Cerebral Venous Thrombosis

Factors influencing therapy choice and clinical outcome in cerebral venous sinus thrombosis

We aimed was to assess the factors influencing therapy choice and clinical outcome after 3-4 months in patients with cerebral venous sinus thrombosis (CVST). In a retrospective, bi-centric study, the set consisted of 82 consecutive CVST patients (61 females; mean age 33.5 ± 15.7 years). Following data were collected: baseline characteristics, presence of gender-specific risk factors (GSRF), location and extent of venous sinus impairment, clinical presentation, type of treatment, recanalization, presence of parenchymal lesions, and clinical outcome after 3-4 months (assessed using the modified Rankin Scale [mRS], with excellent outcome defined as mRS 0-1). Multivariate logistic regression analysis was used for statistical evaluation. After 3-4 months, complete recovery was achieved in 41 (50%) and excellent clinical outcome in 67 (81.7%) patients. Female sex (OR 0.11; p = 0.0189) and presence of focal neurologic deficit (OR 0.16; p = 0.0165) were identified as significant independent negative predictors and, the presence of GSRF (OR 15.63; p = 0.0011) as significant independent positive predictor of excellent clinical outcome. In conclusion, in our CVST patients, the presence of GSRF was associated with excellent clinical outcome, while the female sex itself was associated with poorer clinical outcome.

Cerebral Venous Sinus Thrombosis in the COVID-19 Pandemic

BACKGROUND

Recent studies have noted concern for increased thromboembolic events in the setting of Coronavirus Disease 2019 (COVID-19). Cerebral venous sinus thrombosis (CVST) is a form of thromboembolism that has been observed as a neuro-ophthalmologic complication of COVID-19.

METHODS

Review of the scientific literature.

RESULTS

In this article, we report an overview of CVST epidemiology, clinical presentation, diagnostics, disease pathophysiology, and management in the setting of COVID-19.

CONCLUSION

CVST is an uncommon thromboembolic event with variable phenotypes and multiple etiologies. Neurologic complications can be severe, including significant visual deficits and death. Current observations suggest that the risk of CVST may be profoundly impacted by this novel COVID-19 pandemic, thus prompting increased attention to disease presentation, pathogenesis, and management.

Cerebral Venous Sinus Thrombosis

The frequency of patients diagnosed with cerebral venous sinus thrombosis (CVST) has increased due to the expanded use of noninvasive brain imaging methods. The aim of this study was to assess the correlations between the location and extent of venous sinus impairment, clinical presentation during the acute phase, recanalization, the presence of parenchymal lesions, and clinical outcome after 3 to 4 months in patients with CVST. In a retrospective study, clinical and magnetic resonance imaging data from a cohort of 51 consecutive patients with CVST (mean age 33.1 ± 15.4 years) were collected and analyzed. Good clinical outcome after 3 to 4 months, which was assessed using the modified Rankin scale, significantly negatively correlated with a thrombosis location in the left transverse, left sigmoid, or superior sagittal sinus ( P = .022, P = .045, and P = .046, respectively) and positively correlated with recanalization ( P = .048). The clinical outcome was significantly more favorable in the females with gender-specific risk factors than in the males ( P = .029). In conclusion, successful recanalization substantially helps to achieve good clinical outcome in patients with CVST.

Optic nerve sheath fenestration for the treatment of papilledema secondary to cerebral venous thrombosis

A 16-year-old adolescent girl with multiple risk factors for thrombosis presented with acute onset of headache, decreased vision, and papilledema. Evaluation demonstrated cerebral venous thrombosis (CVT) involving the left transverse and sigmoid sinuses and left internal jugular vein. Following bilateral optic nerve sheath fenestration (ONSF), she experienced improvement in vision and resolution of papilledema. In selected cases, ONSF is an effective surgical option for the treatment of papilledema due to CVT after medical treatment has failed.

Lateral sinus thrombosis: complication of minor head injury

OBJECTIVE

Our review aims: (1) to highlight the suspicion of lateral sinus thrombosis (LST) following a minor head injury in the pediatric population; (2) to discuss the different etiologies of lateral sinus thrombosis; (3) to identify an exact mechanism of the thrombus formation; (4) to clarify the role of each diagnostic tool; (5) to implement an algorithm for the treatment of LST due to a minor head injury.

METHOD

We performed a MEDLINE search for LST following a minor head trauma related articles that were published between 1950 and June 2008. We identified 19 related studies of which 22 patient records were noted. We also added our case to this series. The information from the reports was analyzed to characterize the clinical aspects, the radiologic findings, the treatment, the follow-up, and the management of this disease.

RESULTS

Twenty-three cases (20 pediatrics and 3 adults) of LST following a minor head trauma have been published including the new one presented here. The mean pediatric age in this series is 7.8 years. There were 11 cases on the right side and 8 on the left side. Male to female ratio is 1.4:1. Side and sex were not reported in 4 and 6 cases, respectively. Sigmoid and transverse sinuses were the most affected one. Eighty-three percent were treated by observation while the remaining 17% received anticoagulation. The outcome was good in all patients without any notable major complications. The radiological investigation showed that there was a complete recanalization in 9 patients and a partial recanalization in 3 patients with a mean time of 8.3 weeks.

CONCLUSION

Lateral sinus thrombosis seldomly occurs following a minor head injury. This entity is difficult to diagnose and one should exercise a high degree of suspicion when confronted with an ambiguous neurological status following a closed head trauma. The most accurate imaging test according to our experience is a multiple detector row computerized tomography (MDCT) venography completed at the time of the presentation. The indication to proceed with an MRI has to be assessed on a case-by-case basis. Anticoagulation is reserved for patients presenting a papilledema or for patients complaining of persistent headaches, vomiting, or disequilibrium.

[Place of local thrombolytic therapy in the treatment for cerebral venous thrombosis]

INTRODUCTION

Cerebral venous thrombosis (CVT) is uncommon with a variable clinical presentation and an unpredictable outcome. Heparin is used for first-line treatment in association with symptomatic and etiologic management. Despite adequate anticoagulation, the condition may deteriorate in some patients warranting the use of local thrombolysis (LT) known for good efficacy and safety. But there are few cases and trials upon which to base guidelines for the use of LT.

METHODS

A retrospective review of the medical and radiological records of patients with CVT was managed in the Caen hospital over a six-year period. We compared clinical factors of poor prognosis and radiological findings according to treatment delivered.

RESULTS

Thirty-six patients are treated for CVT. LT was performed in eight of them; dose-adjusted intravenous heparin was the only treatment in the 28 others. Good outcome was achieved in two thirds of the patients with functional sinus patency in all cases. Based on an analysis of the radiological data of the 36 patients, we propose a summary of radiological risk factors associated with a worsening condition despite adequate anticoagulation.

DISCUSSION/CONCLUSION

Based on our experience and a review of the literature which includes 98 previous cases, LT appears to be a relative effective end safe procedure even in the presence of a hemorrhagic infarct. The treatment by LT should be considered in patients who present clinical criteria of gravity and radiological risk factors associated with failure of heparin treatment. The usefulness of LT remains to be determined in a randomized trial comparing heparin alone and heparin associated with LT.

Bilateral ophthalmic vein thrombosis secondary to nasal furunculosis

We were presented with a teenage female who developed superior ophthalmic vein thrombosis and cavernous sinus thrombophlebitis after a 1-week history of a single acne-like lesion or furuncle at the anterior tip of the nose. She was managed aggressively with heparin and intravenous antibiotic. Signs and symptoms improved after 2 weeks of treatment, and she was discharged with an anticoagulant.

Predictors of Outcome in Patients With Cerebral Venous Thrombosis and Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Although intracerebral hemorrhages are frequent in patients with cerebral venous thrombosis, and lead to worse outcome, predictors of outcome in cerebral venous thrombosis patients with intracerebral hemorrhages have never been evaluated in adequately powered studies.

METHODS

This study was conducted as a part of the International Study on Cerebral Vein and Dural Sinus Thrombosis. We evaluated predictors of outcome in cerebral venous thrombosis patients who had an "early intracerebral hemorrhage," ie, intracerebral hemorrhages already present at time of diagnosis of cerebral venous thrombosis by a logistic regression analysis, with a modified Rankin scale 3 to 6 at month 6 as dependent variable. The same analysis was performed with "delayed intracerebral hemorrhages," ie, intracerebral hemorrhages that occurred after the diagnosis of cerebral venous thrombosis, as dependent variable.

RESULTS

Of 624 patients recruited in International Study on Cerebral Vein and Dural Sinus Thrombosis, 245 (39%) had an early intracerebral hemorrhage: at month 6, 51 (21%) of them had a modified Rankin Scale 3 to 6. Independent predictors of having modified Rankin scale 3 to 6 at month 6 were older age (adjusted odds ratio for 1-year increase in age, 1.05; 95% CI, 1.02 to 1.08); male gender (adjusted odds ratio, 3.25; 95% CI, 1.29 to 8.16); having a deep cerebral venous system thrombosis (adjusted odds ratio, 5.43; 95% CI, 1.67 to 17.61) or a right lateral sinus thrombosis (adjusted odds ratio, 2.56; 95% CI, 1.03 to 6.40); and having a motor deficit (adjusted odds ratio, 2.94; 95% CI, 1.21 to 7.10). Of the 36 patients who had a delayed intracerebral hemorrhage, those who had a modified Rankin scale 3 to 6 at month 6 were less likely to have received heparin at the acute stage, and more likely to have had early intracerebral hemorrhage.

CONCLUSIONS

Among patients with early intracerebral hemorrhage, those who were older, men, had a thrombosis of the deep cerebral venous system or of the right lateral sinus, and a motor deficit were at higher risk for death or dependency at month 6. This subgroup of patients with predictors of poor outcome can be the target for new therapeutic strategies.

Cerebral venous thrombosis: influence of risk factors and imaging findings on prognosis

PURPOSE

To investigate imaging findings, risk factors and outcome in patients with cerebral venous thrombosis (CVT).

METHODS

Records of all patients with diagnosis of CVT between 1992 and 2002 were reviewed. Patients with CNS infection and with CVT secondary to invasive procedures were excluded. Inherited and acquired thrombophilia were searched in all patients.

RESULTS

Twenty-four patients (18 women, 6 men) with mean age of 29.5 years (range 3-48 years) were identified. Mean follow-up was 44 months (range 11-145 months). The most common symptoms were headache (75%), vomiting (33%) and impairment of consciousness (21%). Probable causes of CVT could be determined in 21 (88%) patients: pregnancy or puerperium in six (25%), oral contraceptive use in four (17%), head trauma in two (8%), mastoiditis in one (4%), nephrotic syndrome in one (4%), systemic disease in three (13%), and inherited thrombotic risk factors in four (17%) patients. CVT associated with pregnancy, puerperium and use of oral contraceptives had a significant better outcome than CVT caused by inherited thrombophilia or systemic disease (OR=14.4; p=0.02). CT scans were abnormal in 15 (62.5%) patients and MRI with gadolinium was abnormal in all. Those with parenchymal involvement had neurological sequelae during follow-up. All were treated with heparin followed by oral anticoagulants, and none had new or worsening of pre-existing intracerebral hemorrhage.

CONCLUSION

MRI is superior to conventional CT for diagnosing CVT. Patients with parenchymal lesions, thrombophilia and antiphospholipid syndrome had greater risk to be left with neurological sequelae. Anticoagulant therapy did not predispose to further intracerebral hemorrhage.