Cerebral venous thrombosis in four patients with multiple sclerosis

Extracellular Purine Metabolism-Potential Target in Multiple Sclerosis

The purinergic signaling system comprises a complex network of extracellular purines and purine-metabolizing ectoenzymes, nucleotide and nucleoside receptors, ATP release channels, and nucleoside transporters. Because of its immunomodulatory function, this system is critically involved in the pathogenesis of multiple sclerosis (MS) and its best-characterized animal model, experimental autoimmune encephalomyelitis (EAE). MS is a chronic neuroinflammatory demyelinating and neurodegenerative disease with autoimmune etiology and great heterogeneity, mostly affecting young adults and leading to permanent disability. In MS/EAE, alterations were detected in almost all components of the purinergic signaling system in both peripheral immune cells and central nervous system (CNS) glial cells, which play an important role in the pathogenesis of the disease. A decrease in extracellular ATP levels and an increase in its downstream metabolites, particularly adenosine and inosine, were frequently observed at MS, indicating a shift in metabolism toward an anti-inflammatory environment. Accordingly, upregulation of the major ectonucleotidase tandem CD39/CD73 was detected in the blood cells and CNS of relapsing-remitting MS patients. Based on the postulated role of A2A receptors in the transition from acute to chronic neuroinflammation, the association of variants of the adenosine deaminase gene with the severity of MS, and the beneficial effects of inosine treatment in EAE, the adenosinergic system emerged as a promising target in neuroinflammation. More recently, several publications have identified ADP-dependent P2Y12 receptors and the major extracellular ADP producing enzyme nucleoside triphosphate diphosphohydrolase 2 (NTPDase2) as novel potential targets in MS.

Stroke risk in multiple sclerosis: a critical appraisal of the literature

Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.

Anti-MOG Antibody Syndrome and Cerebral Sinovenous Thrombosis: A Cause–Effect Hypothesis

Cerebral venous thrombosis is an uncommon event of stroke in childhood. Its origin is multifactorial and often it manifests with nonspecific symptoms that may overlap with underlying predisposing factors. Anti–myelin oligodendrocyte glycoprotein (MOG) antibody syndrome is a group of recently recognized acquired demyelinating diseases that occur more commonly in children, usually, with a favorable outcome. The association between cerebral venous thrombosis and demyelinating syndrome has been reported but their clinical relationship is matter of debate and various hypotheses have been advanced including intravenous (IV) steroid therapy and/or the consequence of a shared inflammatory-thrombotic process. Herein, we report the case of a child with anti-MOG antibody syndromes who developed a thrombosis of the superior sagittal sinus and of the right Trolard's vein.

Dural venous sinus thrombosis after lumbar puncture in a patient with idiopathic intracranial hypertension

INTRODUCTION

Idiopathic intracranial hypertension (IIH) is one of the most common causes of papilloedema seen by ophthalmologists and neurologists. Patients with IIH routinely undergo lumbar puncture (LP) for diagnosis. Dural venous sinus thrombosis (DVST) is a rare complication of cerebrospinal fluid pressure (CSF)-lowering procedures such as lumbar puncture and epidural and may be an intracranial complication of IIH.

CASE DESCRIPTION

A 29-year-old obese woman was diagnosed with severe idiopathic intracranial hypertension (IIH) after she presented with new-onset headache, pulsatile tinnitus and blurred vision. Magnetic resonance imaging (MRI) and venography (MRV) were normal apart from signs of intracranial hypertension. Lumbar puncture (LP) revealed an opening pressure of 40 cm of water. Due to the severity of the papilloedema and vision loss, she was referred for a ventriculoperitoneal shunt and found to have venous sinus thrombosis involving the superior sagittal sinus on the pre-operative computed tomography (CT) head 5 days after the LP. CT venography (CTV) one day later and MRV 3 days later showed significant worsening as the thrombosis extended into the deep venous system. She was started on therapeutic heparin and her symptoms and vision improved and she did not develop any neurological complications.

CONCLUSIONS

DVST should be considered in IIH patients who have worsening papilloedema or symptoms of intracranial hypertension. Repeat venous imaging can prevent devastating consequences such as venous infarcts of haemorrhage in these patients.

Subcutaneous Interferon-β1a Does Not Increase the Risk of Stroke in Patients with Multiple Sclerosis: Analysis of Pooled Clinical Trials and Post-Marketing Surveillance

INTRODUCTION

Previous studies suggest that multiple sclerosis (MS) patients have a greater stroke risk than the general population but there is limited evidence of stroke risk in patients receiving disease-modifying treatment. We assessed stroke risk in MS patients treated with subcutaneous interferon-β1a (sc IFN-β1a) using pooled data from clinical trials and post-marketing surveillance.

METHODS

Seventeen phase II-IV Merck KGaA-sponsored trials of sc IFN-β1a were assessed to estimate the stroke incidence rate (IR) and IR ratio (IRR) per 100 patient-years (PY), and associated 95% confidence intervals (CI). The association of treatment duration with stroke was assessed through a Cox model. IR, IRR, and hazard ratio (HR) were adjusted by age, sex, presence of any comorbidity, and MS duration. Individual case safety reports were retrieved from the Global Patient Safety Database. The reporting rates of stroke were calculated and classified as medically confirmed or non-medically confirmed according to the source of each report.

RESULTS

In 17 clinical trials, 4412 patients were treated with sc IFN-β1a for a total of 10,622 PY and 1055 patients with placebo for 2005 PY. The IR/100 PY (95% CI) of stroke was 0.025 (0.004, 0.150) in sc IFN-β1a patients and 0.051 (0.008, 0.349) in placebo patients. The IRR for sc IFN-β1a vs placebo was 0.486 (0.238, 0.995) and the HR was 0.496 (0.235, 1.043) for time to stroke-related event for sc IFN-β1a treatment at any dose compared with placebo. Among sc IFN-β1a patients, the IRR in those treated for < 2 years was 0.602 (0.159, 2.277) and for ≥ 2 years 0.469 (0.196, 1.124). Analysis of the safety database showed that the overall reporting rate for stroke was 13.286/10,000 PY.

CONCLUSION

Safety data from both clinical trial and post-marketing settings indicate that treatment with sc IFN-β1a does not increase stroke risk in patients with MS.

FUNDING

Merck KGaA, Darmstadt, Germany.

Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP), the absence of structural lesions on neuroimaging, and normal cerebrospinal fluid composition. Cerebral venous sinus thrombosis (CVST) is a common cause of increased ICP and can be differentiated from IIH with magnetic resonance venography. We describe a young woman with typical IIH who underwent lumbar puncture and was treated with a short course of high-dose corticosteroids followed by acetazolamide. She subsequently developed CVST, subarachnoid hemorrhage, and stroke. Risk factors that may have resulted in CVST are discussed.

Contraceptive use among women with multiple sclerosis: a systematic review

BACKGROUND

Contraception is an important consideration for women with multiple sclerosis (MS); however, little is known about the possible effects of hormonal contraception on disease progression or other adverse outcomes (e.g., thrombosis, low bone mineral density).

OBJECTIVE

To evaluate the evidence on the safety of contraceptive use among women with MS.

SEARCH STRATEGY

We searched the PubMed database for peer-reviewed articles published in any language from database inception through July 2015.

SELECTION CRITERIA

We included studies that examined health outcomes among women diagnosed with MS initiating or continuing a contraceptive method. We excluded case reports and case series but included all other study designs.

RESULTS

From 111 articles, we identified four studies (from 5 articles) that met our inclusion criteria. Evidence from one randomized controlled trial, two retrospective cohort studies, and one cross-sectional study suggests that use of combined oral contraceptives (COCs) or oral contraceptives (OCs) (type not specified) among women with MS does not worsen the clinical course of disease, defined as disability level, disease severity or progression, relapse or number of new brain lesions on magnetic resonance imaging (body of evidence grading Level I, fair to Level II-3, poor). No studies were identified that examined the safety of other contraceptive methods or examined other outcomes of interest (venous thromboembolism, changes in bone mineral density) related to contraceptive use among women with MS.

CONCLUSIONS

Limited evidence suggests that COC or OC use after MS onset does not worsen the clinical course of disease.

Cerebral venous thrombosis and demyelinating diseases: report of a case in a clinically isolated syndrome suggestive of multiple sclerosis onset and review of the literature

Cerebral venous thrombosis (CVT) has been described in several cases of clinically definite multiple sclerosis (MS). In the majority of these, lumbar puncture followed by intravenous corticosteroid treatment was suspected as the cause. We report what is, to our knowledge, the first case of a patient with a multifocal clinically isolated syndrome suggestive of MS onset, who developed multiple CVT after lumbar puncture and during high-dose i.v. corticosteroid treatment. We conclude that the sequence ‘lumbar puncture followed by corticosteroid treatment’ may be a contributory risk factor for the development of CVT when associated with other risk factors.

Cerebral venous sinus thrombosis in the patient with multiple sclerosis associated with congenital antithrombin deficiency

We report the case of a 25-year-old man with multiple sclerosis (MS) who had severe headache and unconsciousness. He suffered from optic neuritis that had started at age 6. From the age of 12 years, he had suffered from multiple sclerosis (MS) cerebral lesions that relapsed three times over for 5 years. At age 25, he showed a new lesion in the cerebellar cortex, suggesting an exacerbation of the MS. However, magnetic resonance imaging findings the next day showed cerebral venous sinus thrombosis. His laboratory findings showed low antithrombin activity. Genetic analysis revealed a single-base substitution (C>T) at the codon 359 (Arg to STOP) in the 5th exon portion of the antithrombin gene, heterozygote. In the literature review, 17 cases of multiple sclerosis associated with cerebral venous sinus thrombosis, which occurred after the lumbar puncture and the treatment with high-dose methylpredonisolone in 11 of these cases. In our case, antithrombin deficiency, hyperhomocystinemia, infection, and lumbar puncture were suggested as the risk factors.

Postdural Puncture Superior Sagittal Sinus Thrombosis in a Juvenile Case of Clinically Isolated Syndrome

Background. The causes of cerebral venous thrombosis (CVT) are manifold as is its clinical presentation. Case. We report the case of a CVT following lumbar puncture and intravenous glucocorticosteroid therapy in a female adolescent with a clinically isolated syndrome and risk factors for thrombosis. Conclusion. In adolescent patients with acute inflammatory disease undergoing lumbar puncture followed by intravenous high-dose glucocorticosteroid therapy, one should be aware of the elevated risk for thrombosis. A persistent headache with change in the headache pattern and loss of a postural component might be a sign for CVT, requiring emergency imaging of the brain.

[Is it always useful to perform lumbar puncture for the diagnosis of multiple sclerosis? No]

In the absence of a specific test for the diagnosis of multiple sclerosis (MS), cerebrospinal fluid analysis (CSF) remains discussed. There are robust evidences which demonstrated that an early diagnosis of MS must be done, due to the availability of disease-modifying drugs that could influence the natural history of the disease. However, several arguments can be put forward to assert that CSF analysis is not useful for the diagnosis of MS and thus should not be realized in a systematic way. First, MRI remains the most sensitive and specific marker to validate dissemination in space and in time and CSF analysis is not recommended by the 2010 McDonald criteria. The second argument is related to the low sensitivity and specificity of abnormalities detected in CSF analysis to confirm the diagnosis of MS. Moreover, there is currently no evidence that the presence of oligoclonal bands could represent a surrogate marker on an individual prognostic way. Furthermore, lumbar puncture could be traumatic, may entail some infrequent risks and represents unnecessary expense. Thus, there are strong reasons to not recommend systematic CSF examination to diagnose MS.

Dural puncture: an overlooked cause of cerebral venous thrombosis

Cerebral venous thrombosis (CVT) accounts for 0.5-1 % of all strokes. Although dural puncture is proposed as one of the rare risk factors, this association has only been mentioned in anecdotal reports. Headache, i.e., usually the first and the most frequent clinical symptom on admission, is often attributed to the dural puncture itself. We investigated the frequency of CVT following a recent dural puncture in our stroke database, together with the other risk factors. The computerized medical records of patients (n = 10,740) registered in our tertiary-care neurology clinic stroke database were reviewed retrospectively. Patients diagnosed with CVT were reanalyzed. Patients who had a dural puncture in the preceding 7 days were included in the study. A total of 46 patients were diagnosed with CVT. Nine patients (19.6 %) had a recent dural puncture before the onset of the symptoms. Patients were younger than 45 years and had at least one more predisposing condition for thromboembolism other than the dural puncture. All patients have received either spinal anesthesia or intrathecal chemotherapy. Dural puncture seems to trigger CVT particularly in patients with predisposing disorders. Although reported as an extremely rare complication, our data indicate a much higher association. This case series emphasize the importance of reevaluation of patients with persistent/progressive headache following dural puncture. The effect of change in the biochemical composition of CSF due to intrathecal drug administration in pathogenesis is not known. Larger controlled trials are warranted to clarify the causal relationship between lumbar puncture and/or intrathecal drug administration and CVT.

Cerebral venous thrombosis as a complication of neuropsychiatric systemic lupus erythematosus

A 51-year-old woman undergoing steroid treatment for systemic lupus erythematosus (SLE) was admitted to our hospital after developing a fever, consciousness disturbance and seizures, leading to a diagnosis of SLE-induced meningoencephalitis. Although steroid therapy improved her symptoms, she complained of post-lumbar puncture thunderclap headaches during follow-up, and cerebral venous thrombosis (CVT) was subsequently diagnosed on magnetic resonance venography and cerebral angiography. This is a rare case of neuropsychiatric SLE complicated by CVT during treatment for aseptic meningoencephalitis. The onset of aseptic meningoencephalitis and administration of the lumbar puncture and steroid therapy may have induced the development of the patient's CVT symptoms.

Cerebral venous thrombosis in post-lumbar puncture intracranial hypotension: case report and review of literature

The spectrum of presentation of intracranial hypotension is clinically perplexing. We report a case of 31-year-old post-partum woman who underwent an uneventful caesarean section under spinal anesthesia. From the second day of surgery she developed postural headache, the headache lost its postural character after few days. She then developed seizures and ataxic hemiparesis. Magnetic resonance imaging showed features of severe intracranial hypotension in the brain and the spinal cord, and magnetic resonance venography showed cortical vein and partial superior sagittal sinus thrombosis. Prothrombotic (etiological) work-up showed Protein C and S deficiency. She responded to anticoagulation therapy and recovered completely. On review of literature two distinct groups could be identified obstetric and non-obstetric. The non-obstetric group included patients who underwent diagnostic lumbar puncture, intrathecal injection of medications and epidural anesthesia for non-obstetric surgeries. Poor outcome and mortality was noted in non-obstetric group, while obstetric group had an excellent recovery.

Cerebral venous thrombosis in a patient with clinically isolated spinal cord syndrome

Background. The association between cerebral venous thrombosis (CVT) and multiple sclerosis (MS) has already been reported in patients with clinically definite MS in relation to intravenous methylprednisolone (IVMP) or previously performed lumbar puncture (LP). Case Summery. We report a 29-year-old Indian female who presented with a clinically isolated spinal cord syndrome according to the revised 2010 McDonald Criteria. She developed CVT after a lumbar puncture and two days of finishing the course of IVMP. Conclusion. We conclude that the sequence of doing lumbar puncture followed by high-dose IVMP may increase the risk of CVT. A prophylactic anticoagulation may be indicated in this setting.

Cerebral venous thrombosis after lumbar puncture and intravenous high dose corticosteroids: a case report of a childhood multiple sclerosis

The association between cerebral venous thrombosis (CVT) and multiple sclerosis (MS) has already been reported in several adult patients with clinically definite MS, in a suspected relation to i.v. corticosteroids or previously performed lumbar puncture (LP). We are reporting a case, which is, to our knowledge, the first one concerning a child patient with a MS, who developed multiple CVT after LP and during high-dose i.v. corticosteroid. Our conclusions are that the sequence LP followed by high dose corticosteroids may be a contributory factor for the development of CVT when associated with other risk factors.

Chronic cerebrospinal venous insufficiency in multiple sclerosis: a highly prevalent age-dependent phenomenon

Background

This study aimed to investigate the prevalence and clinical relevance of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients and healthy controls using extra- and intracranial colour Doppler sonography.

Methods

We examined 146 MS patients, presenting with a clinically isolated syndrome, relapsing-remitting, secondary progressive, or primary progressive MS, and 38 healthy controls. Sonographic examination was performed according to Zamboni’s protocol and was performed by three independent sonographers. The results of sonographic examination were compared with clinical and demographic characteristics of the patients.

Results

CCSVI, defined as the presence of at least two positive Zamboni’s criteria, was found in 76% of MS patients and 16% of control subjects. B-mode anomalies of internal jugular veins, such as stenosis, malformed valves, annuli, and septa were the most common lesions detected in MS patients (80.8%) and controls (47.4%). We observed a positive correlation between sonographic diagnosis of CCSVI and the patients’ age (p = 0.003). However, such a correlation was not found in controls (p = 0.635). Notably, no significant correlations were found between sonographic signs of CCSVI and clinical characteristics of MS, except for absent flow in the jugular veins, which was found more often in primary (p<0.005) and secondary (p<0.05) progressive patients compared with non-progressive patients. Absent flow in jugular veins was significantly correlated with patients’ age (p < 0.0001).

Conclusions

Sonographically defined CCSVI is common in MS patients. However, CCSVI appears to be primarily associated with the patient’s age, and poorly correlated with the clinical course of the disease.

Venous thrombosis in multiple sclerosis patients after high-dose intravenous methylprednisolone: the preventive effect of enoxaparin

Aim. This study was designed to examine the possible role of high-dose intravenous methylprednisolone (IVMP) in the development of venous thrombosis (VT). The cerebral one anecdotally had been reported in patients with relapsing remitting multiple sclerosis (RRMS) in acute attacks and the possible preventive role of enoxaparin. Material and Methods. From a pool of 520 patients, 388 patients with definite RRMS who fulfilled entry characteristics were selected and randomly received either a 5-day course of daily 1 gr IVMP or the aforementioned plus 5 days of daily subcutaneous 40 units of enoxaparin according to a predefined protocol. Results. Mean age, gender ratio, mean relapse rate, and EDSS were similar in both groups of patients (P > 0.05). Finally, 366 patients remained in the study. Of 188 patients treated with IVMP with 855 relapses, 5 developed VT (0.37% per patient per year and 0.58% per each course of IVMP) within 3 to 15 days of starting therapy. None of the 178 patients who experienced 809 relapses who received IVMP plus enoxaparin developed such complications. Conclusion. The study implies that high-dose IVMP in MS exacerbation may increase the risk of VT and prophylactic anticoagulant treatment in this setting is warranted.

Anaesthetic management in a patient with multiple sclerosis

Multiple sclerosis (MS) is a rare autoimmune demyelinating disorder of the central nervous system clinically manifesting as periodic attacks of varied neurologic symptoms, eventually progressing to fixed neurologic deficits and disability. The treatment is symptomatic and directed towards prevention of future progression of the disease involving multiple agents. We present here a case report of a patient with MS who underwent an orthopaedic procedure under general anaesthesia (G.A.) uneventfully. Anaesthetic implications include assessment of neurological deficits with documentation pre- and postoperatively, awareness towards side-effects, potential drug interactions of medications, selection of suitable techniques/anaesthetic agents, neuromuscular monitoring-guided titration of non-depolarizing blocking agents with lowest necessary dose and avoidance of hyperthermia along with temperature, haemodynamic and respiratory monitoring. Lower concentrations of local anaesthetic (LA) should be used for regional blocks keeping in mind the susceptibility of demyelinated neurons, towards LA neurotoxicity. To the best of our knowledge, this is the first report of anaesthetic management of MS in India.

Activities of the enzymes that hydrolyze adenine nucleotides in platelets from multiple sclerosis patients

Multiple sclerosis (MS) is the most common chronic disabling neurological disease in young adults. Alterations in platelet function have been observed in MS; however, the mechanism and the relevance of this blood cell disorder with regard to MS pathogenesis are not yet understood. The aim of this study was to evaluate activities of ectonucleoside thiphosphate diphosphohydrolase (NTPDase, CD39), ectonucleotide pyrophosphatase/phosphodiesterase (E-NPP), 5'-nucleotidase and adenosine deaminase (ADA) in platelets from patients with the relapsing-remitting form of MS (RRMS), as well as to analyze platelet aggregation and expression of NTPDase. The results obtained show that NTPDase, 5'-nucleotidase, E-NPP and ADA activities were decreased in platelets of RRMS patients when compared with the control group (p < 0.05). In addition, NTPDase expression in platelets was also decreased in these patients (p < 0.05); however, no differences were observed in platelet aggregation between RRMS patients and the control group. Our results suggest that the alterations in NTPDase, E-NPP, 5'-nucleotidase and ADA may have contributed to the alterations in platelet function in MS by altering the levels of nucleotides and nucleosides in the circulation.

Are steroids useful to treat cerebral venous thrombosis?

BACKGROUND AND PURPOSE

No randomized controlled trial has evaluated the efficacy of steroids in acute cerebral venous thrombosis (CVT). We aimed to analyze the effect of steroids on the outcome of patients in the International Study on Cerebral Veins and Dural Sinus Thrombosis (ISCVT).

METHODS

ISCVT is a prospective observational study that included 624 CVT patients. Death or dependence at 6 months was compared between cases (patients treated with steroids) and controls (patients not treated with steroids), using 3 designs: (1) Matched case-control study (each case matched with a control for prognostic factors); (2) Nonmatched case-control study of the ISCVT cohort; (3) Case-control study in different strata according to the number of poor prognostic variables in each patient.

RESULTS

One hundred and fifty (24%) patients were treated with steroids. (1) In the matched case-control study, poor outcome was similar in the two groups of patients (26/146 versus 17/149, OR=1.7; 95% CI 0.9 to 3.3, P=0.119). (2) In the ISCVT cohort, no significant difference in poor outcomes was found whether patients were treated with steroids or not (26/146 versus 60/469, OR=1.5; 95% CI 0.9 to 2.4). Patients without parenchymal lesions treated with steroids had worse prognosis than those treated without steroids (8/45 versus 9/184, OR=4.2, 95% CI 1.6 to 11.6, P=0.008). (3) Treatment with steroids was not associated with a better outcome in any strata of patients according to the number of poor prognostic factors.

CONCLUSIONS

Steroids in the acute phase of CVT were not useful and were detrimental in patients without parenchymal cerebral lesions. These results do not support the use of steroids in CVT (evidence level III).

Cerebral venous thrombosis caused by spontaneous intracranial hypotension: two cases

The association of spontaneous intracranial hypotension (SIH) with cerebral venous thrombosis (CVT) is rare. We are reporting two new cases. In one case, CVT is extensive concerning three sinuses and bilateral parietal cortical veins and, in the other case, only a cortical vein is involved. Both the patients presented had no thrombosis risk factors. There is certainly a link between these two pathologies. SIH should be considered as a risk factor of CVT. Modification of symptoms of SIH leading to CVT must be known to start early treatment.

Les myélopathies secondaires aux fistules durales artério-veineuses peuvent-elles être aggravées par la corticothérapie intraveineuse ?

Dural fistulas are the most common vascular malformations of the spinal cord. They are of unknown origin but constitute a recognized cause of myelopathy. Aggravation of the clinical manifestations, either spontaneously or after invasive procedures, has been described. We report the case of a patient with a four-month history of myelopathic syndrome involving the lower limbs. Intravenous corticosteroid steroid treatment (1g) given for a suspected inflammatory disorder, induced a dramatic flare-up of the neurological symptoms which were reversible within 48 hours after corticosteroid withdrawal. The causal effect of the steroid treatment is discussed.

Cerebral venous thrombosis initially considered as a complication of spinal-epidural anaesthesia

Cerebral venous thrombosis is an unusual condition characterized by headache, nausea, vomiting, focal deficits and epileptic seizures. In this case report we describe a patient who presented with headache and focal motor deficits after an uneventful Caesarean section, performed using combined spinal-epidural anaesthesia. Magnetic resonance imaging was performed because of the pronounced neurological symptoms, and a diagnosis of cerebral venous thrombosis was made. The patient was treated with anticoagulant agents and made a complete recovery. This case emphasizes the importance of considering cerebral venous thrombosis in the differential diagnosis of headache in the post-partum period prior to instituting conventional therapy.

Lumbar Puncture and Dural Sinus Thrombosis – A Causal or Casual Association?

BACKGROUND

A few cases of cerebral venous thrombosis (CVT) were reported after a lumbar puncture (LP), suggesting a causal association. The purpose of our study was to document that LP might predispose to CVT by decreasing blood flow velocities (BFV) in veins or dural sinus.

METHODS

We performed a transcranial Doppler ultrasound study to register the mean BFV of the straight sinus (SS) before, during and after LP.

RESULTS

Thirteen patients were studied. LP induced a decrease of 47% of mean BFV in the SS. The mean decrease of BFV was significant immediately at the end (p = 0.003), 30 min after (p = 0.015) and more than 6 h after LP (p = 0.008).

CONCLUSIONS

LP induced a sustained decrease of mean BFV in the SS. The decrease of venous blood flow is a possible mechanism contributing to the occurrence of CVT.