Association of admission clinical predictors and functional outcome in patients with Cerebral Venous and Dural Sinus Thrombosis

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.

Association of neutrophil to lymphocyte ratio and D-dimer with functional outcome in patients with cerebral venous sinus thrombosis

BACKGROUND

Investigations on the risk factors for the prognosis of cerebral venous sinus thrombosis (CVST) are limited. This study aimed to explore whether specific inflammatory factors and coagulation indictors are associated with functional outcome in patients treated for CVST.

METHODS

This retrospective study included 137 patients admitted to our hospital between January 2010 and October 2021. The functional outcome was assessed with the modified Rankin Scale (mRS) score at discharge. Patients were divided into two groups, 102 patients with favorable outcomes (mRS 0-1) and 35 patients with poor outcomes (mRS 2-6). The clinical indexes were compared between two groups. Multivariable logistic regression was performed to identify the independent influencing factors for poor outcomes of CVST patients. The prognostic indicators were analyzed using the receiver operating characteristic (ROC) curve.

RESULTS

Compared with the favorable outcome group, the incidence of impaired consciousness and brain lesion, the levels of D-dimer, RDW, neutrophil count, neutrophil to lymphocyte ratio (NLR) and red blood cell distribution width to platelet ratio (%) on admission were significantly higher in the poor outcome group, while the level of lymphocyte count was significantly lower. After multivariable logistic regression analysis, baseline D-dimer level (odds ratio (OR), 1.180; 95% confidence interval (CI), 1.019-1.366, P = 0.027) and NLR (OR, 1.903; 95%CI, 1.232-2.938, P = 0.004) were significantly associated with unfavorable outcome at discharge. The ROC curve analysis showed that the areas under the curve of D-dimer, NLR and their combined detection for predicting worse outcome were 0.719, 0.707 and 0.786, respectively.

CONCLUSIONS

Elevated D-dimer level and NLR on admission were associated with an increased risk of poor functional outcome in patients with CVST.

Predicting poor response to anti-coagulation therapy in cerebral venous thrombosis using a simple clinical-radiological score

BACKGROUND

Multiple studies have attempted to determine predictors of poor clinical outcomes in cerebral venous thrombosis (CVT). Fewer studies target to identify predictors of poor response to anticoagulation therapy in CVT.

OBJECTIVE

We aimed to determine the predictors of poor clinical response to therapeutic anticoagulation in patients with acute CVT.

METHODS

We performed a retrospective analysis of patients therapeutically anticoagulated for acute CVT. We defined poor clinical outcomes as death, need for mechanical thrombectomy during the hospitalization, or a modified Rankin Scale (mRS) > 3 at clinical follow-up. Bivariate and multivariate analyses identified factors associated with poor outcomes in anticoagulated patients for acute CVT, and we used the identified factors to create the PRACT-CVT (Poor Response to Anticoagulation Therapy in CVT) score.

RESULTS

We included 109 patients anticoagulated with acute CVT. The mean patient age was 37 years old (SD 19); nine patients were > 65 years, ten patients were < 10 years, and 64 (59%) were female. Twenty-one (19%) patients had poor clinical outcomes. Age > 65 or < 10 years (OR: 3.16, 95% CI: 1.06-9.44), a GCS ≤ 12 upon presentation (OR: 19.2, 95% CI: 4.05-91.4), focal motor deficits at admission (OR: 5.03, 95% CI: 1.64-15.44), clinical deterioration following admission (OR: 28.18, CI: 4.81-164.86), seizures following admission (OR: 5.59, 95% CI: 1.27-24.51), evidence of brain bleeding/ischemia on admission (OR: 4.67, 95% CI: 1.42-15.34), involvement of the superior sagittal sinus (OR: 3.88, CI: 1.33-11.32), or involvement of both transverse sinuses (OR: 3.87, 95% CI: 1.01-14.90) predicted poor clinical outcome despite therapeutic anticoagulation. A PRACT-CVT score (0-22 points) of ≥ 7 points provided a sensitivity of 71% and a specificity of 95% for predicting poor clinical outcomes with anticoagulation alone.

CONCLUSION

Patients with acute CVT aged > 65 or < 10 years old, presenting with a GCS ≤ 12, with focal motor deficits, showing clinical deterioration after admission, having clinical seizures during hospitalization, with brain bleeding/ischemia on initial neuroimaging, involvement of the superior sagittal sinus, or involvement of both transverse sinuses had poor response to anticoagulation. Clinicians may employ the PRACT-CVT score to predict poor response to anticoagulation for acute CVT.

Management of Cerebral Venous Thrombosis Due to Adenoviral COVID-19 Vaccination

Objective

Cerebral venous thrombosis (CVT) caused by vaccine‐induced immune thrombotic thrombocytopenia (VITT) is a rare adverse effect of adenovirus‐based severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. These comprised immunomodulation, non‐heparin anticoagulants, and avoidance of platelet transfusion. The aim of this study was to evaluate adherence to these recommendations and its association with mortality.

Methods

We used data from an international prospective registry of patients with CVT after the adenovirus‐based SARS‐CoV‐2 vaccination. We analyzed possible, probable, or definite VITT‐CVT cases included until January 18, 2022. Immunomodulation entailed administration of intravenous immunoglobulins and/or plasmapheresis.

Results

Ninety‐nine patients with VITT‐CVT from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11 of 24 (46%), and 28 of 37 (76%) of the patients diagnosed in March, April, and from May onward, respectively, were treated in‐line with VITT recommendations (p < 0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 [32%] vs 29/55 [52%], adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.16–1.19). However, patients who received immunomodulation had lower mortality (19/65 [29%] vs 24/34 [70%], adjusted OR = 0.19, 95% CI = 0.06–0.58). Treatment with non‐heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 [33%] vs 13/35 [37%], adjusted OR = 0.70, 95% CI = 0.24–2.04). Mortality was also not significantly influenced by platelet transfusion (17/27 [63%] vs 26/72 [36%], adjusted OR = 2.19, 95% CI = 0.74–6.54).

Conclusions

In patients with VITT‐CVT, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT‐CVT. ANN NEUROL 2022;92:562–573

Updates in Cerebral Venous Thrombosis

Purpose of Review

Cerebral venous thrombosis (CVT) is a rare cause of stroke that most commonly affects younger women. Here, we review new literature relevant to the management and prognosis of individuals with CVT and ongoing areas of uncertainty.

Recent Findings

Direct-acting oral anticoagulants (DOACs) are being increasingly integrated into routine care but are not yet recommended by guidelines. Recent randomized clinical trials and available case series offer reassuring safety data. Routine use of endovascular therapy is not associated with improved outcomes. The relationship between recanalization and prognosis is uncertain.

Summary

The evidence base for management of CVT continues to improve. Ongoing areas of uncertainty include duration of therapy and whether certain subgroups of patients may benefit from neurointervention or personalized approaches to antithrombotic strategy. The state of knowledge will continue to benefit from large collaborative international efforts, and integration of patient partnerships to identify research priorities.

Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature

BACKGROUND

COVID-19 infection has been known to predispose patients to both arterial and venous thromboembolic events such as deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke. A few reports from the literature suggest that Cerebral Venous Sinus Thrombosis (CVSTs) may be a direct complication of COVID-19.

OBJECTIVE

To review the clinical and radiological presentation of COVID-19 positive patients diagnosed with CVST.

METHODS

This was a multicenter, cross-sectional, retrospective study of patients diagnosed with CVST and COVID-19 reviewed from March 1, 2020 to November 8, 2020. We evaluated their clinical presentations, risk factors, clinical management, and outcome. We reviewed all published cases of CVST in patients with COVID-19 infection from January 1, 2020 to November 13, 2020.

RESULTS

There were 8 patients diagnosed with CVST and COVID-19 during the study period at 7 out of 31 participating centers. Patients in our case series were mostly female (7/8, 87.5%). Most patients presented with non-specific symptoms such as headache (50%), fever (50%), and gastrointestinal symptoms (75%). Several patients presented with focal neurologic deficits (2/8, 25%) or decreased consciousness (2/8, 25%). D-dimer and inflammatory biomarkers were significantly elevated relative to reference ranges in patients with available laboratory data. The superior sagittal and transverse sinuses were the most common sites for acute CVST formation (6/8, 75%). Median time to onset of focal neurologic deficit from initial COVID-19 diagnosis was 3 days (interquartile range 0.75-3 days). Median time from onset of COVID-19 symptoms to CVST radiologic diagnosis was 11 days (interquartile range 6-16.75 days). Mortality was low in this cohort (1/8 or 12.5%).

CONCLUSIONS

Clinicians should consider the risk of acute CVST in patients positive for COVID-19, especially if neurological symptoms develop.