Cerebral venous thrombosis in adults: the role of imaging evaluation and management

Is a minimum duration of 5 days of unfractionated heparin infusion necessary before transition to oral anticoagulation in cerebral venous thrombosis? a retrospective chart review

In managing cerebral venous sinus thrombosis (CVT), the standard approach has been administering parenteral anticoagulation for at least five days, despite limited supporting evidence. This study aimed to determine the optimal duration of parenteral anticoagulation for CVT patients and its potential impact on their functional outcomes upon discharge. This retrospective observational cohort study was conducted across multiple healthcare centers and included adult CVT patients who received varying durations of parenteral anticoagulation: less than 5 days (n = 25) or 5 days or more (n = 16). The primary focus was on the duration of acute anticoagulation treatment, with secondary endpoints including hospital stay length and functional outcomes. The study found that a shorter duration of anticoagulation treatment (< 5 days) was linked to more favorable outcomes, as measured by the modified Rankin Scale (mRS) (68% vs. 25%, RR = 0.37, CI 0.15-0.90, p = 0.007). However, regression analysis showed non statistically significant associations for all variables except gender. Female patients were significantly more likely to receive a shorter duration of anticoagulation (Odds Ratio: 2.6, 95% CI: 2.2-3.1, P-Value: <0.001). These findings suggest a potential connection between shorter anticoagulation duration (< 5 days) and improved CVT patient outcomes, as indicated by their mRS scores at discharge. The observed relationship between female gender and shorter anticoagulation duration warrants further exploration. Nevertheless, caution is necessary when interpreting these findings due to the small sample size and specific patient characteristics. Further research in a larger and more diverse cohort is essential to validate these results and understand their implications fully.

An emergency nursing and monitoring procedure on cognitive impairment and neurological function recovery in patients with acute cerebral infarction

BACKGROUND

The optimization and standardization of emergency nursing and monitoring procedures are of great significance for thrombolytic treatment of acute cerebral infarction.

OBJECTIVE

Studies on the emergency nursing and monitoring procedure on cognitive impairment and neurological function in patients with acute cerebral infarction are still limited.

METHODS

The study was a randomized controlled trial and 134 patients with acute cerebral infarction were recruited. They were randomly arranged into the control group (n = 67) receiving normal nursing procedure and the intervention group (n = 67) receiving emergency nursing and monitoring procedure after pre-intervention assessment. The cognitive impairment, neurological function and levels of inflammatory biomarkers and neuron-specific enolase of the participants were evaluated and analyzed.

RESULTS

Emergency nursing and monitoring procedure improved Mini-mental State Examination and Montreal Cognitive Assessment scores of patients with cerebral infraction compared with the control group. It also improved the scores of National Institutes of Health Stroke Scale, activities of daily living scale, Fugl-Meyer scale in the participants. Emergency nursing and monitoring procedure led to significantly decreased neuron-specific enolase and inflammatory cytokines in the serum of the participants.

CONCLUSION

Emergency nursing and monitoring procedure are beneficial for cognitive impairment and neurological function recovery in patients with acute cerebral infarction.

Clinical profile, diagnostic challenges, and outcomes in subacute/chronic cerebral sinus venous thrombosis

Purpose:

To report clinical profile, diagnostic challenges, and outcomes in cases of subacute/chronic cerebral sinus venous thrombosis (CSVT) presenting to neuro-ophthalmologists/neurologists.

Methods:

This was a multicentric, retrospective, observational study. Records of patients with neuroimaging proven subacute/chronic CSVT seen the from January 1, 2016 to March 31, 2020 were analyzed. Data collected included duration of symptoms, diagnosing physician, ophthalmological vs. focal/generalized neurological symptoms, optic disc examination, perimetry, and neuroimaging findings. Statistical analysis was performed using STATA software.

Results:

Forty-three patients with subacute (30)/chronic (13) CSVT were identified (32 males, 11 females). Median age was 37 (IQR 27–47) years. The presenting complaints were blurred vision 34 (79%), headaches in 25 (58%), vomiting 12 (28%), and diplopia 11 (26%). Eleven patients had associated sixth cranial nerve palsy. All but two patients had either disc edema/optic atrophy; four had unilateral disc edema at presentation. Ophthalmologists and neurologists diagnosed/suspected CSVT correctly in 13/29 (45%) and 11/14 (78.5%) patients, respectively. Most common initial alternate diagnosis was idiopathic intracranial hypertension in 12 (28%). Female gender, age ≤36, unilateral papilledema, not obtaining venogram at initial workup increased chances of initial alternate diagnosis. Median follow-up duration was 21 days. Average visual function remained stable in majority of patients at last follow-up. In total, 47.6% of patients had best-corrected visual acuity ≥20/30 at the final follow-up.

Conclusion:

In our series, subacute or chronic CSVT presented presented primarily with symptoms of intracranial hypertension. Unilateral papilledema, middle-aged patients, female gender, lack of focal/generalized neurological symptoms created diagnostic dilemma. Visual function remained stable in majority of patients.

Hypercoagulability in Vestibular Schwannoma Surgery

OBJECTIVE

Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature.

PATIENTS

Two patients who underwent resection of vestibular schwannomas.

INTERVENTIONS

Surgical resection and diagnostic testing.

MAIN OUTCOME MEASURES

Postoperative venous thromboses.

RESULTS

One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course.

CONCLUSIONS

In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.

Optimization of 3D phase contrast venography for the assessment of the cranio-cervical venous system at 1.5 T

PURPOSE

The aim of this work was to optimize a three-dimensional (3D) phase-contrast venography (PCV) product MR pulse sequence in order to obtain clinically reliable images with less artifacts for an improved depiction of the cranio-cervical venous vessels.

METHODS

Starting from the product sequence, the 3D PCV protocol was optimized in eight steps with respect to the velocity encoding (V_enc) direction and value, slice thickness, reduction of susceptibility artifacts and arterial contamination, gradient mode and radio-frequency (RF)-spoiling, B₀-Shimming, asymmetric echo technique and RF-pulse type, and flip angle. The product and optimized protocol was used to perform 3D PCV in 12 healthy male volunteers with a median age of 50 years using a state-of-the-art 1.5-T MR system. For evaluation, the cranio-cervical venous system was divided into 15 segments. These segments were evaluated by three radiologists with experience in neuroradiology. An ordinal scoring system was used to access the overall diagnostic quality, arterial contamination, and the quality of visualization.

RESULTS

Image quality in the optimized 3D PCV was graded as "excellent" by all readers in 65.3% of the cases (p < 0.0001). The visualization of venous segments was strongly improved: it was considered diagnostic in 81.8% of all cases using the optimized sequence and in 47.6% for the product 3D PCV (p < 0.0001), respectively. The optimized protocol improved the imaging of all venous segments (p < 0.0001).

CONCLUSION

The optimized 3D PCV pulse sequence showed superior results compared to the product 3D PCV for the visualization and evaluation of the venous system in all healthy volunteers.

Cerebral venous thrombosis: state of the art diagnosis and management

PURPOSE

This review article aims to discuss the pathophysiology, clinical presentation, and neuroimaging of cerebral venous thrombosis (CVT). Different approaches for diagnosis of CVT, including CT/CTV, MRI/MRV, and US will be discussed and the reader will become acquainted with imaging findings as well as limitations of each modality. Lastly, this exhibit will review the standard of care for CVT treatment and emerging endovascular options.

METHODS

A literature search using PubMed and the MEDLINE subengine was completed using the terms "cerebral venous thrombosis," "stroke," and "imaging." Studies reporting on the workup, imaging characteristics, clinical history, and management of patients with CVT were included.

RESULTS

The presentation of CVT is often non-specific and requires a high index of clinical suspicion. Signs of CVT on NECT can be divided into indirect signs (edema, parenchymal hemorrhage, subarachnoid hemorrhage, and rarely subdural hematomas) and less commonly direct signs (visualization of dense thrombus within a vein or within the cerebral venous sinuses). Confirmation is performed with CTV, directly demonstrating the thrombus as a filling defect, or MRI/MRV, which also provides superior characterization of parenchymal abnormalities. General pitfalls and anatomic variants will also be discussed. Lastly, endovascular management options including thrombolysis and mechanical thrombectomy are discussed.

CONCLUSIONS

CVT is a relatively uncommon phenomenon and frequently overlooked at initial presentation. Familiarity with imaging features and diagnostic work-up of CVT will help in providing timely diagnosis and therapy which can significantly improve outcome and diminish the risk of acute and long-term complications, optimizing patient care.

A Multicenter Study of 1144 Patients with Cerebral Venous Thrombosis: The VENOST Study

BACKGROUND

Based on a number of small observational studies, cerebral venous sinus thrombosis has diverse clinical and imaging features, risk factors, and variable outcome. In a large, multicenter cerebral venous thrombosis (VENOST) study, we sought to more precisely characterize the clinical characteristics of Caucasian patients.

METHODS

All data for the VENOST study were collected between the years 2000 and 2015 from the clinical follow-up files. Clinical and radiological characteristics, risk factors, and outcomes were compared in terms of age and sex distribution.

RESULTS

Among 1144 patients 68% were women, and in older age group (>50 years) male patients were more prevalent (16.6% versus 27.8%). The most frequent symptoms were headache (89.4%) and visual field defects (28.9%) in men, and headache (86.1%) and epileptic seizures (26.8%) in women. Gynecological factors comprised the largest group in women, in particular puerperium (18.3%). Prothrombotic conditions (26.4%), mainly methylenetetrahydrofolate reductase mutation (6.3%) and Factor V Leiden mutation (5.1%), were the most common etiologies in both genders. 8.1% of patients had infection-associated and 5.2% had malignancy-related etiology that was significantly higher in men and older age group. Parenchymal involvement constitutively hemorrhagic infarcts, malignancy, and older age was associated with higher Rankin score. Epileptic seizures had no effect on prognosis.

CONCLUSIONS

Clinical and radiological findings were consistent with previous larger studies but predisposing factors were different with a higher incidence of puerperium. Oral contraceptive use was not a prevalent risk factor in our cohort. Malignancy, older age, and hemorrhagic infarcts had worse outcome.

[Cerebral venous thrombosis]

There is ample evidence that arterial and venous links of the vascular bed are interrelated, with the venous part, as the highly organized reflexogenic zone, responsible for the development of complex reactions providing the stability of the cerebral blood flow. There is few publications devoted to the venous pathology of the brain however the prevalence of cerebral venous thrombosis (CVT) is relatively high. The annual prevalence of CVT is 4-7 per 1 million of population. Timely recognition and early diagnosis of CVT are most important for successful treatment of patients. It can lead to effective therapy, decrease the consequences of this disease and the fatal outcomes. The review and systematization of the literature on the epidemiology, etiology, risk factors, clinical presentations, diagnosis and treatment of CVT are presented.

Dural sinus obstruction following head injury: a diagnostic and clinical study

OBJECTIVE The aim of this study is to describe the clinical characteristics of patients with skull fracture adjacent to a dural venous sinus (DVS) and evaluate the role of CT venography (CTV) in the diagnosis of the effect of this fracture on the involved DVS. METHODS The study comprised patients with vault or skull base fracture adjacent to a DVS who were admitted to 1 medical center during a 2-year period. The medical records were reviewed for the clinical and radiographic characteristics. All patients had undergone CTV to evaluate potential DVS pathology. The clinical and radiological findings of the patients with DVS pathology were compared with those of the patients with normal DVS. The groups were compared using the chi-square and t-tests for categorical and continuous data, respectively. The potential risk for poor outcome among the patients with DVS pathology was also investigated. RESULTS Of 434 patients with skull fractures, 41 (9.4%) had fractures adjacent to a DVS. DVS pathology was detected in 51% of patients (21 of 41 patients). For 9 (43%) patients, obstruction was extraluminal without thrombosis, and 12 (57%) patients had dural sinus thrombosis (DST). In patients with a positive-CTV scan, the severity of injury according to the Glasgow Coma Scale score at presentation was correlated with the presence of DST (p = 0.007). The sensitivity of noncontrast CT (NCCT) for DVS involvement was 38% among the patients with positive-CTV scans. For patients with DVS pathology, poor outcome was correlated with DST (intraluminal), rather than extraluminal obstruction without thrombosis (p = 0.02), and superior sagittal sinus (SSS) involvement (p = 0.05). CONCLUSIONS NCCT is not sensitive enough to detect DVS obstruction in patients with skull fracture adjacent to a DVS, and CTV should be performed in order to rule it out. A correlation was found between the severity of injury and the presence of DST, rather than extraluminal obstruction. The authors' findings suggest that DST and SSS involvement may be indicators of poor outcome in patients with skull fracture adjacent to DVS.

Central Nervous System Venous Thrombosis: The Role of CT & MRI. A Review

The clinical presentation of central nervous system venous thrombosis (CNSVT) is variable and non specific. Advances in CT and MRI technology have redefined the role of these 2 modalities in assessing suspected CNSVT. T1, T2, FLAIR and DWI/ADC (diffusion weighted imaging/apparent diffusion coefficient) MRI (magnetic resonance imaging) sequences together with a gadolinium enhanced MRV (magnetic resonance venography) would the imaging of first choice in suspected venous thrombosis of the central nervous system. Where there are still problems with identifying the thrombus and this is crucial to the management, a CTV (computed tomographic venography) should be performed. Catheter angiography would be used as a last resort or associated with direct thrombolysis. There may be circumstances where CT may be used as the first choice. There may be contraindication to MRI such as pacemakers, aneurysms clips etc.

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.

Safety and validity of mechanical thrombectomy and thrombolysis on severe cerebral venous sinus thrombosis

BACKGROUND

Although the majority of patients with cerebral venous sinus thrombosis (CVST) obtain an optimistic clinical outcome after heparin or warfarin treatment, there remains a subgroup of patients who do not respond to conventional anticoagulation treatment. These patients, especially younger people, as documented by hospital-based studies, have a high morbidity and mortality rate.

OBJECTIVE

To verify the safety and efficacy of a dual mechanical thrombectomy with thrombolysis treatment modality option in patients with severe CVST.

METHODS

Fifty-two patients diagnosed with CVST were enrolled and treated with mechanical thrombectomy combined with thrombolysis. Patients underwent urokinase 100 to 1500 × 10 IU intravenous sinus injection via a jugular catheter after confirming diagnoses of CVST by using either magnetic resonance imaging/magnetic resonance venography or digital subtract angiography. Information obtained on the patients included recanalization status of venous sinuses as evaluated by magnetic resonance venography or digital subtract angiography at admission, during operation, and at 3- and 6-month follow-up after treatment.

RESULTS

The percentage of patients that showed complete and partial recanalization were 87% and 6%, respectively, after mechanical thrombectomy combined with thrombolysis treatment; 8% of the patients showed no recanalization. The modified Rankin Scale scores were 1.0 ± 0.9, 0.85 ± 0.63, and 0.37 ± 0.53 for discharge, and 3- and 6-month follow-up, respectively. A total of 6 patients died despite receiving aggressive treatment. No cases of relapse occurred after 3 to 6 months of follow-up.

CONCLUSION

Thrombectomy combined with thrombolysis is a safe and valid treatment modality to use in severe CVST cases or in intractable patients that have shown no adequate response to antithrombotic drugs.

The role of unenhanced CT alone for the management of headache in an emergency department. A feasibility study

OBJECTIVE

To determine whether unenhanced CT alone could be sufficient for the screening of patients admitted with a suspicion of secondary headache in an emergency center.

MATERIAL AND METHODS

A feasibility study including consecutive patients admitted to our emergency department for acute non-traumatic headache, in whom a brain CT was required by the emergency physician, was conducted over a 3-month period of time. Patients with a suspicion of intracranial pathology, which can only be depicted by i.v. images (arterial dissection, venous thrombosis, or postoperative complication) were recorded but excluded from analysis. All patients underwent both unenhanced and i.v. enhanced cerebral CT, including CT angiography. Unenhanced CTs were reviewed by two radiologists, blinded to the clinical data, to the radiological reports and to the i.v. enhanced images. Unenhanced CT were sorted by the radiologists into three groups: (1) normal CT, (2) benign finding that could explain headache without need of injection of contrast media, (3) evidence of an intracranial pathology, requiring further imaging. Results were compared to i.v. enhanced CT images.

RESULTS

A brain CT was required in 105 patients (34 males, 71 females) during the study period, 74 (70%) of them met our inclusion criteria. Fifty-nine (80%) were sorted in group 1 (normal), four (5%) in group 2, 11 (15%) in group 3. No further finding that could explain acute headache was found on i.v. CT images in patients of group 1 or 2. A significant pathology was confirmed by i.v. CT in all patients of group 3.

CONCLUSION

This feasibility study suggests that a normal unenhanced CT might be sufficient to exclude the cause of headache in the initial screening of a selected group of patients admitted with cephalalgia. It compels researchers to perform further prospective studies to confirm the current data on a larger amount of patients.

Treatment of progressive cerebral sinuses thrombosis with local thrombolysis

Cerebral venous thrombosis (CVT) is a potentially serious disease, with nonspecific clinical symptoms and an unpredictable outcome. Despite adequate anticoagulation, a patient's clinical condition can rapidly deteriorate. The aim of this study was to evaluate the efficacy of local thrombolysis in these patients. Consecutive patients with progressive cerebral venous thrombosis between October 2008 and January 2011 were enrolled prospectively. Progressive CVT was defined as the persistence of neurologic findings (headache, blurred vision, and visual field defects) despite at least four days (or 48 hours in patients with involvement of more than one sinus) on full anticoagulation therapy with heparin and development of focal neurologic deficits or cortical hemorrhage. We excluded patients with large hematomas and predisposing malignancies like leukemia. All patients underwent local thrombolysis with 30 mg recombinant tissue plasminogen activator (rtPA). Overall, 26 patients were enrolled with a mean age of 35.5 years (range 18 to 56 years). Six patients (23%) were male and twenty patients (77%) were female. The most common presenting feature was headache and the most common neurologic finding was papilledema, which was present in all patients. Eighty-five percent of women had a history of oral contraceptive pill consumption. Successful recanalization was achieved in all patients except one (96.2%). Neurological examinations and follow-up assessments were based on a modified Rankin scale (mRS). Favorable outcome and recovery was defined as a mRS score of 0-1. Follow-up assessments at the third week showed that 25 out of 26 recovered, with 18 having a mRS score of 0 and 7 with a mRS score of 1. There were no procedure-related neurological complications. Our results show that local thrombolysis is a safe and effective treatment modality for patients suffering from progressive CVT.

The role of imaging studies for evaluation of stroke in children

Stroke is a major cause of morbidity and mortality in children and long-term neurological deficits. Although cerebrovascular disorders occur less often in children than in adults, recognition of stroke in children has probably increased because of the widespread application of noninvasive diagnostic studies such as magnetic resonance imaging and computed tomography.Computed tomography (CT) should be the first imaging choice in the emergency setting when stroke is suspected. It will show the presence of hemorrhage (eg, bleeding from arteriovenous malformation). It is often normal within the first hours in arterial ischemic stroke. As in adults, magnetic resonance imaging is the neuroimaging modality to confirm the clinical diagnosis of ischemic stroke. In children, however, magnetic resonance imaging requires sedation and may not be as readily available as CT. Perfusion imaging demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for this technique in children. Angiography detects arterial disease (eg, aneurysm); however, its use has been largely superseded by better magnetic resonance angiography, which is sensitive enough to visualize lesions in the proximal anterior cerebral artery, middle cerebral artery, and distal internal carotid artery (ICA). Magnetic resonance imaging using diffusion- weighted imaging is the most versatile and sensitive imaging technique for identifying ischemic lesions. In the future, we need to identify the pediatric patient presenting to the emergency department with an acute stroke and develop a pathway for the use of particular imaging techniques (eg, CT vs magnetic resonance imaging).

Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND

The purpose of this statement is to provide an overview of cerebral venous sinus thrombosis and to provide recommendations for its diagnosis, management, and treatment. The intended audience is physicians and other healthcare providers who are responsible for the diagnosis and management of patients with cerebral venous sinus thrombosis.

METHODS AND RESULTS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represent different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 1966 and used the American Heart Association levels-of-evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee.

CONCLUSIONS

Evidence-based recommendations are provided for the diagnosis, management, and prevention of recurrence of cerebral venous thrombosis. Recommendations on the evaluation and management of cerebral venous thrombosis during pregnancy and in the pediatric population are provided. Considerations for the management of clinical complications (seizures, hydrocephalus, intracranial hypertension, and neurological deterioration) are also summarized. An algorithm for diagnosis and management of patients with cerebral venous sinus thrombosis is described.

Cerebral sinovenous thrombosis. Neuroimaging diagnosis and clinical management

SUMMARY

Cerebral sinovenous thrombosis (CSVT) is an uncommon disorder that affects the dural venous sinus and cerebral vein. In our study, thirty- four patients were examined. Pre and/or post contrast-enhanced CT was done in 28 patients. MRI studies were done in 24 patients. 2-D TOF MR venography (MRV) and contrast-enhanced MRV (CEMRV) were done in 19 cases. Digital subtraction angiography (DSA) was done in 18 patients. Sixteen patients received systemic intravenous heparinization, and 12 received endovascular thrombolytic treatment with urokinase combined with anticoagulant therapy. Neuroimages of CSVT can be acquired by direct visualization of the thrombus within the dural sinus or by parenchymal changes secondary to venous occlusion. As there are some pitfalls to MRI in the diagnosis of CSVT, the combination of MRI and MRV is now the gold standard in the diagnosis of CSVT. Usually, accuracy can be improved by applying 2-D TOF MRV and CE MRV. Furthermore, the source image of MRV is critical in differentiating between normal sinus variations and diseased ones. DSA is the best tool for demonstrating dynamic intracranial circulation in CSVT and mostly is used for endovascular treatment. Systemic intravenous anticoagulant therapy with heparin is accepted as a first line treatment. Except for clinical manifestations after systemic heparinization, abnormal MR findings of parenchymal change can be used to determine when to initiate thrombolytic treatment. Endovascular therapy can be finished at the antegrade flow within the dural sinus and continuous anticoagulation is sufficient to facilitate clinical improvement. Clinical suspicion and excellent neuroimaging are crucial in making the diagnosis of CSVT. Proper management with anticoagulants and/or endovascular thrombolytic therapy is mandatory in preventing propagation of the thrombosis and improving the clinical outcome.

Cerebral venous thrombosis and multidetector CT angiography: tips and tricks

Because of the great diversity of clinical features, its unforeseeable evolution, and a small proportion of cases that will worsen in the acute phase, cerebral venous thrombosis must be diagnosed as early as possible so that specific treatment can be started, typically transcatheter thrombolysis or systemic anticoagulation. Unenhanced computed tomography (CT) is usually the first imaging study performed on an emergency basis. Unenhanced CT allows detection of ischemic changes related to venous insufficiency and sometimes demonstrates a hyperattenuating thrombosed dural sinus or vein. Helical multidetector CT venography with bolus power injection of contrast material and combined use of two-dimensional and three-dimensional reformations (maximum intensity projection, integral display, and volume rendering) provides exquisite anatomic detail of the deep and superficial intracranial venous system and can demonstrate filling defects. However, common variants of the sinovenous system should not be mistaken for sinus thrombosis. A comprehensive diagnostic approach facilitates imaging of cerebral venous thrombosis with multidetector CT.

[Noninvasive diagnosis of cerebral venous thrombosis]

OBJECTIVES

Cerebral venous thrombosis (CVT) is an uncommon condition. Its variable, unspecific clinical presentation causes delays in diagnosis. We analyze the validity of different neuroimaging techniques, including CT, MRI, MR angiography, and conventional angiography in the diagnosis of CVT.

MATERIAL AND METHODS

We review the imaging findings of 12 patients with the final diagnosis of CVT. All 12 patients underwent CT as the initial imaging test; all 12 underwent MRI; 11 underwent MR angiography; and 4 underwent conventional angiography. Visualization of the thrombus or filling defects in the affected vessel were considered direct signs of CVT, whereas findings compatible with venous infarction were considered indirect signs.

RESULTS

Of the 12 CT examinations, 4 showed direct signs, 2 indirect signs, and 6 only normal findings. Indirect signs of CVT were seen on follow-up CT in three of the patients with normal initial CT examination. CT failed to show the real extent of the process except in one case in which a cortical vein was affected. MRI detected thrombi in the affected territory in 6 cases; the empty delta sign was seen in 2 and signs of venous infarction in 8. MRI failed to diagnose CVT in one case. MR angiography showed direct signs of CVT in all cases, even without intravenous contrast, and the results were similar to those seen at conventional angiography. More than two locations were affected in 11 patients.

CONCLUSIONS

At CT, indirect signs of CVT are seen, although sometimes not immediately. Direct signs can be so subtle that they can only be interpreted with experience. Furthermore, CT does not show the real extent of the process. Nevertheless, given its availability, contrast-enhanced CT should be the primary imaging test, both to rule out other possibilities and to indicate other neuroimaging studies, in this case MRI and MR angiography. The results obtained when these two techniques are performed simultaneously, even without contrast administration, are sufficient for diagnosis and are comparable to those at conventional angiography, but without the risks entailed and without exposing the patient to ionizing radiation.

Alterações parenquimatosas na trombose venosa cerebral: aspectos da ressonância magnética e da angiorressonância

OBJETIVO: Determinar a freqüência e localização das alterações parenquimatosas da trombose venosa cerebral nos exames de ressonância magnética e de angiorressonância, bem como a correlação com o território e a drenagem venosa comprometida. MATERIAIS E MÉTODOS: Foram analisados exames de 21 pacientes realizados entre 1996 e 2004, com diagnóstico clínico e radiológico de trombose venosa cerebral em exames de ressonância magnética e de angiorressonância nas seqüências 2D PC, 3D PC e 3D TOF com contraste paramagnético. Análise estatística foi realizada com o teste do qui quadrado. Quatro pacientes tinham exames de controle e três realizaram angiografia por subtração digital. RESULTADOS: Dos 21 pacientes, 18 eram mulheres, todos com idade entre três e 82 anos (média de 40 anos e mediana de 36 anos). Os principais fatores etiológicos foram infecção, uso de contraceptivos orais, reposição hormonal e colagenoses. Predominaram os sintomas de déficit focal, cefaléia, alteração do nível de consciência e convulsões. Por freqüência, as manifestações parenquimatosas foram: edema/infarto de distribuição cortical e/ou subcortical, congestão venosa e circulação colateral, realce meníngeo e infarto ou edema dos tálamos e núcleos da base. Os principais seios comprometidos foram o sagital superior, o transverso esquerdo, o sigmóide esquerdo e o seio reto, sendo incomum o acometimento dos seios cavernosos e de veias corticais. CONCLUSÃO: A trombose venosa cerebral é causa incomum de acidente vascular encefálico, com prognóstico favorável pelo caráter reversível das lesões. Seu diagnóstico depende fundamentalmente da capacidade do radiologista reconhecer suas formas de apresentação, principalmente nos casos em que ele é sugerido pelas alterações parenquimatosas e não necessariamente pela visualização do trombo. A precisão e a rapidez no diagnóstico permitem o pronto tratamento, reduzindo a morbi-mortalidade da doença.

Cerebral sinovenous thrombosis and idiopathic nephrotic syndrome in childhood: report of four new cases and review of the literature

INTRODUCTION

Nephrotic children are prone to develop thromboembolic complications secondary to an acquired hypercoagulable state. Cerebral sinovenous thrombosis (CSVT) is increasingly recognised in this population, but clinical characteristics and outcome are not well documented.

PATIENTS AND METHODS

The database of the Canadian Pediatric Ischemic Stroke Registry (Toronto Site) containing prospectively enrolled children from 1992-2004 with CSVT identified four children with NS. A pooled literature analysis retrieved 17 additional cases reports.

RESULTS

CSVT presented in the majority of cases during the first flare or within 6 months after the onset of NS and was found to occur more often in SSNS/SDNS (n=13) than in SRNS (n=4). Clinical manifestations were non-specific and consisted primarily of seizures (n=8) and signs of raised intracranial pressure (n=16). Imaging studies revealed a predilection for superior sagittal sinus involvement (n=21) and rare parenchymal lesions (n=4). The most consistent biological risk factors were a severe hypoalbuminaemia (n=14) and, to a lesser extent, decreased antithrombin (AT) levels (n=9/16). Deficiency of other coagulation inhibitors (protein S, protein C) was not identified. Inherited thrombophilia was documented in a single case, suggesting that acquired, more than genetic, coagulation factors are involved. Anticoagulation was safe, and the outcome was good in most patients, and no recurrence of thrombotic event was reported.

DISCUSSION

In conclusion, CSVT is now a well-described complication of NS with potential morbidity. A high index of suspicion is required, especially in young children with NS presenting neurological symptoms. Reliable biological predictors of CSVT are lacking.

[Pseudotumor cerebri secondary to dural sinus thrombosis: pediatric case report]

Pseudotumor cerebri is a relatively common neurologic syndrome in adolescence. In most cases, etiology is idiopathic, but it may have serious complications, such as blindness, that are related to increased intracranial pressure. The aim of this article is to emphasize the differential diagnosis of pseudotumor cerebri, with special attention to treatable etiologies. We report a case of an 12 year-old adolescent who presented with diplopia and headache 9 days after right-sided otitis media and mastoiditis. Head computerized tomography was normal, but brain magnetic resonance imaging demonstrated thrombosis of ipsilateral transverse and sigmoid sinuses, which responded promptly to early anticoagulation. The conclusion is that magnetic resonance imaging is essential for patients with a clinical diagnosis of pseudotumor cerebri in order to exclude treatable causes, such as dural sinus thrombosis.

Recommendations for Comprehensive Stroke Centers

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease.

Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors.

Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.