Evaluation of cerebral venous thrombosis secondary to oral contraceptive use in adolescents

Prediction Score for Clinical Outcome of Chinese Patients with Cerebral Venous Thrombosis

Background

Although numerous prognostic markers for cerebral venous thrombosis (CVT) have been reported, inconsistencies exist in their predictive values, leading to contradictory forecasts. This study was designed to develop a comprehensive clinical outcome prediction score for Chinese patients with CVT, integrating key prognostic markers to furnish an overall prognosis.

Methods

Participants were selected from the CCC cohort, a multicenter study encompassing 26 tertiary hospitals across mainland China. Between January 2021 and May 2022, 170 patients with CVT were prospectively recruited. Potential prognostic markers were extracted from the CCC database and subsequently analyzed.

Results

Age, diastolic blood pressure (DBP), neutrophil-to-lymphocyte ratio (NLR), and neuron-specific enolase (NSE) emerged as significant prognostic markers for CVT after a multivariate logistic analysis. Specific cut-off values were identified: Age > 27.5 years, DBP > 79.5 mmHg, NLR > 6.6, and NSE >16.5 ng/mL. The points assigned were: one each for age and NSE level, two for DBP, and three for NLR, based on the adjusted odds ratio. A positive correlation was found between the baseline CVT outcome score and the mRS at six months' follow-up. A CVT outcome score of 3.5 served as an effective cut-off value for predicting CVT clinical outcomes. Further analysis revealed that patients with CVT outcome scores > 3 exhibited significantly higher mRS scores than those with scores ≤ 3.

Conclusion

This study led to the development of the CVT outcome score, consisting of age, DBP, NLR, and NSE level, specifically for Chinese patients with CVT. The baseline CVT outcome score positively correlated with the mRS score at the six-month follow-up. A CVT outcome score of > 3 serves as a reliable indicator to identify patients at a higher risk of unfavorable clinical outcomes. These patients may benefit from additional care and early interventions to avert potential deterioration.

Epidemiology, Clinical Features, and Outcome in a Cohort of Adolescents With Cerebral Venous Thrombosis

BACKGROUND AND OBJECTIVES

We aimed to analyze the epidemiologic, clinical, and paraclinical features of adolescents with cerebral venous thrombosis (CVT) and its therapeutic management and outcome.

METHODS

This multicenter retrospective cohort included patients 10 to 18 years of age hospitalized for a first episode of CVT in 2 French regions between 1999 and 2019. The number of cases was compared to the number recorded by the French health insurance system. The CVT registry of the Lariboisière hospital allowed comparisons with adults.

RESULTS

One hundred two patients were included (52.9% female; median age 15.1 years). Estimated incidence was 0.37 to 0.38 per 100,000 adolescents per year; 45.5% of patients presented with focal deficits or seizures or in a coma. Male patients were younger than female patients (14.2 vs 15.6 years; p < 0.01) and more often admitted to intensive care (52.1% vs 24.1%; p = 0.0,035). The lateral sinus was the most common CVT location (72.3%), and 29.4% of adolescents had associated venous infarction or hematoma. Most patients (94.1%) received anticoagulation. Treatment also included an endovascular procedure (2.9%), decompressive craniectomy (4.9%), and CSF shunt (6.9%). The most frequently identified CVT-associated condition was local infection in male (18.6%) and systemic disease in female (14.8%; p < 0.001) patients. The proportion of CVTs in adolescents without an identified associated condition or risk factor was low (1.9% vs 11.4% in adults; p < 0.002). Adverse outcome at 1 year was more frequent than in adults (33.3% vs 11.8%; p = 0.0,001).

DISCUSSION

CVT in adolescents is rare and complex with specific epidemiology, including differences in clinical presentation and associated conditions between sexes, and more severe outcomes than in adults. Careful specialized management and follow-up are therefore recommended.

Cyclosporin A-related cerebral venous sinus thrombosis: A case report

RATIONALE

Cerebral venous sinus thrombosis (CVST) is a complex life-threatening condition, and its etiology is not well understood. Although oral cyclosporin A is not a common cause of the symptoms related to CVST, there is limited information available.

PATIENT CONCERNS

In this study, we report a rare case of CVST in a 44-year-old woman with aplastic anemia, who was given cyclosporin A orally for a period of 18 months. She had experienced a headache for 20 days.

DIAGNOSES

The patient was diagnosed with CVST by computed tomography venography.

INTERVENTIONS

Low molecular heparin (enoxaparin, 4000 AXaIU, subcutaneous injection, once every 12 hours) was administered for anticoagulation.

OUTCOMES

The patient developed no recurrence of thrombosis during the 13-month follow-up period.

LESSONS

Clinicians should be aware of the possibility of CVST when patients are treated with cyclosporin A and have symptoms such as headaches.

The incidence and prognosis of thromboembolism associated with oral contraceptives: Age-dependent difference in Japanese population

Aim

We analyzed the incidence and prognosis of thromboembolism associated with combined oral contraceptives (COCs) by age groups in Japan.

Methods

A total of 581 events of venous thromboembolism (VTE) and arterial thromboembolism (ATE) associated with COCs were analyzed from the Pharmaceuticals and Medical Devices Agency database from 2004 to 2013. In a statistical analysis, a good‐prognosis group included recovery cases and a poor‐prognosis group involved unrecovered cases with some sequela and fatal cases. The significant difference between these two groups was calculated by Pearson's chi‐square test, and the age‐specific tendency and the trend of differences in prognosis according to different hormonal contraceptives were examined by Cochran–Armitage trend test.

Results

A total of 543 events were analyzed except 38 events due to unknown age, in which DVT only was the most frequent, followed by cerebral infarction, PE with DVT, PE only, cerebral vein thromboses. ATE ratio for overall thromboembolism tended to increase with advancing age (P = 0.0041). Good‐prognosis group was common (291 cases in VTE and 83 cases in ATE), followed by poor‐prognosis group (46 cases in VTE and 34 cases in ATE). All ATE cases had a significantly poorer prognosis in comparison with all VTE cases (P < 0.0001). Types of progestin and age difference, however, showed no trend in the differences between good‐prognosis group and poor‐prognosis group (P = 0.3548 and P = 0.6097).

Conclusion

Thromboembolic events were the most frequent in the 40s. The ATE ratio for overall thromboembolism tended to increase with advancing age. All ATE cases had a significantly poorer prognosis in comparison with all VTE cases.

Clinical associations, biological risk factors and outcomes of cerebral venous sinus thrombosis

Objective Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease affecting young adults. The majority of the patients are female. The aim of this study is to assess the clinical associations, risk factors and outcomes of the patients with CVST. Methods The data of 75 patients with CVST admitted to our hospital between 2006 and 2016 were reviewed. Demographic and clinical features and the thrombophilic risk factors of the patients were recorded. The localizations of the thrombi were determined and modified Rankin score at the time of onset and discharge were calculated. Results The majority of our patients (78.7%) were female. Median age was 35 years (16-76). The most common symptom was headache (86.7%). In 82.6% of our patients, inherited or acquired risk factors for thrombosis were detected. Transverse sinus was the most common site of thrombosis followed by sigmoid and superior sagittal sinuses. Two thirds of the patients had involvement of multiple sinuses. The patients with the involvement of sagittal sinus had better disability at the time of admittance ( p = 0.013) while the number of involved sinuses was correlated worse disability ( p = 0.015). The neurologic states in the majority of the patients were improved by the end of the hospitalization period ( p = 0.001). There was no significant difference in disability score at discharge between men and women ( p = 0.080). No patient with CVST died in the hospitalization period. Conclusions This study is one of the largest cohort studies on CVST in our region. The results of the study disclosed that CVST had wide range of clinical manifestations and non-specific symptoms at the beginning. For that reason, in especially high risk groups for thrombosis, the diagnosis of CVST should be kept in mind.

Cerebral Venous Thrombosis: Current and Newer Anticoagulant Treatment Options

BACKGROUND

Cerebral venous thrombosis (CVT) is rare and involves thrombosis of the veins and sinuses of the brain, most commonly the superior sagittal sinus. Approximately 5 CVT cases occur per 1 million persons in western countries. CVT causes 0.5% of strokes. Early diagnosis is crucial to prevent such outcomes as hydrocephalus, intracranial hypertension, and further seizures. Standard medical treatment of CVT consists of low-molecular-weight heparin and endovascular thrombolysis. Small case reports have found that the newer oral anticoagulants can be used for CVT treatment; however, they are associated with increased risk of bleeding and other adverse effects.

REVIEW SUMMARY

CVT can be triggered by an imbalance of the body's homeostasis or reduced action of the intrinsic antithrombotic mechanism. Factors influencing this change include infection, brain tumor, inflammatory conditions, genetic thrombophilias, head trauma that causes intracranial bleeding, and certain medications. CVT may cause brain infarction and increased intracranial pressure. Sometimes, idiopathic intracranial hypertension presents as the only clinical manifestation. Confirmation of the diagnosis typically is through neuroimaging. Current CVT treatment depends on disease extent and severity.

CONCLUSIONS

CVT is a rare neurological disease with potentially serious implications and high neurological morbidity and mortality rates. Understanding the role of risk factors-such as genetic or acquired thrombophilia, pregnancy, use of oral contraceptives, and hyperhomocysteinemia-in CVT development is important. Although heparin and warfarin have been used for more than 50 years, newer oral anticoagulants (eg, dabigatran, rivaroxaban, apixaban) might offer an alternative to traditional therapy.