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Early isolated subarachnoid hemorrhage versus hemorrhagic infarction in cerebral venous thrombosis. Radiol Oncol 2022; 56:303-310. [PMID: 35962950 PMCID: PMC9400440 DOI: 10.2478/raon-2022-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) is a rare cerebral vascular disease, the presentation of which is highly variable clinically and radiologically. A recent study demonstrated that isolated subarachnoid hemorrhage (iSAH) in CVT is not as rare as thought previously and may have a good prognostic significance. Hemorrhagic venous infarction, however, is an indicator of an unfavorable outcome. We therefore hypothesized that patients who initially suffered iSAH would have a better clinical outcome than those who suffered hemorrhagic cerebral infarction. PATIENTS AND METHODS We selected patients hospitalized due to CVT, who presented either with isolated SAH or cerebral hemorrhagic infarction at admission or during the following 24 hours: 23 (10 men) aged 22-73 years. The data were extracted from hospital admission records, our computer data system, and the hospital radiological database. RESULTS The iSAH group consisted of 8 (6 men) aged 49.3 ± 16.2 and the hemorrhagic infarction group included 15 (4 men) aged 47.9 ± 16.8. Despite having a significantly greater number of thrombosed venous sinuses/deep veins (Mann-Whitney Rank Sum Test, p = 0.002), the isolated SAH group had a significantly better outcome on its modified Rankin Score (mRs) than the hemorrhagic infarction group (Mann-Whitney Rank Sum Test, p = 0.026). Additional variables of significant impact were edema formation (p = 0.004) and sulcal obliteration (p = 0.014). CONCLUSIONS The patients who suffer iSAH initially had a significantly better outcome prognosis than the hemorrhagic infarction patients, despite the greater number of thrombosed sinuses/veins in the iSAH group. A possible explanation might include patent superficial cerebral communicating veins.
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Mehvari Habibabadi J, Saadatnia M, Tabrizi N. Seizure in cerebral venous and sinus thrombosis. Epilepsia Open 2018; 3:316-322. [PMID: 30187001 PMCID: PMC6119760 DOI: 10.1002/epi4.12229] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
| | - Mohammad Saadatnia
- Isfahan Neuroscience Research Center Isfahan University of Medical Sciences Isfahan Iran
| | - Nasim Tabrizi
- Department of Neurology Mazandaran University of Medical Sciences Sari Iran
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Squier W, Mack J, Jansen AC. Infants dying suddenly and unexpectedly share demographic features with infants who die with retinal and dural bleeding: a review of neural mechanisms. Dev Med Child Neurol 2016; 58:1223-1234. [PMID: 27435495 DOI: 10.1111/dmcn.13202] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 01/01/2023]
Abstract
The cause of death in infants who die suddenly and unexpectedly (sudden unexpected death in infancy [SUDI]) remains a diagnostic challenge. Some infants have identified diseases (explained SUDI); those without explanation are called sudden infant death syndrome (SIDS). Demographic data indicate subgroups among SUDI and SIDS cases, such as unsafe sleeping and apparent life-threatening events. Infants dying suddenly with retinal and dural bleeding are often classified as abused, but in many there is no evidence of trauma. Demographic features suggest that they may represent a further subgroup of SUDI. This review examines the neuropathological hypotheses to explain SIDS and highlights the interaction of infant oxygen-conserving reflexes with the brainstem networks considered responsible for SIDS. We consider sex- and age-specific vulnerabilities related to dural bleeding and how sensitization of the dural innervation by bleeding may influence these reflexes, potentially leading to collapse or even death after otherwise trivial insults.
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Affiliation(s)
- Waney Squier
- Formerly Department of Neuropathology, Oxford University John Radcliffe Hospital, Oxford, UK
| | - Julie Mack
- Department of Radiology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Anna C Jansen
- Paediatric Neurology Unit, Department of Paediatrics, UZ Brussel, Brussels, Belgium.,Neurogenetics Research Unit, Vrije Universiteit Brussel, Brussels, Belgium
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Roncallo F, Turtulici I, Arena E, Bisio N, Inglese M, Assini A, Gasparetto B, Bartolini A. Cerebral Venous Sinus Thrombosis: Prognostic and Therapeutic Significance of an Early Radiologic Diagnosis. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140099801100409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We describe the CT and MRI patterns of cerebral venous sinus thrombosis (CVST) on the basis of the venous angioarchitecture and the underlying pathophysiological mechanism. We also investigated if any radiologic data exist to establish which patients can be followed conservatively and which warrant endovascular treatment. The clinical, CT-CTA and MRI-MRA findings of 11 patients (2 men; 9 women; 24 to 69 years-old) with CVST were reviewed. The morphological patterns of CVST were divided into two major groups: Vascular signs: spontaneous sinusal hyperdensity (9); spontaneous all-sequences hyperintensity (4); venous engorgement (9); empty delta sign (4); lack of sinusal contrast-enhancement (3); delayed sinusal transit-time (11); lack of flow-related signal (3). Parenchymal signs: mass effect and cortical sulcal effacement (8), white matter edema (7), venous ischemia (6), haemorrhagic infarct (3), breakdown of the blood-brain barrier (4), hydrocephalus (2). The clinical and radiologic pictures are related to cerebral venous angioarchitecture and underlying pathophysiologic mechanism of venous thrombosis. Reversibility of clinical symptoms and parenchymal lesions is far more frequent, because vessel damage slowly and progressively develops, whereas damage to brain tissue occurs later. Consequently, a prompt CT-MRI diagnosis may allow a good prognosis. Treatment using selective sinusal instillation of urokinase is considered only when the patient clinically and radiologically does not improve within the first two weeks after heparinization.
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Affiliation(s)
| | | | | | | | | | | | - B. Gasparetto
- CNR - Centro di Studio per la Neurofisiologia Cerebrale; Genova
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5
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Price M, Günther A, Kwan JSK. Antiepileptic drugs for the primary and secondary prevention of seizures after intracranial venous thrombosis. Cochrane Database Syst Rev 2016; 4:CD005501. [PMID: 27098266 PMCID: PMC7265129 DOI: 10.1002/14651858.cd005501.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intracranial venous thrombosis (ICVT) commonly presents with seizures in the acute period, and some people may develop recurrent seizures in the long term. The prophylactic use of antiepileptic drugs (AEDs) for the management of post-ICVT seizures is controversial, and there is currently no consensus on the optimal management of post-ICVT seizures. This is an updated version of the Cochrane review first published in theCochrane Database of Systematic Reviews 2006, Issue 3. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures related to ICVT.(1) For the question of primary prevention, we aimed to examine whether AEDs reduce the likelihood of seizures in people who have had an ICVT but have not had a seizure.(2) For the question of secondary prevention, we aimed to examine whether AEDs reduce the likelihood of further seizures in people who have had an ICVT and at least one seizure. SEARCH METHODS For the latest update, we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), and MEDLINE (Ovid 1946 onwards) to 20 April 2015, and we checked the reference lists of articles retrieved from the searches. SELECTION CRITERIA We planned to include all randomised and quasi-randomised controlled trials in which participants with a diagnosis of ICVT were assigned to a treatment group (that is, receiving at least one AED) or control group (receiving placebo or no drug). DATA COLLECTION AND ANALYSIS Both review authors independently screened and assessed the methodological quality of the studies. If studies had been included in the review, one review author would have extracted the data and another would have checked the extracted data. MAIN RESULTS No relevant studies were found. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of antiepileptic drugs for the primary or secondary prevention of seizures related to intracranial venous thrombosis. Well-designed randomised controlled trials are urgently needed to inform practice. Since the last version of this review no new studies have been found.
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Affiliation(s)
| | - Albrecht Günther
- Jena University HospitalDepartment of NeurologyErlanger Allee 101JenaGermany07747
| | - Joseph SK Kwan
- The University of Hong Kong, Queen Mary HospitalDepartment of Medicine102 Pok Fu Lam RoadHong KongChina
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6
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Mahale R, Mehta A, John AA, Buddaraju K, Shankar AK, Javali M, Srinivasa R. Acute seizures in cerebral venous sinus thrombosis: What predicts it? Epilepsy Res 2016; 123:1-5. [PMID: 27023399 DOI: 10.1016/j.eplepsyres.2016.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/01/2015] [Accepted: 01/30/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Seizures are the presenting feature of cerebral venous sinus thrombosis (CVST) in 12-31.9% of patients. 44.3% of patients have seizures in the early stage of the disease. Acute seizures (AS), refers to seizures which take place before the diagnosis or during the first 2 weeks afterward. OBJECTIVE To report the predictors of acute seizures in cerebral venous sinus thrombosis (CVST). METHODS 100 patients with CVST were included in the study. The occurrence of acute seizures was noted. The predictors of acute seizure were evaluated by univariate analysis including the demographic (gender, age), clinical (headache, focal neurological deficit, papilloedema, GCS score), type and number of risk factors, MRI findings (Type of lesion: hemorrhagic infarction or hematoma, location of lesion) and MRV findings (superficial or deep sinus, cortical veins). RESULTS A total of 46 patients had acute seizures. On univariate analysis, altered mental status (p<0.001), paresis (p=0.03), GCS score <8 (p=0.009), hemorrhagic infarct on imaging (p=0.04), involvement of frontal lobe (p=0.02), superior sagittal sinus (p=0.008), and high D-dimer levels (p=0.03) were significantly associated with acute seizure. On multivariate analysis, the hemorrhagic infarct on MRI and high D-dimer was independently predictive for early seizure. CONCLUSION The predictive factors for the acute seizures are altered mental status (GCS<8), focal deficits, hemorrhagic infarct, involvement of frontal lobe and superior sagittal sinus with high D-dimer levels.
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Affiliation(s)
- Rohan Mahale
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
| | - Anish Mehta
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
| | - Aju Abraham John
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
| | - Kiran Buddaraju
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
| | - Abhinandan K Shankar
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
| | - Mahendra Javali
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
| | - Rangasetty Srinivasa
- Department of Neurology, MS Ramaiah Medical College & Hospital, MSRIT Post, New BEL Road, Bangalore 560054, Karnataka, India.
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Price M, Günther A, Kwan JSK. Antiepileptic drugs for the primary and secondary prevention of seizures after intracranial venous thrombosis. Cochrane Database Syst Rev 2014:CD005501. [PMID: 25086250 DOI: 10.1002/14651858.cd005501.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intracranial venous thrombosis (ICVT) commonly presents with seizures in the acute period, and some people may develop recurrent seizures in the long term. The prophylactic use of antiepileptic drugs (AEDs) for the management of post-ICVT seizures is controversial, and there is currently no consensus on the optimal management of post-ICVT seizures. This is an updated version of the original Cochrane review published in The Cochrane Library 2006, Issue 3. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures related to ICVT.(1) For the question of primary prevention, we aimed to examine whether AEDs reduce the likelihood of seizures in people who have had an ICVT but have not had a seizure.(2) For the question of secondary prevention, we aimed to examine whether AEDs reduce the likelihood of further seizures in people who have had an ICVT and at least one seizure. SEARCH METHODS We aimed to identify relevant studies in the Cochrane Epilepsy Group and Cochrane Stroke Group Specialised Registers. We also undertook specialised searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 7) and MEDLINE (Ovid 1946 to 22 August 2013) and checked the reference lists of articles retrieved from the searches. SELECTION CRITERIA We considered all randomised and quasi-randomised controlled trials in which participants were assigned to a treatment group (that is, receiving at least one AED) or control group (receiving placebo or no drug). DATA COLLECTION AND ANALYSIS Both review authors independently screened and assessed the methodological quality of the studies. If studies had been included in the review, then one review author would have extracted the data and the other would have checked the extracted data. MAIN RESULTS No relevant studies were found. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of antiepileptic drugs for the primary or secondary prevention of seizures related to intracranial venous thrombosis. Well-designed randomised controlled trials are urgently needed to inform practice. Since the last version of this review no new studies have been found.
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8
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Einhäupl K, Stam J, Bousser MG, De Bruijn SFTM, Ferro JM, Martinelli I, Masuhr F. EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. Eur J Neurol 2011; 17:1229-35. [PMID: 20402748 DOI: 10.1111/j.1468-1331.2010.03011.x] [Citation(s) in RCA: 300] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed as a result of the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis and symptomatic therapy including control of seizures and elevated intracranial pressure. METHODS We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence but consensus was clear we stated our opinion as good practice points. RESULTS AND CONCLUSIONS Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous LMWH or with dose-adjusted intravenous heparin (level B recommendation). Concomitant intracranial haemorrhage (ICH) related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulant therapy after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with "mild" thrombophilia, such as heterozygous factor V Leiden or prothrombin G20210A mutation and high plasma levels of factor VIII. Indefinite AC should be considered in patients with recurrent episodes of CVST and in those with one episode of CVST and 'severe' thrombophilia, such as antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without large ICH and threatening herniation (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. However, in severe cases with impending herniation craniectomy can be used as a life-saving intervention (good practice point).
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Affiliation(s)
- K Einhäupl
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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9
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Kastrup O, Koeppen S, Diener HC. Paraneoplastic cerebal venous and sinus thrombosis. Eur J Neurol 2011. [DOI: 10.1111/j.1468-1331.1996.tb00280.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Peng Y, Xuan JG, Yang YL, Wang SN. Endovascular thrombolysis for severe cerebral sinus thrombosis. Interv Neuroradiol 2009; 15:407-12. [PMID: 20465877 DOI: 10.1177/159101990901500405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Accepted: 10/04/2009] [Indexed: 11/15/2022] Open
Abstract
SUMMARY Cerebral venous and sinus thrombosis (CVST) is a rare but life-threatening disease accounting for less than 1% of all strokes and a poor outcome in around 10% of all patients. Early diagnosis is crucial because anticoagulation may reduce the risk of a fatal outcome and severe disability. However, the absence of specific features and the possibility of presentation without associated neurological signs can make its early recognition difficult. For these CVST patients with deteriorating symptoms, endovascular thrombolysis might give better outcome. We describe our five cases of CVST with clinical deteriorating symptoms treated with endovascular thrombolysis. Four patients made an excellent recovery, whereas one patient died despite maximal treatment including decompressive craniectomy.
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Affiliation(s)
- Y Peng
- The first Hospital of Changzhou City, Suzhou University, Changzhou City, China -
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11
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Soda T, Edagawa K, Tsuji K, Dehara M, Nakajima Y, Ito M. [Case of deep cerebral venous thrombosis associated with breast cancer]. Rinsho Shinkeigaku 2008; 48:646-650. [PMID: 19048947 DOI: 10.5692/clinicalneurol.48.646] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A 69-year-old woman was admitted to our hospital because of disturbed consciousness. She awoke to a solid mass in her left breast, but it had been present for about 20 years. On arrival to our hospital, she was comatose, and Babinski's reflexes were present bilaterally. She had no paresis or neck stiffness. Her left breast contained a 10 cm x 12 cm node with multiple ulcers. Blood analysis showed she was in a hypercoagulative state. Computed tomography of the brain demonstrated bilateral hypodensities in the thalamus and hyperdensities at the vein of Galen and at the straight sinus. Angiography showed an absence of flow in the inferior sagittal sinus, in the vein of Galen, and in the straight sinus. Thus, she was diagnosed as having a deep cerebral venous thrombosis. She was treated by continuous heparin infusion, and her consciousness improved gradually. The biopsy of her left breast confirmed the presence of a mucinous carcinoma. The hypercoagulative state associated with the carcinoma was considered to be the cause of her deep cerebral venous thrombosis. It is very rare to diagnose deep cerebral venous thrombosis in a cancer patient while the patient is still alive. In this case, computed tomography of the brain was useful for the diagnosis.
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Affiliation(s)
- Takao Soda
- Department of Neurology, Rinku General Medical Center
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12
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Mitaki S, Fukuda H, Kitani M. [Case of transient cortical blindness due to thrombosis of the transverse sinus]. Rinsho Shinkeigaku 2008; 48:351-354. [PMID: 18540384 DOI: 10.5692/clinicalneurol.48.351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
An 62-year-old man presented visual impairment and generalized seizure. Brain CT performed on the day of admission showed thrombus in the right transverse sinus, and DWI showed high intensity areas in the bilateral occipital and parietal lobes. According to bilateral occipital lobe lesions, we considered his visual impairment as cortical blindness. He was diagnosed as venous sinus thrombosis and intravenous heparin, edaravone and osmotic diuretics were administered. MR venography performed after starting of intravenous treatment showed flow gap in the left transverse sinus but no abnormalities in the right transverse sinus. On the second day of hospitalization, his cortical blindness showed improvement and thrombus in the right transverse sinus were disappeared. This indicated that his left transverse sinus originally hypoplastic, thrombus and hemostatis in the right transverse sinus (his dominant side) caused his cortical blindness and generalized seizure. There was a recanalization in the right transverse sinus after heparin therapy.
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13
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Ferro JM, Canhão P, Bousser MG, Stam J, Barinagarrementeria F. Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics. Stroke 2008; 39:1152-8. [PMID: 18309177 DOI: 10.1161/strokeaha.107.487363] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The risk of seizure early after the diagnosis of cerebral vein and dural sinus thrombosis (CVT) is not known, and the use of prophylactic antiepileptic (AED) medication in the acute phase of CVT is controversial. METHODS In a multicenter, prospective, observational study, we analyzed the risk factors for seizures experienced before the diagnosis of CVT was confirmed (presenting seizures) or within the following 2 weeks (early seizures). The risk of occurrence of early seizures was compared in 4 risk strata and related to whether patients received AEDs or not. Criteria for the strata were "presenting seizures" and "supratentorial lesions." RESULTS Two hundred forty-five of 624 (39.3%) patients with CVT experienced presenting seizures, and 43 (6.9%) patients had early seizure. In logistic-regression analysis, supratentorial lesion (odds ratio [OR]=4.05, 95% CI=2.74 to 5.95), cortical vein thrombosis (OR=2.31, 95% CI=1.44 to 3.73), sagittal sinus thrombosis (OR=2.18, 95% CI=1.50 to 3.18), and puerperal CVT (OR=2.06, 95% CI=1.19 to 3.55) were associated with presenting seizures, whereas supratentorial lesion (OR=3.09, 95% CI=1.56 to 9.62) and presenting seizures (OR=1.74, 95% CI=0.90 to 3.37) predicted early seizures. The risk of early seizures in patients with supratentorial lesions and presenting seizures was significantly lower when AED prophylaxis was used (1 with seizures in 148 patients with AEDs vs 25 in 47 patients without AEDs; OR=0.006, 95% CI=0.001 to 0.05). CONCLUSIONS CVT patients with supratentorial lesions had a higher risk for both presenting and early seizures, whereas patients with presenting seizures had a higher risk of recurrent seizures within 2 weeks. Our results support the prescription of AEDs in acute CVT patients with supratentorial lesions who present with seizures.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences and Mental Health, Hospital Santa Maria, Lisboa, Portugal.
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14
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Müller-Forell W, Engelhard K. Neuroimaging for the anesthesiologist. Anesthesiol Clin 2007; 25:413-39, vii-viii. [PMID: 17884702 DOI: 10.1016/j.anclin.2007.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Neuroimaging is essential in the treatment of cerebral nervous system disorders or in patients in the ICU with deterioration of their neurologic function. Leading clinical symptoms are acute neurologic deficits with different stages of hemisymptomatology, primary or progressing loss of consciousness or vigilance deficit, focal or generalized seizures, sometimes combined with an acute respiratory or circulatory insufficiency. The resulting questions can be summarized in those of intracranial space occupying hemorrhage; acute infarction; and signs for reduced cerebral blood flow, cerebrovascular vasospasm, or intracranial mass. Recent evolutions in imaging have contributed to an increase in diagnostic sensitivity and specificity along with reduced side effects. This article illustrates typical and atypical differential diagnoses, with some emphasis on traumatic brain injury.
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Affiliation(s)
- Wibke Müller-Forell
- Institute of Neuroradiology, Johannes Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
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15
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Müller-Forell W, Urban P. [Isolated cortical vein thrombosis. Clinical and neuroradiological aspects]. Radiologe 2007; 47:255-61. [PMID: 16235092 DOI: 10.1007/s00117-005-1281-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Isolated cortical vein thrombosis is only rarely diagnosed, although it presents with typical signs on imaging, presented in the paper. We report on five patients with this diagnosis, who all presented with focal sensomotoric seizures. Imaging with CT and MRI was the leading method. All patients were treated with oral anticoagulation and showed full recovery.
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Affiliation(s)
- W Müller-Forell
- Institut für Neuroradiologie, Klinikum der Johannes-Gutenberg-Universität, 55101Mainz.
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16
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Sagduyu A, Sirin H, Mulayim S, Bademkiran F, Yunten N, Kitis O, Calli C, Dalbasti T, Kumral E. Cerebral cortical and deep venous thrombosis without sinus thrombosis: clinical MRI correlates. Acta Neurol Scand 2006; 114:254-60. [PMID: 16942545 DOI: 10.1111/j.1600-0404.2006.00595.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cortical and/or deep vein thrombosis (CDVT) without dural sinus involvement is uncommon and presents diagnostic difficulty for many reasons. Our aim is to determine the relationship between magnetic resonance imaging (MRI) findings and clinical findings in patients with CDVT. METHODS Forty-six patients with venous stroke proved on MRI included in our Registry, corresponding to 0.1% of 4650 patients with stroke, were studied. Magnetic resonance angiography (MRA) was performed in all patients, and 18 of them had follow-up MRA. Outcome was evaluated by using the Glasgow Outcome Scale at the time of discharge and during follow-up. RESULTS Thirty-two patients presented cortical venous stroke; 21 of them had involvement of the dorsomedial venous system, six had a defect in the posteroinferior venous group, and five had a defect in the anteroinferior venous group. Thirteen patients presented simultaneous involvement of the superficial and deep venous system; seven with a defect in the parietal and internal cerebral veins (three with involvement of vein of Gallen), four with a defect in the temporooccipital (vein of Labbé) and basal vein of Rosenthal, two with a deficit in the anterior frontotemporal and uncal-pterygoid venous system. One patient had deep venous thrombosis primarily localized to the thalami bilaterally and the basal ganglia on the right because of occlusion of the thalamostriate veins. The main presenting symptoms of CDVT were headache, focal neurologic signs, partial complex or secondary generalized seizures, and consciousness disturbances in those with deep venous thrombosis, presented alone or in combination at onset. CDVT was more than twofold more frequent in women than in men. Pregnancy, puerperium, oral contraceptive use, and infections were the most common predisposing factors. CONCLUSION Computerized tomography, conventional MRI and diffusion-weighted imaging showing ischemic and/or hemorrhagic lesion that does not follow the boundary of classical arterial boundaries without signs of sinus thrombosis, and partial or generalized seizures followed by focal neurologic signs may predict CDVT. The outcome of patients with cortical venous stroke was good, but not in those with cortical plus deep venous infarction.
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Affiliation(s)
- A Sagduyu
- Stroke Unit, Department of Neurology, Ege University School of Medicine, Izmir, Turkey
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Masuhr F, Busch M, Amberger N, Ortwein H, Weih M, Neumann K, Einhäupl K, Mehraein S. Risk and predictors of early epileptic seizures in acute cerebral venous and sinus thrombosis. Eur J Neurol 2006; 13:852-6. [PMID: 16879295 DOI: 10.1111/j.1468-1331.2006.01371.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We assessed the risk and determined predictors of early epileptic seizures (ES) in patients with acute cerebral venous and sinus thrombosis (CVST). A prospective series of 194 consecutive patients with acute CVST admitted to neurological wards in two German university hospitals was analysed for frequency of ES and in-hospital mortality. Demographic, clinical and radiological characteristics during the acute stage were retrospectively analysed for significant association with ES in univariate and multivariate analyses. During the acute stage, 19 patients (9.8%) died. Early symptomatic seizures were found in 86 patients (44.3%). Status epilepticus occurred in 11 patients (12.8%) of whom four died. Amongst patients with epileptic seizures, mortality was three times higher in those with status than in those without (36.4% and 12%, respectively). In multivariate logistic regression analysis, motor deficit [odds ratio (OR) 5.8; 95% CI 2.98-11.42; P < 0.001], intracranial haemorrhage (OR 2.8; 95% CI 1.46-5.56; P = 0.002) and cortical vein thrombosis (OR 2.9; 95% CI 1.43-5.96; P = 0.003) were independent predictors of early epileptic seizures. Status epilepticus was an important source of morbidity and early mortality in patients with CVST in this study. Patients with focal motor deficits, cortical vein thrombosis and intracranial haemorrhage carried the highest risk for ES. Prophylactic antiepileptic treatment may be an option for these patients.
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Affiliation(s)
- F Masuhr
- Department of Neurology, Charité University Hospital, Humboldt-University Berlin, and Centre of Stroke Research, Berlin, Germany.
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18
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Kwan J, Guenther A. Antiepileptic drugs for the primary and secondary prevention of seizures after intracranial venous thrombosis. Cochrane Database Syst Rev 2006:CD005501. [PMID: 16856099 DOI: 10.1002/14651858.cd005501.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intracranial venous thrombosis (ICVT) commonly presents with seizures in the acute period, and some patients may develop recurrent seizures in the long term. The prophylactic use of antiepileptic drugs (AEDs) for the management of post-ICVT seizures is controversial and there is currently no consensus on the optimal management of post-ICVT seizures. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures related to ICVT.(1) Do AEDs reduce the likelihood of seizures in patients who have had an ICVT but have not had a seizure?(2) Do AEDs reduce the likelihood of further seizures in patients who have had an ICVT and at least one seizure? SEARCH STRATEGY We aimed to identify relevant studies in the Cochrane Epilepsy Group and Cochrane Stroke Group Trials Registers. We also undertook specialised searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE, and checked the reference lists of articles retrieved from the searches. SELECTION CRITERIA We considered all randomised and quasi-randomised controlled trials in which patients were assigned to a treatment group (that is, receiving at least one AED) or control group (receiving placebo or no drug). DATA COLLECTION AND ANALYSIS Both review authors independently screened and assessed the methodological quality of the studies. If studies had been included, then one review author would have extracted the data and the other would have checked the extracted data. MAIN RESULTS No relevant studies were found. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of antiepileptic drugs for the primary or secondary prevention of seizures related to intracranial venous thrombosis. Well-designed randomised controlled trials are urgently needed to inform practice.
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Affiliation(s)
- J Kwan
- University of Southampton, Elderly Care Research Unit, Level E (MP 807), Southampton General Hospital, Tremona Road, Southampton, Hants, UK SO16 6YD.
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Einhäupl K, Bousser MG, de Bruijn SFTM, Ferro JM, Martinelli I, Masuhr F, Stam J. EFNS guideline on the treatment of cerebral venous and sinus thrombosis. Eur J Neurol 2006; 13:553-9. [PMID: 16796579 DOI: 10.1111/j.1468-1331.2006.01398.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed due to the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence, but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation should be treated either with body weight-adjusted subcutaneous LMWH or dose-adjusted intravenous heparin (good practice point). Concomitant intracranial haemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulation after the acute phase is unclear. Oral anticoagulation may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with 'mild' hereditary thrombophilia. Indefinite anticoagulation (AC) should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and 'severe' hereditary thrombophilia (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Antioedema treatment (including hyperventilation, osmotic diuretics and craniectomy) should be used as life saving interventions (good practice point).
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Affiliation(s)
- K Einhäupl
- Department of Neurology, Charité, Humboldt-University Berlin, Germany.
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20
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Celebisoy N, Sagduyu A, Atac C. Alexia without agraphia following cerebral venous thrombosis associated with protein C and protein S deficiency. Clin Neurol Neurosurg 2005; 108:52-5. [PMID: 16311147 DOI: 10.1016/j.clineuro.2004.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2004] [Revised: 09/13/2004] [Accepted: 11/03/2004] [Indexed: 10/26/2022]
Abstract
A 26-year-old right handed female was admitted to hospital with right homonymous hemianopia associated with alexia without agraphia. Her cranial magnetic resonance imaging and magnetic resonance angiography revealed a left occipital venous infarction due to thrombosis of the left transverse, sigmoid sinuses and the left internal jugulary vein. The underlying conditions were protein C and protein S deficiency associated with the use of oral contraceptives. To our knowledge, alexia without agraphia has never been described due to a venous infarction associated with hereditary thrombophilia in the literature.
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Affiliation(s)
- Nese Celebisoy
- Department of Neurology, Ege University Medical School Hospital, Bornova, Izmir, Turkey.
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21
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Appenzeller S, Zeller CB, Annichino-Bizzachi JM, Costallat LTL, Deus-Silva L, Voetsch B, Faria AV, Zanardi VA, Damasceno BP, Cendes F. Cerebral venous thrombosis: influence of risk factors and imaging findings on prognosis. Clin Neurol Neurosurg 2005; 107:371-8. [PMID: 16023530 DOI: 10.1016/j.clineuro.2004.10.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2004] [Revised: 09/07/2004] [Accepted: 10/04/2004] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate imaging findings, risk factors and outcome in patients with cerebral venous thrombosis (CVT). METHODS Records of all patients with diagnosis of CVT between 1992 and 2002 were reviewed. Patients with CNS infection and with CVT secondary to invasive procedures were excluded. Inherited and acquired thrombophilia were searched in all patients. RESULTS Twenty-four patients (18 women, 6 men) with mean age of 29.5 years (range 3-48 years) were identified. Mean follow-up was 44 months (range 11-145 months). The most common symptoms were headache (75%), vomiting (33%) and impairment of consciousness (21%). Probable causes of CVT could be determined in 21 (88%) patients: pregnancy or puerperium in six (25%), oral contraceptive use in four (17%), head trauma in two (8%), mastoiditis in one (4%), nephrotic syndrome in one (4%), systemic disease in three (13%), and inherited thrombotic risk factors in four (17%) patients. CVT associated with pregnancy, puerperium and use of oral contraceptives had a significant better outcome than CVT caused by inherited thrombophilia or systemic disease (OR=14.4; p=0.02). CT scans were abnormal in 15 (62.5%) patients and MRI with gadolinium was abnormal in all. Those with parenchymal involvement had neurological sequelae during follow-up. All were treated with heparin followed by oral anticoagulants, and none had new or worsening of pre-existing intracerebral hemorrhage. CONCLUSION MRI is superior to conventional CT for diagnosing CVT. Patients with parenchymal lesions, thrombophilia and antiphospholipid syndrome had greater risk to be left with neurological sequelae. Anticoagulant therapy did not predispose to further intracerebral hemorrhage.
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Affiliation(s)
- Simone Appenzeller
- Department of Internal Medicine, Rheumatology Unit, State University of Campinas, UNICAMP, Brazil
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22
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Urban PP, Müller-Forell W. Clinical and neuroradiological spectrum of isolated cortical vein thrombosis. J Neurol 2005; 252:1476-81. [PMID: 16021356 DOI: 10.1007/s00415-005-0893-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Revised: 03/24/2005] [Accepted: 04/14/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Isolated cortical vein thrombosis is only rarely diagnosed, although it may commonly be overlooked. RESULTS We report on four patients with this diagnosis who all presented with focal sensorimotor seizures. The diagnosis was made by a typical CT and MRI-pattern, which is described in detail. CONCLUSIONS The prognosis was excellent in all patients and the treatment options are discussed.
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Affiliation(s)
- Peter P Urban
- Dept. of Neurology, University of Mainz, Langenbeckstr. 1, 55101 Mainz, Germany.
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23
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Canhão P, Ferro JM, Lindgren AG, Bousser MG, Stam J, Barinagarrementeria F. Causes and predictors of death in cerebral venous thrombosis. Stroke 2005; 36:1720-5. [PMID: 16002765 DOI: 10.1161/01.str.0000173152.84438.1c] [Citation(s) in RCA: 227] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE The causes of death of patients with cerebral venous thrombosis (CVT) have not been systematically addressed in previous studies. We aimed to analyze the causes and predictors of death during the acute phase of CVT in the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) to identify preventable or treatable causes. METHODS ISCVT is a multinational, prospective, observational study including 624 patients with CVT occurring between May 1998 and May 2001, in which 27 patients (4.3%) died during the acute phase, 21 (3.4%) within 30 days from symptom onset. Inclusion forms and a questionnaire assessing the causes of death were analyzed. A logistic regression analysis was performed to identify the predictors of death within 30 days from symptom onset of CVT. RESULTS Median time between onset of symptoms and death was 13 days and between diagnosis and death, 5 days. Causes of death were mainly transtentorial herniation due to a unilateral focal mass effect (10 patients) or to diffuse edema and multiple parenchymal lesions (10 patients). Independent predictors of death were coma (odds ratio [OR], 8.8; 95% confidence interval [CI], 2.8 to 27.7), mental disturbance (OR, 2.5; 95% CI 0.9 to 7.3), deep CVT thrombosis (OR, 8.5; 95% CI, 2.6 to 27.8), right intracerebral hemorrhage (OR, 3.4; 95% CI, 1.1 to 10.6), and posterior fossa lesion (OR, 6.5; 95% CI, 1.3 to 31.7). Worsening of previous focal or de novo focal deficits increased the risk of death. CONCLUSIONS The main causes of acute death were neurologic, the most frequent mechanism being transtentorial herniation.
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Affiliation(s)
- Patrícia Canhão
- Department of Neurosciences and Mental Health, Hospital Santa Maria, 1649-035 Lisbon, Portugal.
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24
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Grunwald IQ, Politi M, Holst B, Dorenbeck U, Papanagiotou P, Reith W. [Sinus and venous thrombosis--differential diagnosis of acute stroke]. Radiologe 2005; 45:471-8. [PMID: 15871002 DOI: 10.1007/s00117-005-1223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thrombosis of the cerebral veins and sinus is a rare, but important cause of stroke. The clinical picture varies. This contribution addresses the etiology, clinical picture, imaging procedures, and therapeutic options.
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Affiliation(s)
- I Q Grunwald
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes Homburg/Saar.
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25
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26
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Abstract
Cerebral venous thrombosis is an infrequent condition characterized by extreme variability in its clinical presentation and mode of onset. The combination of magnetic resonance imaging and magnetic resonance angiography is currently the best method for diagnosis. The proportion of cases of unknown etiology remains high. The prognosis, although better than previously thought, remains unpredictable. Treatment, which should be started as soon as the diagnosis is established, consists of reversing the underlying cause when known, control of seizures and intracranial hypertension, and the use of antithrombotics. Heparin should be the first-line antithrombotic agent. Recent studies have confirmed its safety even in patients with hemorrhagic parenchymal lesions. Local thrombolysis is indicated in the very rare cases that deteriorate despite adequate anticoagulation. Cerebrospinal fluid diversion or optic nerve fenestration is used for vision-threatening papilledema when intracranial pressure control is difficult.
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27
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28
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Abstract
Because of its wide range of presentations, its highly variable mode of onset, its numerous causes, and its unpredictable outcome, cerebral venous thrombosis (CVT) remains a diagnostic and therapeutic challenge. Treatment of CVT consists primarily of symptomatic treatment of seizures and intracranial hypertension, antithrombotics, and etiologic treatment whenever possible. Heparin remains the first line of treatment for CVT; although its systematic use remains debated, recent studies have confirmed its safety even in patients with large hemorrhagic infarctions. The addition of local thrombolysis is indicated for patients with clinical worsening related to extension of the venous thrombosis, despite adequate anticoagulation and optimal symptomatic and etiologic treatment. In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation and eventually thrombolysis, even when the clinical situation seems desperate. New techniques using mechanical devices disrupting the clot may be used in addition to thrombolysis in rare cases. Ventricular drainage is indicated in cases of cerebellar infarction or deep venous thrombosis associated with hydrocephalus. Decompressive craniotomy may be performed acutely in patients with untractable intracranial hypertension and herniation.
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Affiliation(s)
- Valérie Biousse
- Neuro-ophthalmology Unit, Emory Eye Center, 1365-B Clifton Road, Atlanta, GA 30322, USA.
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29
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Abstract
Because of its wide range of presentations, its highly variable mode of onset, its numerous causes, and its unpredictable outcome, cerebral venous thrombosis (CVT) remains a diagnostic and therapeutic challenge. Treatment of CVT consists primarily of symptomatic treatment of seizures and intracranial hypertension, antithrombotics, and etiologic treatment whenever possible. Heparin remains the first line of treatment for CVT; although its systematic use remains debated, recent studies have confirmed its safety even in patients with large hemorrhagic infarctions. The addition of local thrombolysis is indicated for patients with clinical worsening related to extension of the venous thrombosis, despite adequate anticoagulation and optimal symptomatic and etiologic treatment. In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation and eventually thrombolysis, even when the clinical situation seems desperate. New techniques using mechanical devices disrupting the clot may be used in addition to thrombolysis in rare cases. Ventricular drainage is indicated in cases of cerebellar infarction or deep venous thrombosis associated with hydrocephalus. Decompressive craniotomy may be performed acutely in patients with untractable intracranial hypertension and herniation.
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Affiliation(s)
- Valérie Biousse
- Neuro-ophthalmology Unit, Emory Eye Center, 1365-B Clifton Road, Atlanta, GA 30322, USA.
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30
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Abstract
A 19-year-old woman presented with frontal headaches, papilledema, and binocular horizontal double vision due to a left VI nerve palsy. MRV demonstrated sagittal sinus and bilateral transverse sinus thrombosis. The clinical and neuro-radiologic signs resolved after anticoagulation.
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Affiliation(s)
- Ivan G Castillo
- Neuro-Ophthalmology Service, Wills Eye Hospital, Thomas Jefferson Medical College, Philadelphia, PA 19107, USA
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Abstract
Cranial sinovenous disorders comprise a disparate group of illnesses affecting one or more intracranial venous sinuses and cerebral veins, alone or in combination, due to a variety of causes. As medical knowledge advances, fewer and fewer patients have an "idiopathic" diagnosis, with causes clarified in an ever-increasing number of patients. These not only include the long-known puerperal, marantic, infective, and traumatic causes, but in recent years, also a variety of congenital and acquired coagulation disorders, such as protein S, protein C, and antithrombin III deficiency. Certain sinuses are preferentially involved with certain causative entities; for example, cavernous and lateral sinuses are more frequently occluded in relation to infectious processes, either directly or as a parameningeal focus, whereas the superior sagittal sinus is most often occluded by trauma, tumor, or coagulopathy. The optimal treatment of sinovenous occlusion depends on establishing the cause with alacrity, because delays in diagnosis may lead to life-threatening hyperpyrexia, elevations in intracranial pressure, venous infarctions, seizures, coma, and death. However, because up to a third of patients with nonseptic occlusions may survive untreated, with few residua, controversy persists regarding optimal management. There has been a dearth of randomized, prospective treatment trials in this group of disorders. The little data that exist suggest that rapid control of infection, seizure prophylaxis, and anticoagulation must be achieved early so as to prevent progression of thrombosis and intracranial venous hypertension. In recent years, direct retrograde venous thrombolysis has become increasingly available, and has produced such remarkable results that it is likely soon to become the primary treatment of choice for the nontraumatic or nontumoral occlusions.
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Affiliation(s)
- Ferdinando S. Buonanno
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Heckmann JG, Tomandl B, Erbguth F, Neidhardt B, Zingsem H, Neundörfer B. Cerebral vein thrombosis and prothrombin gene (G20210A) mutation. Clin Neurol Neurosurg 2001; 103:191-3. [PMID: 11532562 DOI: 10.1016/s0303-8467(01)00127-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recently, prothrombin gene mutation G20210A has been associated with elevated thrombosis risk and rarely with cerebral vein thrombosis (CVT). Three patients are described who had this genetic predisposition and who developed CVT in an unusual constellation with other factors. In the first patient, the intake of valproic acid (VPA) may have played an aggravating role in the development of CVT; in the second patient diagnosis of coagulation disorder was made during pregnancy consultation 6 years after CVT; in the third patient the CVT occurred at the age of 78 years. In patients with CVT, coagulation-examinations should include tests for the prothrombin gene (G20210A) mutation.
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Affiliation(s)
- J G Heckmann
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Dzialo AF, Black-Schaffer RM. Cerebral venous thrombosis in young adults: 2 Case reports. Arch Phys Med Rehabil 2001; 82:683-8. [PMID: 11346848 DOI: 10.1053/apmr.2001.19244] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cerebral venous thrombosis (CVT) is a disease with multiple known etiologies that present with a remarkably wide spectrum of clinical signs and symptoms. We present a case of a 34-year-old man with a history of meningeal symptoms for 1 week after receiving a lumbar injection for lower back pain. He subsequently developed dense right hemiplegia and global aphasia. Head magnetic resonance imaging revealed superior sagittal sinus thrombosis. The patient was started on intravenous heparin but deteriorated neurologically. Urokinase infusion directly into the superior sagittal sinus was performed, with striking functional and neurologic improvement. Lupus anticoagulant was positive. We also present the case of a 24-year-old pregnant woman who developed an acute onset of meningeal symptoms and resultant left hemiparesis. Head magnetic resonance angiography revealed thrombosis of right transverse and sigmoid sinuses. Protein S deficiency was found. She was started on intravenous heparin, then enoxaparin, with improvement in symptoms. These cases demonstrate that CVT can be a cause of stroke in young patients with hypercoagability disorders, and a heightened awareness of CVT will promote optimal medical care and functional outcomes. Excellent functional recovery is likely with early recognition and treatment of the underlying etiology, as well as successful lysis of the clot.
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Affiliation(s)
- A F Dzialo
- Department of Physical Medicine and Rehabilitation, Tufts University School of Medicine, Boston, MA, USA
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34
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Buccino G, Scoditti U, Pini M, Menozzi R, Piazza P, Zuccoli P, Mancia D. Loco-regional thrombolysis in the treatment of cerebral venous and sinus thrombosis: report of two cases. Acta Neurol Scand 2001; 103:59-63. [PMID: 11153890 DOI: 10.1034/j.1600-0404.2001.00058.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although intravenous (i.v.) heparin is widely used as the first line treatment for cerebral venous and sinus thrombosis (CVST), the most appropriate therapy for this disease is still controversial. We report 2 cases of CVST who were successfully treated by means of loco-regional thrombolysis with urokinase. In the first case we chose this treatment instead of i.v. heparin because clinical conditions of the patient appeared critical for life on hospital admission; in the second case loco-regional thrombolysis was performed because a full-dose heparin treatment over 8 days failed to improve the clinical picture of the patient. In the literature, there are no established criteria for the use of loco-regional thrombolysis in CVST. On the basis of our own experience and few previous reports on the matter, we suggest that loco-regional thrombolysis should be considered an appropriate treatment for CVST when patients are at life risk, when an involvement of deep cerebral veins is present or when, after full heparinization, patients are doing poorly clinically.
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Affiliation(s)
- G Buccino
- Institute of Neurology, University of Parma, Italy
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35
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Abstract
Cerebral venous thrombosis is a rare disorder with highly variable and nonspecific clinical presentations. For these reasons, specific treatment should be given only when the diagnosis has been firmly established. Etiologic diagnosis should begin in the emergency department to identify underlying conditions that require specific treatment. The mainstay of treatment is anticoagulation with heparin, even in the case of cerebral hemorrhage, followed as soon as possible by oral anticoagulant administration. The optimal duration of oral anticoagulation has not been established. By analogy with systemic venous thrombosis, it should be prolonged 3 to 6 months. When a high risk of recurrence is present, treatment should be continued until the risk disappears. In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation even when the clinical situation seems desperate. For the same reason, aggressive treatment of intracranial hypertension and seizures or status epilepticus is warranted. Screening for extraneurologic venous thrombosis should be done by means of clinical examination and, if necessary, specific imaging procedures. Local thrombolysis is not yet of proven efficacy and safety. It can be used in patients with clinical worsening related to documented extension of the venous thrombosis despite anticoagulation and in the absence of cerebral hematoma. Surgical treatment is limited to external ventricular drainage and suboccipital craniotomy in the very rare cases of cerebellar vein thrombosis with edematous cerebellar infarct.
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Affiliation(s)
- P Niclot
- Service de Neurologie, Hôpital Lariboisière, 2 Rue A. Paré, 75010 Paris, France
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36
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Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke 2000; 31:1274-82. [PMID: 10835444 DOI: 10.1161/01.str.31.6.1274] [Citation(s) in RCA: 247] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The study goal was to identify potential risk factors for peripartum or postpartum stroke and intracranial venous thrombosis. METHODS Data from the Healthcare Cost and Utilization Project were analyzed for the years 1993 and 1994. Observed values were weighted with poststratification discharge weights to project to the universe of all discharges from community hospitals located in the United States. Nationally representative estimates of risk were calculated on the basis of age, race, mode of delivery, income, third-party payer, hospital size, hospital ownership, hospital location (rural versus urban), hospital teaching status, census region, and presence of specific complications. Multivariate models were developed with the use of logistic regression. RESULTS Among 1 408 015 sampled deliveries, there were 183 observed cases of peripartum stroke and 170 cases of peripartum intracranial venous thrombosis in 17 states in the United States in 1993 and 1994. There were an estimated 975 cases of stroke and 864 cases of intracranial venous thrombosis during pregnancy and the puerperium in the United States among 7 463 712 deliveries during 1993 and 1994, for estimated risks of 13.1 cases of peripartum stroke and 11.6 cases of peripartum intracranial venous thrombosis per 100 000 deliveries. Multivariate analysis showed that the following were strongly and significantly associated with both peripartum and postpartum stroke: cesarean delivery; fluid, electrolyte, and acid-base disorders; and hypertension. Covariates that were strongly and significantly associated with both peripartum and postpartum intracranial venous thrombosis included cesarean delivery, hypertension, and infections other than pneumonia and influenza. CONCLUSIONS Pregnancy-related hypertension and cesarean delivery are important risk factors for both stroke or intracranial venous thrombosis.
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Affiliation(s)
- D J Lanska
- Department of Veterans Affairs Medical Center, Great Lakes Health Care System, Tomah, WI 54660, USA.
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Frey JL, Muro GJ, McDougall CG, Dean BL, Jahnke HK. Cerebral venous thrombosis: combined intrathrombus rtPA and intravenous heparin. Stroke 1999; 30:489-94. [PMID: 10066841 DOI: 10.1161/01.str.30.3.489] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We chose to evaluate the safety and efficacy of combined intrathrombus rtPA and intravenous heparin in cerebral venous thrombosis (CVT). METHODS We treated 12 patients with symptoms of 1 to 40 days' duration (eg, headache, somnolence, focal deficits, seizures, and nausea and vomiting). Pretreatment MRI disclosed subtle hemorrhagic venous infarction in 4 patients, obvious hemorrhagic infarction in 2, small parenchymal hemorrhage from recent pallidotomy in 1, and no focal lesion in 5. Magnetic resonance venography and contrast venography identified thrombi in the superior sagittal sinus (SSS) in 3 patients; transverse/sigmoid sinus (TS/SS) in 2; SSS and both TS/SS in 1; SSS and 1 TS/SS in 5; and SSS, 1 TS/SS, and straight sinus in 1 patient. A loading dose of rtPA was instilled throughout the clot at 1 mg/cm, followed by continuous intrathrombus infusion at 1 to 2 mg/h. Intravenous heparin was infused concomitantly. RESULTS Flow was restored completely in 6 patients and partially in 3, with a mean rtPA dose of 46 mg (range, 23 to 128 mg) at a mean time of 29 hours (range, 13 to 77 hours). Symptoms improved in these 9 patients concomitantly with flow restoration. Flow could not be restored in 3 patients. In 1 of them, treatment was stopped when little progress had been made, and fibrinogen level dropped to 118 mg/dL. In the other 2 patients, hemorrhagic worsening occurred, and treatment was abbreviated after initial rtPA dosing. In 1 of these, the hematoma was evacuated. CONCLUSIONS Our experience with intrathrombus rtPA in conjunction with intravenous heparin in patients with CVT is encouraging. This therapy should probably be regarded as unsafe in patients with obvious hemorrhage. Time to restore flow may be faster than with urokinase (an average of 71 hours has been reported for 29 documented patients). Further evaluation of rtPA with heparin in CVT is warranted.
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Affiliation(s)
- J L Frey
- Barrow Neurological Institute, Phoenix, AZ, USA
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Weih M, Mehraein S, Valdueza JM, Einhäupl KM, Vetter B, Kulozik AE. Coincidence of factor V Leiden mutation and a mutation in the prothrombin gene at position 20210 in a patient with puerperal cerebral venous thrombosis. Stroke 1998; 29:1739-40. [PMID: 9707222 DOI: 10.1161/01.str.29.8.1739] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Biousse V, Conard J, Brouzes C, Horellou MH, Ameri A, Bousser MG. Frequency of the 20210 G-->A mutation in the 3'-untranslated region of the prothrombin gene in 35 cases of cerebral venous thrombosis. Stroke 1998; 29:1398-400. [PMID: 9660394 DOI: 10.1161/01.str.29.7.1398] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A novel sequence variation in the 3'-untranslated region of the prothrombin (factor II) gene (nucleotide 20210 G-->A) has been recently described as a risk factor for deep vein thrombosis and pulmonary embolism. It is found in approximately 1% to 4% of healthy subjects. We studied the frequency of this factor II variant in patients with cerebral venous thrombosis. METHODS The 20210A allele of the prothrombin gene was studied after DNA extraction, polymerase chain reaction amplification, and HindIII digestion in 35 patients with magnetic resonance imaging or angiographically confirmed cerebral venous thrombosis (23 women and 12 men, aged 11 to 71 years). RESULTS Two patients (5.7%) had the 20210A allele of the prothrombin gene. Both had other risk factors for thrombosis (use of oral contraceptives and of intrathecal steroids). CONCLUSIONS The 20210A allele of the prothrombin gene in association with other prothrombic factors may increase the risk of cerebral venous thrombosis, but case-control studies will be necessary to clarify these associations.
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Affiliation(s)
- V Biousse
- Service de Neurologie, Hôpital Lariboisière, Paris, France.
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Weih M, Vetter B, Ziemer S, Mehraein S, Valdueza JM, Koscielny J, Kulozik AE, Einhäupl KM. Increased rate of factor V Leiden mutation in patients with cerebral venous thrombosis. J Neurol 1998; 245:149-52. [PMID: 9553844 DOI: 10.1007/s004150050195] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We investigated the association between cerebral venous thrombosis and hereditary resistance to activated protein C (APC) in 12 consecutive German patients with non-fatal cerebral venous thrombosis and in 187 controls without a history of thrombotic disorder. Three patients (25%) had a mutation in the factor V Leiden gene against only one subject in the control group. This difference was significant (P < 0.05), with an odds ratio of 11.7 (1.5-87; 95% confidence interval). Two patients carrying the mutation had additional common risk factors for thrombosis, and 2 had a positive family history of thromboembolism. We conclude that inherited APC resistance by a mutation in factor V Leiden is an important risk factor in non-fatal cerebral venous thrombosis. We recommend testing for APC resistance and, if abnormal for factor V Leiden mutation in patients with cerebral venous thrombosis.
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Affiliation(s)
- M Weih
- Department of Neurology, Charité and Virchow Hospital, Humboldt-University, Berlin, Germany.
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Scoditti U, Buccino GP, Pini M, Pattacini C, Mancia D. Risk of acute cerebrovascular events related to low oestrogen oral contraceptive treatment. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1998; 19:15-9. [PMID: 10935854 DOI: 10.1007/bf03028806] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
To establish if an association exists between use of oral contraceptives (OC) and the occurrence of cerebral arterial thromboembolism, cerebral venous thrombosis and retinal vein/artery thrombosis, we identified all women aged 15-44 years resident in the province of Parma, Italy, who were hospitalized because of a documented cerebral or retinal thromboembolic event during the period 1989-1993. The numbers of users and nonusers of OC were estimated from drug sale data and demographic statistics for the province. There were 21 cases of cerebral arterial thromboembolism during the study period: 10 in OC users and 11 in nonusers, for an estimated incidence rate of 1.70 and 0.35 per 10,000 woman-years OC of use and nonuse, respectively (RR=4.8, 95% CI = 1.8-9.0). Eight cases of cerebral venous thrombosis were observed: 6 in OC users and 2 in nonusers (both in puerperium), for an incidence rate of 1.00 and 0.06 per 10,000 woman-years, respectively (RR=16.7, 95% CI = 3.3-81.4). Finally, 13 cases of retinal vein/artery thrombosis were found: 1 in OC users and 12 in nonusers, for an incidence rate of 0.17 and 0.37 per 10,000 woman-years, respectively (RR=0.46, 95% CI = 0.06-3.7). In our population study the use of low oestrogen OC was associated with an increased risk of cerebral venous thrombosis and ischemic stroke, but not of retinal vein/artery thrombosis.
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Affiliation(s)
- U Scoditti
- Institute of Neurology, University of Parma, Italy
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Deschiens MA, Conard J, Horellou MH, Ameri A, Preter M, Chedru F, Samama MM, Bousser MG. Coagulation studies, factor V Leiden, and anticardiolipin antibodies in 40 cases of cerebral venous thrombosis. Stroke 1996; 27:1724-30. [PMID: 8841318 DOI: 10.1161/01.str.27.10.1724] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral venous thrombosis (CVT) is an infrequent condition with a large variety of causes. However, in 20% to 35% of cases, no cause is found. We studied coagulation parameters, including activated protein C resistance associated with factor V gene mutation (factor V Leiden) and anticardiolipin antibodies, in a large series of patients with CVT with or without identified cause or risk factor. METHODS Forty patients (30 women and 10 men) aged 19 to 71 years (mean age, 36.2 years) with CVT diagnosed by angiography and/or MRI were studied 1 to 18 years after thrombosis. No known cause was found in 10 idiopathic cases. Coagulation studies included the following tests: fibrinogen, antithrombin, protein C, protein S, plasminogen, anticardiolipin antibodies, activated protein C resistance, and factor V Leiden. RESULTS Six cases of thrombophilia (15%) were found: 1 protein C deficiency, 1 protein S deficiency, and 4 activated protein C resistance with heterozygous factor V Leiden mutation (10%). Only 1 case (protein S deficiency) was found in the group of 10 patients with idiopathic CVT. In the other 5, there was another cause or risk factor. Three patients (8%) had increased anticardiolipin antibodies: 1 with systemic lupus and 2 with primary antiphospholipid syndrome; 2 of these 3 patients also had factor V Leiden mutation. CONCLUSIONS Although present in a number of CVT cases, acquired (anticardiolipin) or congenital varieties of thrombophilia (factor V Leiden being the most frequent) are almost invariably associated with other predisposing factors. This suggests that (1) these abnormalities should be looked for in patients with CVT, whether a cause is found or not, and (2) their presence should not deter the search for other potential causes. The detection of such abnormalities has major practical consequences on the long-term management of patients to prevent further thrombotic episodes.
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Affiliation(s)
- M A Deschiens
- Service de Neurologie Hôpital Saint-Antoine, Paris, France
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