanced CT: Intracranial Imaging Score (IIS) and Venous Occlusion Imaging Score (VOIS). ISS considers parenchymal venous strokes, hemorrhage, mass effect, and hydrocephalus; VOIS evaluates unilateral or bilateral venous occlusion extension. Modified Rankin Scale (mRS) and vessel recanalization status were assessed at follow-up.

RESULTS

At diagnosis, higher IIS was related to bilateral venous thrombosis involvement (p 0,02; r:0,60), but parenchymal strokes were not related to venous occlusion extension (unilateral or bilateral) (p > 0,05). Moreover, the symptoms' onset time did not correlate with the severity scores (p > 0,05). At follow-up, 8 out of 14 patients showed good clinical outcomes with complete recanalization and neurological improvement, 1 patient showed a poor neurological outcome, whereas 5 patients died within 1 week. Positive correlations were found between IIS and mRS (p 0,003, r = 0,73), between IIS and vessels' recanalization status (p 0,002, r = 0,75), and between vessels' recanalization status and mRS (p < 0,001, r = 0,98).

CONCLUSION

Neuroradiological scores may enhance diagnostic accuracy, and they may have a predictive significance. In patients with DCVT, although intracranial involvement was not influenced by symptoms' onset time or extension of venous occlusion, clinical outcome was related to both intracranial involvement and venous recanalization state. Collateral venous drainage status may counterbalance the thrombotic process improving prognosis.

Apixaban for the Treatment of Cerebral Venous Sinus Thrombosis: A Single-Centre Experience and Systematic Review of the Literature

BACKGROUND AND OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare disease, and data regarding direct oral anticoagulant therapy are insufficient. Apixaban could have a safer profile than other direct oral anticoagulants. We present our case series of patients with CVT treated with apixaban and a systematic review of published real-world cases.

METHODS

We described our series of patients with CVT treated with apixaban and searched PubMed for similar published cases with reported complete outcome data: recanalisation rate, recurrent CVT, modified Rankin score, intracranial haemorrhage, other bleedings and mortality.

RESULTS

Four male patients (average age 43.5 years) with idiopathic CVT, who presented with a headache and/or seizure without neurological deficits/symptoms or cerebral infarcts/haemorrhage were treated with apixaban 5 mg twice daily for an average 28 months (18-46 months) and followed for on average 2.8 years. In two patients, a partial/complete recanalisation was achieved, there was no recurrent CVT, all patients achieved a modified Rankin score of 0, none experienced an intracranial haemorrhage, other bleedings or died. One patient, in whom anti-phospholipid syndrome was later diagnosed, had a recurrence of CVT after stopping apixaban. Our systematic review identified only 15 eligible patients (average age 39 years, 60% female). Partial/complete recanalisation was achieved in 74% of cases, there was no recurrent CVT, 95% achieved a modified Rankin score of ≤ 2, none experienced an intracranial haemorrhage, other bleedings or died.

CONCLUSIONS

Our cases and the review of similar published cases, albeit obtained on a smaller scale, suggest that apixaban may be a safe and effective therapy for CVT. This assumption should be tested in a large randomised study.

Postpartum Cerebral Venous Sinus Thrombosis: A Case Report

Introduction

Cerebral venous thrombosis (CVT) remains one of the most frequent cause of stroke in young adults although it is a rare disorder. It has a serious emergency manifestation during pregnancy and postpartum. It is frequently under diagnosed and limited publications in developing countries especially sub-Saharan Africa.

Case Presentation

Here, we report the case of a 35-year-old female, para 8 and gravida 8, brought to emergency department on her ninth day postpartum, having severe headaches and confusion; during her admission to emergency, she suffered two episodes of generalized seizure. On admission, the patient's blood pressure was 200/120 mmHg. The patient was firstly diagnosed with postpartum eclampsia and managed with magnesium sulfate for seizures and hydralazine for blood pressure control. On ward admission, she continued having seizures and her level of consciousness decreased with left side weakness. An urgent MRI of head and MR venography performed immediately revealed acute thrombosis involving the anterior aspect of superior sagittal sinus and the left transverse sinus. The patient was moved to the ICU. Anti-coagulant LMW enoxaparin and anticonvulsant were started. After improving on clinical and biochemical tests, the patient was transferred to the inpatient ward on fifth day. Another two days later in the ward, she improved significantly, and then a head CT (contrast) angiography/venography was performed before she was discharge and showed no evidence of filling defect in cortical/dural venous sinuses.

Conclusion

Cerebral venous sinus thrombosis (CVST) and postpartum eclampsia may have similar manifestations in young women of reproductive age. Early prompt diagnosing and therapeutic intervention of CVST can prevent further neurological deterioration and immediately improve the patient.

Long-term Anticoagulation with Apixaban in Patients with Cerebral Venous Thrombosis

Introduction: Cerebral venous thrombosis (CVT) is a life-threatening neurological condition. There is limited evidence for the use of direct oral anticoagulants (DOAC) for long-term anticoagulation in this patient population. We report a case series of patients treated with apixaban and their clinical course. Methods: This was a retrospective cohort study. Patients diagnosed with CVT in a defined time period at our institution were screened for long-term anticoagulation and patients who were treated with apixaban were included in this study. Results: A total of nine patients were included in this study. The mean age was 36 years and 56% of the patients included were women. All received initial anticoagulation with unfractionated heparin (UFH) infusion for at least twenty-four hours, except for one patient who had anti-thrombin III deficiency and was treated with argatroban infusion. For long-term anticoagulation, 56% of patients received apixaban 10 mg twice daily for the first five to seven days followed by 5 mg twice daily, while the remaining 44% were transitioned from IV anticoagulation to apixaban 5 mg twice daily. There were no adverse events reported, except for one patient who developed anemia after 7 months of treatment and required a blood transfusion. Complete recanalization was achieved in 78% while 22% had partial recanalization. Follow-up time ranged from six to twenty-three months. Conclusion: The use of apixaban for long-term anticoagulation in CVT resulted in recanalization in all of the patients in this case series without any major side effects. This case series adds to the emerging studies demonstrating the utility of apixaban for CVT.

Incidence of Cerebral Venous Thrombosis: A Population-Based Study, Systematic Review, and Meta-Analysis

BACKGROUND

Studying the baseline incidence of cerebral venous thrombosis (CVT) prior to COVID-19 and the limitations of how this has been previously reported in the literature will help improve understanding of this disease and how risks may have changed in the post-COVID era.

METHODS

We examined CVT incidence using linked administrative data in British Columbia, Canada (population 5.2 million). To contextualize our findings, we also examined CVT incidence in the published literature and searched MEDLINE and EMBASE for article titles and abstracts up to Nov 2, 2021 on CVT incidence in adults. We performed abstract screening and full-text review prior to data extraction and explored associations between CVT incidence and year of study, geographic location, and study quality with meta-analyses and meta-regression. A random-effects restricted maximum likelihood model was used. Publication bias was assessed using the Egger tests and using visual inspection of the funnel plot for symmetry.

RESULTS

There were 554 unique CVT cases (mean age 50.9 years, 55.4% women) in British Columbia from 2000 to 2017; overall annual incidence was 8.7 (95%CI' 8.0-9.4) per million. Incidence increased over time in men across the entire study period, and from 2011 to 2017 in women. We identified 22 other studies on CVT incidence before 2020 (21/23 total studies included in meta-analysis). Annual incidence overall was 12.1 (95% CI' 9.9-14.3) per million with significant between-study heterogeneity (I2 98.8%, Qp-value<0.001). There were no significant associations on meta-regression between incidence and study year, study quality score, or gross national income per capita of the study country. Visual inspection of the funnel plot and a significant Egger test (z=2.8, P<0.01) suggested possible publication bias.

CONCLUSIONS

Incidence of CVT in Canadian data increased over time but remained lower than in other population-based studies. Significant heterogeneity exists in the literature, which may be subject to publication bias.

Cerebral Venous-Associated Brain Damage May Lead to Anxiety and Depression

Background and purpose: Anxiety and depression are common in patients with Cerebral venous outflow disturbance (CVOD). Here, we aimed to explore possible mechanisms underlying this phenomenon. Methods: We enrolled patients diagnosed with imaging-confirmed CVOD, including internal jugular venous stenosis (IJVS) and cerebral venous sinus stenosis (CVSS) between 2017 and 2020. All of them had MRI/PWI scans. The Hamilton Anxiety Scale (HAMA) and 24-item Hamilton Depression Scale (HAMD) were used to evaluate the degree of anxiety and depression at the baseline and three months post-stenting. In addition, the relationships between the HAMA and HAMD scores, white matter lesions, and cerebral perfusion were analyzed using multiple logistic regressions. Results: A total of 61 CVOD patients (mean age 47.95 ± 15.26 years, 59.0% females) were enrolled in this study. Over 70% of them reported symptoms of anxiety and/or depression. Severe CVOD-related anxiety correlated with older age (p = 0.046) and comorbid hyperlipidemia (p = 0.005). Additionally, head noise, sleep disturbances, and white matter lesions (WMLs) were common risk factors for anxiety and depression (p < 0.05). WMLs were considered an independent risk factor for anxiety based on multiple regression analysis (p = 0.029). Self-contrast displayed that CVOD-related anxiety (p = 0.027) and depression (p = 0.017) scores could be corrected by stenting, as the hypoperfusion scores in the limbic lobes of patients with anxiety and depression were significantly higher than those in patients without. Conclusions: CVOD-induced hypoperfusion-mediated changes in the white matter microstructure may represent an underlying mechanism of anxiety and depression in patients with chronic CVOD.

Sigmoid Venous Thrombosis in JAK2 V617F Mutated Polycythemia Vera

A 60-year-old female presented with headaches, blurry vision, diplopia, and dizziness for six weeks. Her workup revealed an elevated hematocrit, thrombocytosis, high ferritin, and normal erythropoietin. She was diagnosed with polycythemia vera with the JAK2 V617F mutation. The patient underwent magnetic resonance venography, which showed left-sided sigmoid venous thrombosis. She was placed on low-molecular-weight heparin, with a plan to transition to oral anticoagulation after four weeks and repeat imaging in three months to assess for resolution. Thrombotic events may occur in patients with polycythemia vera, and a JAK2 mutation further heightens that risk. Even so, intracranial venous thrombosis is not among the most common events, and it should be kept in the differential for any patient with myeloproliferative neoplasms presenting with new neurological symptoms.

Central venous sinus thrombosis in a young girl with ulcerative colitis

Paediatric central venous sinus thrombosis (CVST) is an uncommon but important life-threatening complication of inflammatory bowel disease (IBD). As the incidence of IBD has increased in the last four decades, paediatricians need to be aware of this complication. There is currently no consensus on when children with IBD should receive prophylactic anticoagulation. We present the case of a young girl with ulcerative colitis who suffered an acute ischaemic event secondary to a CVST during an acute flare of her disease. We aim to bring awareness to CVST in IBD due to its high risk of morbidity and mortality.

Treatment of idiopathic internal jugular vein thrombosis in a healthy woman with enoxaparin and rivaroxiban: Case report and literature narrative review

Introduction

Venous thrombosis is a medical condition that occurs when a blood clot forms in a vein. These clots usually develop in the lower leg, thigh, or pelvis but can also occur in the arm. It is essential to know about Venous thrombosis because it can happen to anybody and cause severe illness and disability. Fortunately, if the diagnosis is early, the outcomes will be excellent. However, idiopathic or spontaneous internal jugular vein thrombosis is a rare but potentially fatal condition. Method: here, we presented a rare case of Internal jugular vein thrombosis (IJVT) and reviewed the literature on cases of IJVT to describe clinical features, associated risk factors, possible complications, ways of investigations, and outcomes.

Results

Among 57 cases (56 in the literature plus our case), 25 patients out of 57 had a chief complaint of neck swelling, and only five complained of neck pain; on the other hand, four patients were asymptomatic. Thirty-five patients had a risk factor of developing thrombosis, 19 patients had a malignancy, and 22 did not have an obvious risk factor. To diagnose IJVT, ultrasound alone was used in 11 patients, Ct alone was used in 13 patients, and a combination of CT and ultrasound was used in 21 patients. Conclusion: IJVT thrombosis is a rare condition, but its diagnosis requires reasonable radiological and laboratory investigations; early treatment is warranted to avoid fetal complications.

Cerebral venous sinus thrombosis following intracerebral hemorrhage after COVID-19 AstraZeneca vaccination: A case report

The patient was a 55-year-old female patient who presented with sudden onset of left hemiplegia, facial hemiparesis, and hypoesthesia. She has received her first dose of the AstraZeneca COVID-19 vaccine. This case indicates that vaccination may raise the hypercoagulable state even in a condition of post-ICH and anticoagulant prophylaxis.

Mechanical Thrombectomy with Tandem Double Stent Retriever in Combination with Intermediate Catheter Aspiration for Refractory Severe Hemorrhagic Cerebral Venous Sinus Thrombosis

OBJECTIVE

We aimed to describe the initial experience of mechanical thrombectomy using tandem double stent retrievers combined with intermediate catheter aspiration to treat refractory severe hemorrhagic (SH)-cerebral venous sinus thrombosis (CVST).

METHODS

All refractory SH-CVST patients treated with mechanical thrombectomy using tandem double stent retriever (SR) combined with intermediate catheter aspiration (MT-TDSA) in our institution were retrospectively reviewed. MT-TDSA is a technique that fully engages the clot with double SRs and retrieves the clot using a double SR in combination with aspiration from an intermediate catheter. Demographics, clinical manifestation, medical history, the location of the occluded venous sinus, intraoperative details, procedure-related complications, and modified Rankin Scale (1, 6, 12 months postoperatively) were collected and analyzed.

RESULTS

Fourteen patients (median age, 43 years) with refractory SH-CVST were treated with MT-TDSA between January 2016 and January 2020. Ten of 14 (71.4%) had a successful intraoperative recanalization rate (>90%) using MT-TDSA. No procedure-related complications occurred. Eleven patients had good clinical outcomes (modified Rankin Scale score 0-2 at 12 months postoperatively).

CONCLUSIONS

MT-TDSA for refractory SH-CVST might improve clot-capturing ability and remove blood clots from cerebral venous sinuses effectively and safely, achieving good clinical outcomes.

Potential Anti-Inflammatory and Anti-Coagulation Effects of One-Time Application of Remote Ischemic Conditioning in Patients With Subacute/Chronic Cerebral Arteriostenosis and Venostenosis

BACKGROUND

Remote ischemic conditioning (RIC) is an extremely simple, non-invasive, and cost-effective method with a neuroprotective effect. This study aimed to evaluate the immediate effects of one-time application of RIC on inflammation and coagulation in patients with chronic cerebral vascular stenosis, and compare the different effects of RIC on cerebral arteriostenosis and cerebral venostenosis.

METHOD

A total of 47 patients with defined cerebral arteriostenosis (n=21) or venostenosis (n=26) were prospectively enrolled. RIC intervention was given once with 5 cycles of inflating and deflating for 5 minutes alternately. Blood was sampled 5 minutes before and after RIC for inflammatory and thrombophilia biomarkers. Differences in inflammatory and thrombotic variables at differing time points in the group were assessed using paired t tests or Wilcoxon matched-pairs signed-rank test.

RESULTS

Patients with cerebral arteriostenosis had a higher level of pre-RIC neutrophil-to-lymphocyte ratio ( P =0.034), high-sensitivity C-reactive protein ( P =0.037), and fibrinogen ( P =0.002) than that with cerebral venostenosis. In the arterial group, levels of fibrinogen ( P =0.023) decreased, and interleukin-6 levels were elevated ( P =0.019) after a single RIC. Age was negatively related to interleukin-6, C-reactive protein, and fibrinogen.

CONCLUSION

One-time RIC interventions may show seemingly coexisted proinflammatory and anti-coagulation effects of a single bout on patients with cerebral arteriostenosis. Older age was a negative predictor for multiple biomarkers in the cerebral arteriostensosis group. The protective effect of RIC on cerebral venostenosis patients needs to be further studied in a larger sample size.