Predictors and outcome of status epilepticus in cerebral venous thrombosis

The value of serum albumin concentration in predicting functional outcome of status epilepticus: An observational study

OBJECTIVE

Status epilepticus (SE) is a common neurological emergency with unsatisfying prognoses, and accurate prediction of functional outcome is beneficial in clinical decision-making. The relationship between serum albumin concentration and outcome of SE patients has yet to be unveiled.

METHODS

Clinical profiles of SE patients admitted to Xiangya Hospital, Central South University, from April 2017 to November 2020, were analyzed retrospectively. Outcomes of SE patients at discharge were divided into two groups based on the modified Rankin Scale (mRS): favorable outcome (mRS: 0-3) and unfavorable outcome (mRS: 4-6).

RESULTS

Fifty-one patients were enrolled. Unfavorable functional outcome at discharge was reported in 60.8% (31/51). Serum albumin concentration at admission and the Encephalitis-NCSE-Diazepam resistance-Image abnormalities-Tracheal intubation (END-IT) score remained independent predictors for functional outcome of SE patients. A lower albumin concentration at admission and higher END-IT score indicated a higher chance of unfavorable outcome for SE patients. The cut-off value of serum albumin to predict unfavorable outcome was 35.2 g/L, with a sensitivity of 67.7% and specificity of 85.0%, and an area under the receiver operating characteristic curve (ROC) of .738 (95% CI: .600-.876, p = .004). The preferable END-IT score with optimal sensitivity (74.2%) and specificity (60%) was 2 and the area under the ROC was .742, with 95% CI of .608-.876 (p = .004).

SIGNIFICANCE

Serum albumin concentration at admission and the END-IT score are two independent predictive factors for short-term outcome of SE patients, moreover, the serum albumin concentration is not inferior to the END-IT score in indicating functional outcome at discharge.

Efficacy and safety of levetiracetam versus valproate in patients with established status epilepticus: A systematic review and meta-analysis

Objective

Status epilepticus (SE) is a common neurological emergency that is defined as a prolonged seizure or a series of seizures which often leads to irreversible damage. Levetiracetam (LEV) and valproate (VPA) are second-line anti-seizure drugs that are frequently used in patients with established SE (ESE). This meta-analysis compared the efficacy and safety of LEV and VPA for the treatment of ESE.

Method

MEDLINE, EMBASE, Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched by two authors, which identified six randomized controlled trials (RCTs) that compared LEV and VPA for ESE.

Results

The six RCTs included 1213 patients (LEV group, n = 593; VPA group, n = 620). Integrated patient data information display LEV was not superior to VPA in terms of clinical seizure termination (63.55% vs. 64.08%, respectively; relative risk [RR] = 1.03, 95% confidence interval [CI] = 0.94-1.11, p = 0.55), with no significant differences between LEV and VPA in terms of good functional outcome at discharge (Glasgow Outcome Scale [GOS] = 4 or 5), intensive care unit (ICU) admission, adverse events, and mortality. There was no statistically significant difference between the two drugs in different age groups. Previous multicenter studies have demonstrated that VPA was slightly more effective than LEV, whereas single-center studies showed the opposite results. In addition, LEV and VPA had similar rates of clinical seizure termination, ICU admission, and adverse events between the age subgroups (ages <18 and >18 years).

Conclusions

Levetiracetam (LEV) was not superior to valproate (VPA) in terms of efficacy or safety outcomes. In addition, children (<18 years) and adults (>18 years) might have similar responses to LEV and VPA. Additional RCTs are required to verify our results.

Predictive Value of Combination of D-dimer and Fibrinogen in Diagnosing Acute CVST

Background:

Cerebral venous sinus thrombosis (CVST) is an uncommon subtype of stroke, and the role of D-dimer and fibrinogen in early diagnosis of CVST has been studied with varying results. The present study aims to study the role of the combination of D-dimer and fibrinogen in early diagnosis of acute CVST.

Methods:

Forty consecutive confirmed acute CVST cases admitted at a tertiary care center were recruited for the study. D-dimer and fibrinogen were assessed by a rapid semiquantitative latex agglutination assay.

Results:

Out of the 40 CVST patients, 21 (52.50%) were females. The mean age of the patients was 37.58 years ± 19.17 years. Common clinical features were headache (N = 38 [95%]), papilloedema (N = 15 [37.5%]), and seizures (N = 12 [30%]). Although the sensitivity (75%) of the combination of D-dimer and fibrinogen assay was lower than that of D-dimer or fibrinogen alone, the specificity and positive predictive value (75% each) was higher.

Conclusion:

The combination of D-dimer and fibrinogen testing may aid in an early diagnosis of acute CVST and in better management.

Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is a rare form of stroke that often affects younger age groups, especially reproductive age group females. CVT is a potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. Headache is the most common presenting symptom. However, a wide range of symptoms can be present and the symptom onset can be acute, subacute, or chronic. Neuroimaging is mandatory in cases where CVT is suspected. Both magnetic resonance venography and computed tomography venography can confirm a diagnosis of CVT. Anticoagulation with low-molecular-weight heparin is the mainstay of treatment. Intracranial hemorrhage is not considered a contraindication to the use of anticoagulants in CVT. Endovascular intervention is still controversial but can be a treatment option for patients with neurological deterioration or thrombus progression, despite the use of anticoagulation or with development of new or worsening intracerebral hemorrhage. Patients with CVT have an increased risk of recurrence of CVT and other types of venous thromboembolism. This review provides an overview of the epidemiology, diagnosis, and treatment of CVT in adults. Commentary about increased presentation of CVT in patients with coronavirus disease 2019 (COVID-19), or after immunization against COVID-19, is also provided.

Predictors of seizures in patients with cerebral venous thrombosis in the Thai population: A retrospective study

PURPOSE

This study aimed to define independent factors associated with the onset of early seizure (ES) amongst patients with cerebral venous thrombosis (CVT).

METHODS

This retrospective cohort study recruited patients diagnosed with CVT and hospitalised between 2002 and 2020. Demographic, clinical, and seizure characteristics; neuroimaging findings; and clinical outcomes were compared between the seizure and non-seizure groups. Factors with p-values of <0.05 in univariate analysis were included in multivariate logistic regression analysis to determine independent predictors of ES.

RESULTS

Amongst 180 CVT patients, the incidence of ES was 38.3%. Most seizures presented as the initial symptom. Focal to bilateral tonic-clonic seizure was the most common seizure type (82.6%). Recurrent serial seizure and non-fatal status epilepticus accounted for 56.5% and 8.7% cases, respectively. Intracerebral haemorrhage (adjusted odds ratio [aOR]=6.57, 95% confidence interval [CI], 2.25‒19.21, p = 0.001) and dependency status at admission (aOR=3.32, 95% CI, 1.08‒10.18, p = 0.036) independently predicted ES, whereas isolated increased intracranial pressure (aOR=0.05, 95% CI, 0.01‒0.24, p < 0.001), isolated headache (aOR=0.10, 95% CI, 0.02‒0.45, p = 0.002), straight sinus thrombosis (aOR=0.03, 95% CI, 0.00‒0.37, p = 0.007), and cavernous sinus thrombosis (aOR=0.50, 95% CI, 0.01‒0.53, p = 0.012) showed protective effects.

CONCLUSION

Intracerebral haemorrhage and dependency status at admission independently predicted seizures, whereas isolated increased intracranial pressure, isolated headache, straight sinus thrombosis, and cavernous sinus thrombosis showed preventive effects.

Case Report: Cerebral Venous Sinus Thrombosis and COVID-19 Infection

Coronavirus disease-2019 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus). Coronavirus disease-2019 (COVID-19) was declared a pandemic in March 2020 and has changed our lives in many ways. This infection induces a hypercoagulable state leading to arterial and venous thrombosis, but the exact pathophysiology of thrombosis is unknown. However, various theories have been postulated including excessive cytokine release, endothelial activation, and disseminated intravascular coagulation (DIC). We present a patient diagnosed with cerebral venous sinus thrombosis (CVST) with COVID-19 infection. A 66-year-old man presented to a hospital for evaluation of persistent headaches. He tested positive for COVID-19, and MRI of the brain and CT venogram revealed CVST. He was started on heparin drip in the hospital and transitioned to oral anticoagulants at the time of discharge. His headaches improved with treatment. Even though headache is the most frequent and initial symptom of cerebral venous thrombosis, it is rarely the only symptom. A high index of suspicion is therefore required to diagnose CVST especially if the patient presents with a simple complaint like a headache. Common complaints can delay the diagnosis leading to disease progression. Considering the high mortality rates in patients diagnosed with CVST, we suggest the importance of knowing the association between COVID-19 infection and CVST, especially in susceptible patients.