Cerebral Venous Sinus Thrombosis From a Tertiary Care Teaching Hospital in India

Multi-inflammatory index as a new predictive and prognostic marker of acute symptomatic seizures in patients with cerebral venous sinus thrombosis

BACKGROUND

The multi-inflammatory index (MII) is a novel marker that indicates the diagnosis, prognosis, and clinical severeness of inflammation-associated diseases. It is indicated that inflammatory biomarkers may help predict the occurrence of acute symptomatic seizures(ASS) after ischemic stroke.

OBJECTIVE

Our goal was to search the predictive and prognostic capability of the MII-1 and MII-2 for ASS in cerebral venous sinus thrombosis (CVST) patients.

METHOD

91 patients with CVST were retrospectively analyzed from the medical records of patients between 2010 and 2023 and divided into the ASS group and non-ASS group. The MII-1 and MII-2 levels on admission, demographic and clinic features, predisposing risk factors, radiological characteristics involving thrombotic cerebral veins, and the type of parenchymal lesions were documented. Modified Rankin Scale (mRS) on admission and at the 3rd month were evaluated to determine the disability.

RESULTS

MII-1 and MII-2 were statistically significantly higher in the ASS group and predictors for the occurrence of seizures with CVST in multivariate analysis. The area under the curve (AUC) of the receiver operating characteristics (ROC) curve for MII-1 was 0.791 (95 %CI = 0.691-0.891, p < 0.001), and AUC for MII-2 was 0.761 (95%CI = 0.660-0.861, p < 0.001). When the clinical variables that were included in the multivariate analysis and MII-1 and MII-2 were combined, the predictive power was greater with the AUC of 0.959. A significant positive correlation was found between mRS at the 3rd month and MII-1 and MII-2 in the ASS group.

CONCLUSION

MII-1 and MII-2 can be used as new predictive and prognostic markers of ASS in patients with CVST.

The burden, risk factors and unique etiologies of stroke in South-East Asia Region (SEAR)

The World Health Organization (WHO) South East Asia Region (SEAR) comprises 11 countries, which are one of the most culturally, topographically, and socially diverse areas worldwide, undergoing an epidemiological transition towards non-communicable diseases, including stroke and other cardiovascular diseases (CVDs). This region accounts for over 40% of the global stroke mortality. Few well-designed population-based epidemiological studies on stroke are available from SEAR countries, with considerable variations among them. Ischemic stroke, a common stroke subtype, has higher frequencies of intracerebral hemorrhage in many countries. Along with an aging population, the increased prevalence of risk factors such as hypertension, diabetes mellitus, tobacco and alcohol consumption, lack of physical activity, high ambient pollution, heat, and humidity contribute to the high burden of stroke in this region. SEAR's many unique and uncommon stroke etiologies include cerebral venous thrombosis, tuberculosis, dengue, scrub typhus, falciparum malaria, snake bite, scorpion sting, etc. Current data on stroke burden and risk factors is lacking, compelling an urgent need for high-quality hospital-level and population-level data in all SEAR countries. Strategies towards a consolidated approach for implementing improved stroke prevention measures, stroke surveillance, and established stroke systems of care are the path to bridging the gaps in stroke care.

Clinical features of patients with cerebral venous sinus thrombosis at plateau areas

OBJECTIVE

Cerebral venous sinus thrombosis (CVST) is believed to be associated with high-altitude exposure and has worse clinical prognosis in plateau areas than in plain areas, although this needs to be further verified. This retrospective study aims to compare the clinical differences of patients with CVST in plateau and plain areas and further ascertain the role of high-altitude exposure in the etiology of aggravating predisposition toward CVST.

METHODS

Twenty-four symptomatic CVST patients occurring at plateau areas (altitude ≥ 4000 m), in corresponding with 24 CVST patients occurring at plain areas (altitude ≤ 1000 m), were recruited according to the inclusion and exclusion criteria from June 2020 to December 2021. The collected data and compared parameters include clinical features, neuroimaging findings, hematology profile, lipid profile, and coagulation profile within 24 h of hospital admission, as well as the treatment method and final outcome.

RESULTS

There were no obvious differences of demographic characteristics, including gender, age, height, and weight between patients with CVST in plateau and plain areas, as well as medical history, neuroimaging findings, treatment protocols, and clinical outcome (all p > .05). Compared to patients with CVST at plain areas, time before hospital admission was longer and heartbeat was slower in patients with CVST at plateau areas (all p < .05). More importantly, elevated red blood cells counts, hemoglobin level, and altered coagulation function were found in patients with CVST at plateau areas (all p < .05).

CONCLUSION

CVST patients in plateau areas presented with altered clinical characteristics, altered coagulation function, and aggravated predisposition toward venous thromboembolism compared with CVST patients in plain areas. Future prospective studies will be needed to further elucidate the influences of a high altitude on the pathogenesis of CVST.

Structural Imaging Characteristic, Clinical Features and Risk Factors of Cerebral Venous Sinus Thrombosis: A Prospective Cross-Sectional Analysis from a Tertiary Care Hospital in Pakistan

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that accounts for 0.5-1.0% of all strokes. Clinical presentation, predisposing factors, neuroimaging findings, and outcomes of CVST are extremely diverse, which causes a high index of suspicion in diagnosis. Therefore, early diagnosis of CVST is crucial for prompt treatment to prevent morbidity and mortality.

OBJECTIVE

The purpose of this prospective study is aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan.

MATERIAL AND METHODS

Consecutive patients enrolled in this study had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) along with a clinical presentation to confirm the diagnosis of CVST. Categorical data were presented as percentages. Continuous variable and categorical data were compared (parenchymal lesions vs. non-parenchymal lesions) using the Student's t-test and Chi-square test, respectively.

RESULTS

A total of 3261 patients with stroke were presented during the study period. Out of all patients, 53 confirmed patients with CVST (1.6%) were recruited; the predominant population was female (84.91%), having a male to female ratio of 1:4. Mean age of the cohort was 28.39 ± 7.19 years. Most frequent symptoms observed were headache (92.45%) followed by vomiting (75.47%), seizures (62.26%), papilledema (54.72%), visual impairment (41.51%), and altered consciousness disturbance (52.83%). The presumed risk factors associated with CVST were puerperium (52.83%), use of oral contraceptives (13.21%), antiphospholipid syndrome (7.55%), elevated serum levels of protein C and S (5.66%), and CNS infection (3.77%). On cranial CT scans, 50 patients (94.33%) showed abnormalities while 32 patients exhibited various parenchymal lesions. Seizures were more frequent in CVST patients with parenchymal lesions compared with subjects lacking parenchymal lesions. Seventy-two sinuses, either single or in combination, were involved in CVST patients, being more common in patients with parenchymal lesions than those without parenchymal lesions. The most frequent locations of CVST were the superior sagittal and transverse sinus.

CONCLUSION

In short, non-contrast CT brain may be used as a first line investigation in suspected cases of CVST. Our study also demonstrates some regional differences in the clinical features, risk factors, and neuroimaging details of CVST as described by some other studies. Therefore, care must be taken while diagnosing and predicting the outcome of the CVST.

Cerebral venous thrombosis in COVID-19

BACKGROUND AND AIMS

Initially, novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) was considered primarily a respiratory pathogen. However, with time it has behaved as a virus with the potential to cause multi-system involvement, including neurological manifestations. Cerebral venous sinus thrombosis (CVT) has increasingly been reported in association with coronavirus infectious disease of 2019 (COVID-19). Here, we have shed light upon CVT and its possible mechanisms in the backdrop of the ongoing COVID-19 pandemic.

METHODS

In this review, data were collected from PubMed, EMBASE and Web of Science, until March 30, 2021, using pre-specified searching strategies. The search strategy consisted of a variation of keywords of relevant medical subject headings and keywords, including "COVID-19", "SARS-CoV-2", "coronavirus", and "cerebral venous sinus thrombosis".

RESULTS

COVID-19 has a causal association with a plethora of neurological, neuropsychiatric and psychological effects. CVT has gained particular importance in this regard. The known hypercoagulable state in SARS-CoV-2 infection is thought to be the main mechanism in COVID-19 related CVT. Other plausible mechanisms may include vascular endothelial dysfunction and altered flow dynamics.

CONCLUSIONS

Although there are no specific clinical characteristics, insidious or acute onset headache, seizures, stroke-like, or encephalopathy symptoms in a patient with, or who has suffered COVID-19, should prompt the attending physician to investigate for CVT. The treatment of COVID-19 associated CVT does not differ radically from the therapy of CVT without the infection, i.e. urgent initiation of parenteral unfractionated heparin or low molecular weight heparin followed by conventional or mostly newer oral anticoagulants.

Significance of recanalization of sinuses and resolution of parenchymal lesion in cerebral venous sinus thrombosis

In cerebral venous sinus thrombosis (CVST), the degree of recanalization may determine resolution of parenchymal lesion and clinical outcome. The aim of our study was to evaluate the relationship of recanalization with resolution of MRI lesion and clinical outcome. The patients with CVST diagnosed on the basis of magnetic resonance venography (MRV) were included prospectively. Risk factors, clinical features, and MRI and MRV findings were noted. MRI and MRV were repeated at 6 months and the change in parenchymal lesion and grade of recanalization (I, II, III) were noted. Patients were evaluated clinically at three and six months. Complete recovery was considered if modified Rankin Scale (mRS) score was 0. Thirty-three CVST patients were included, 12 (36.4%) of whom were females. Recanalization occurred in 29 (87.9%), which was complete (grade III) in 6 (21%). Sigmoid sinus (52%) recanalized more frequently. Resolution of parenchymal lesion on repeat MRI occurred in 13.3% (4/30) patients, and they had no sequelae. Degree of recanalization was not related to resolution of neurological sequelae, MRI lesion at follow up and burden of thrombosis at baseline. Varying degree of recanalization occurred in 87.9% patients with CVST, and resolution of parenchymal lesion occurred in 13.3%. Clinical outcome however was not related to recanalization.

Clinical Aspects, Diagnosis and Management of Cerebral Vein and Dural Sinus Thrombosis: A Literature Review

Cerebral vein and dural sinus thrombosis (CVST) is an uncommon cause of stroke, but its delayed diagnosis carries significant morbidity and mortality. Several studies have reported higher incidence of CVST than that previously reported. The clinical presentation of CVST varies and can be atypical. Advancement in neuroimaging modalities has made it possible to make an early diagnosis and initiate management with a wide range of therapeutic options, including direct oral anticoagulants and endovascular treatment. This narrative review summarizes the epidemiology, clinical aspects, diagnosis and management of CVST.

Risk factors and predictors of outcomes in 243 Chinese patients with cerebral venous sinus thrombosis: A retrospective analysis

OBJECTIVES

To investigate the risk factors and predictors of outcomes in a cohort of Chinese patients with cerebral venous sinus thrombosis (CVST), so as to provide a reference for customized clinical decision.

PATIENTS AND METHODS

A total of 243 Chinese patients, diagnosed as a first CVST were enrolled in this retrospective study from March 2013 through April 2017. Risk factors and predictors of outcomes for CVST were summarized and analyzed by Chi-square test and logistic regression analysis.

RESULTS

Of the 243 cases, obstetric cause (19.8%) was the leading risk factor for CVST, followed by infection (17.7%) and anemia (17.7%). Gender differences in the risk factors for CVST were analyzed, showing that obstetric cause was the top risk factor in female, while hyperhomocysteinemia (22.3%) was the top risk factor in male. In age subgroups, obstetric cause (26.3%) and anemia (17.6%) were more commonly observed in age ≤ 44 years and age > 44 years subgroup, respectively. The ratio of poor outcomes (mRS = 3-6) in this cohort was 23.0%, and central nervous system (CNS) infection was closely related to poor outcomes at discharge (p = 0.023).

CONCLUSION

The predominant risk factor for CVST, in this Chinese cohort, may still be obstetric cause in female and hyperhomocysteinemia in male. In addition, CNS infection may predict poor outcomes in CVST patients.

Seizure in cerebral venous and sinus thrombosis

Many conflicting issues exist about seizure in the setting of cerebral venous and sinus thrombosis (CVST). In this article we aimed to address the existing data regarding incidence, characteristics, predictors, treatment, and prognosis of acute and late seizures in patients with CVST and to prepare more practical information for clinicians. PubMed, Embase, Web of science and Cochrane databases were searched within 1966–2016 using relevant keywords. A total of 63 papers met the inclusion criteria. Seizures are classified as acute symptomatic seizures (ASS; first 14 days) and post‐CVST epilepsy (PCE; after 14 days). The incidence had been reported in a wide range of 6.9–76% for ASS and 4–16% for PCE. Focal and generalized seizures were observed with different predominance. ASS commonly occurred in patients with loss of consciousness, focal neurological deficits, supratentorial lesions and thrombosis in superior sagittal sinus, straight sinus, and cortical veins. PCE had been predisposed by occurrence of ASS, motor deficit, and supratentorial lesions, particularly hemorrhage. Most experts believe that primary prophylaxis with antiepileptic drugs in the acute phase is not indicated. However, the initiation of prophylaxis after the first seizure in patients with supratentorial lesions or focal neurological deficit should be recommended. The quality of current evidence is low and most conclusions are based on expert opinions. More accurate reports of seizure semiology, detailed antiepileptic treatment plans, and outcomes are necessary to answer the existing questions.

Diagnosis and Treatment of Cerebral Venous Thrombosis: A Review

Cerebral venous thrombosis (CVT), also called cerebral venous sinus thrombosis (CVST), is a cerebrovascular disease with diverse clinical manifestations that often affects young adults, women of childbearing age, and children. It's most common clinical manifestations are headache, seizures, altered consciousness, and neurological focal signs on physical examination. CVT can manifest as a single symptom, or it can present as a syndrome consisting of multiple symptoms. This non-specific clinical picture makes diagnosing CVT difficult. Although the mortality rate of CVT has been significantly reduced by improvements in treatment and diagnostic techniques, the mortality rate of severe CVT remains as high as 34.2%. Survivors of this type of CVT have varying degrees of residual symptoms and are not able to return to their previous work. Hence, we performed a comprehensive literature search in the PubMed, EMBASE, and Medline databases to review the diagnosis and treatment of CVT.

Cerebral Venous Sinus Thrombosis in a Patient with Meningococcal Meningitis

Meningococcal meningitis has a wide range of neurological complications. However, cerebral venous sinus thrombosis (CVST) following infection with Neisseria meningitidis is uncommon. We report a case of CVST in a 42-year-old male admitted with meningococcal meningitis. The patient was managed with antibiotics. Due to altered coagulation parameters observed in fulminant cases of meningococcemia, deployment of anticoagulation therapy, which would otherwise be the treatment of choice for CVST, is a dilemma.