Superior sagittal sinus thrombosis and pulmonary embolism: a syndrome rediscovered

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

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

Visual loss after long-haul flight

BACKGROUND

Deep cerebral venous sinus thrombosis is a reversible yet potentially serious thromboembolic event. A number of reports suggest a relationship between long-haul flights and thromboembolic events, mainly deep venous thrombosis (DVT) and pulmonary embolism (PE). It is rarely reported to cause deep cerebral venous sinus thrombosis. We report a case of a bilateral papilledema after long-haul flight secondary to deep cerebral venous sinus thrombosis with subsequent complete recovery post corticosteroid and anticoagulant therapy.

CASE

A case of a 21-year-old woman with no known medical illness who presented with gradual painless bilateral visual loss is described. She had a history of travelling on a long-haul flight 3 weeks prior to presentation. Examination showed presence of bilateral papilloedema, no vitritis, choroiditis and retinitis. Blood investigations showed raised international normalised ratio (INR). Otherwise, workup for infectious causes of optic disc swelling, connective tissue disease screening were normal. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain showed loss of flow signal in the right transverse sinus and the left sigmoid sinus. Blood workup for preexisting hypercoagulable state was normal. She was diagnosed with deep cerebral venous sinus thrombosis and showed complete recovery with oral corticosteroid and anticoagulant therapy.

CONCLUSION

Deep cerebral venous sinus thrombosis is a potentially serious consequence of long-haul flights. A high index of suspicion along with radiological techniques is needed for early detection and initiation of anticoagulation for this reversible condition.

Rare presentation of iron deficiency anaemia with cerebral venous sinus thrombosis in a middle-aged woman

This is a case of a female patient presented with a mild headache associated with recurrent episodes of nausea and vomiting, confusion and right-sided hemiparesis, diagnosed of haemorrhagic venous infarction from the thrombosis of left transverse and sigmoid sinus and probably the left vein of Labbe. She had severe microcytic hypochromic anaemia due to iron deficiency, without any other risk factors for cerebral venous thrombosis such as trauma history, infections, coagulation disorders or autoimmune diseases. She had a good prognosis after iron supplementation and anticoagulation therapy.

Venous Thrombotic Recurrence After Cerebral Venous Thrombosis

Background and Purpose—

After cerebral venous thrombosis (CVT), the risk of venous thrombotic events was estimated at 2% to 3% for a new CVT and 3% to 8% for extracranial events. However, because of the paucity of prospective studies, the clinical course of CVT is still largely unknown. We aimed to prospectively evaluate the rate of thrombosis recurrence in a cohort of CVT patients with a long-term follow-up and to detect predisposing factors for recurrence.

Methods—

Consecutive CVT patients with complete clinical, radiological, biological, and genetic data were systematically followed up. New venous thrombotic events were detected after hospital readmission and imaging confirmation.

Results—

One-hundred eighty-seven patients (mean age 45±18 years, 67% women) with angiographically confirmed CVT were included. Cause was found in 73% of patients. Coagulation abnormality and JAK2 gene mutation were detected in 20% and 9%, respectively. Median follow-up length was 73 months (range 1–247 months). Mean duration of the oral anticoagulant treatment was 14 months. Mortality rate was 2.5% per year, with 2% in-hospital mortality. During follow-up, CVT reoccurred in 6 patients, whereas 19 subjects had a symptomatic extracranial venous thrombotic event, with cumulative venous thrombotic recurrence rates of 3% at 1 year, 8% at 2 years, 12% at 5 years, and 18% at 10 years. A previous venous thrombotic event (hazard ratio, 2.8; P =0.018), presence of cancer or malignant hemopathies (hazard ratio, 3.2; P =0.039), and unknown CVT causes (hazard ratio, 2.81; P =0.024) were independently associated with recurrence.

Conclusions—

In our cohort of CVT patients followed on average for >6 years, subjects with a previous venous thrombotic event, cancer/malignant hemopathies, and unknown CVT causes were found to be at higher risk of recurrence.

Cerebral Venous Sinus Thrombosis: Prognostic and Therapeutic Significance of an Early Radiologic Diagnosis

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.

Cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults and children. In contrast to venous thromboembolism, women are affected three times more often than men. Baseline symptoms can vary considerably between patients, but most present with headache, seizures, or focal neurological deficits. Patients can be diagnosed with magnetic resonance imaging, computerized tomography-venography, or catheter angiography, although the latter is rarely required anymore. Approximately 30-50% of patients have an intracerebral hemorrhage, which can range from a small juxtacortical hemorrhage to large space-occupying lesions. Based on limited evidence from clinical trials, the primary therapy for CVT is anticoagulation with heparin. Uncontrolled studies have shown promising results for the use of endovascular treatment in severely affected patients, but these studies require confirmation in prospective clinical trials. In patients who develop clinical and radiological signs of impending herniation decompressive surgery can be both life saving and result in a good functional outcome.

Cerebral venous sinus thrombosis: update on diagnosis and management

Cerebral venous thrombosis (CVT) is less frequent than ischemic stroke or intracerebral haemorrhage. Its incidence is comparable to that of acute bacterial meningitis in adults. Because of the increased use of magnetic resonance imaging (MR) for investigating patients with acute and subacute headaches and new onset seizures, CVT are now being diagnosed with increasing frequency. CVT have a more varied clinical presentation than other stroke types as they rarely present as a stroke syndrome. Their most frequent presentations are isolated headache, intracranial hypertension syndrome, seizures, a focal lobar syndrome and encephalopathy. The confirmation of the diagnosis of CVT relies on the demonstration of thrombi in the cerebral veins and/or sinuses by MR/MR venography or veno CT. The more frequent risk factors for CVT are prothrombotic conditions, either genetic or acquired, oral contraceptives, puerperium and pregnancy, infection and malignancy. The prognosis of CVT is in general favourable, as only around 15% of the patients remain dependent or die. The main intervention in the acute is anticoagulation with either low molecular weight or unfractionated heparin. In patients in severe condition on admission or who deteriorate despite anticoagulation, local thrombolysis or thrombectomy is an option. Decompressive surgery is life-saving in patients with large venous infarcts or haemorrhage. After the acute phase patients remain anticoagulated for a variable period of time, depending on their inherent thrombotic risk. CVT patients may experience recurrent seizures. Prophylaxis with antiepileptics is recommended after the first seizures, in particular in those with hemispheric lesions. There are several ongoing multicentre registries sand trials which will improve evidence-based management of CVT in the near future.

Cerebral Venous Thrombosis and Pulmonary Embolism with Prothrombin G20210A Gene Mutation

A 25-year-old man presented with symptoms of syncope, cough, headache and hemoptysis. Cranial MR and venography showed thrombus formation in the right transverse sinus and superior sagittal sinus. Computed tomographic pulmonary angiography (CTPA) showed an embolic thrombus in the right pulmonary truncus and lung abscess. The patient was young, and there were no signs of lower extremity deep venous thrombosis or other major risk factors for pulmonary embolism (PE) including cardiac anomaly. The only risk factor we were able to identify was the presence of the prothrombin G20210A gene mutation. Anticoagulant treatment with oral warfarin (10 mg daily) and imipenem (4X500 mg) was started. The patient was hospitalized for antibiotic and anticoagulation therapies for three weeks and was discharged on lifelong treatment with warfarin (5 mg daily).

A prospective cohort study on patients treated with anticoagulants for cerebral vein thrombosis

OBJECTIVES

Cerebral vein thrombosis (CVT) is a potentially fatal disorder for which treatment guidelines are scanty. To assess the short- and long-term benefit of anticoagulant therapy, we performed a prospective cohort study on CVT patients.

METHODS

Forty-four consecutive CVT patients received conventional anticoagulation with heparin followed by warfarin for at least 3 months. Patients presenting with symptoms suggestive of pulmonary embolism (PE) underwent confirmatory objective tests. Acquired or inherited risk factors for thrombosis were investigated in all patients. Thrombotic and hemorrhagic events occurring during treatment, and the long-term outcome using the modified Rankin Scale (mRS) were recorded.

RESULTS

Congenital and/or acquired conditions predisposing to thrombosis were detected in 37 patients (84.1%), with a high prevalence of oral contraceptive use (66.7% of females) and thrombophilia (31.8%); more than one risk factor was seen in 31.8% of cases. At referral, six patients (13.6%) presented with symptoms of PE, which was confirmed in all. During the initial treatment period, two patients (4.5%) developed symptomatic progression of CVT, which was fatal in 1, and 2 (4.5%) developed major bleeding complications. A favorable outcome (mRS 0-2) at 6-12 months was recorded in 37 of the 43 patients who survived the acute phase (86%).

CONCLUSIONS

The outcome of CVT patients managed with conventional anticoagulation who survive the initial phase is favorable in the vast majority. The prevalence of concomitant PE is considerably high, supporting the need of anticoagulant therapy.

Iron-deficiency anemia as a rare cause of cerebral venous thrombosis and pulmonary embolism

Cerebral venous thrombosis (CVT) is a relatively rare cause of stroke and has a wide spectrum of unspecific symptoms, which may delay diagnosis. There are many etiologies, including hematological disorders, trauma, infection, and dehydration. Iron-deficiency anemia (IDA) has been reported as an extremely rare cause of CVT, especially in adults.

Pulmonary embolus from acute superior sagittal sinus thrombosis secondary to skull fracture: case report

BACKGROUND AND IMPORTANCE

Pulmonary embolus (PE) occurring concurrent with-and as a result of-traumatic superior sagittal sinus thrombosis (SSST) has never before been reported. We report the first case of a patient who presented with acute traumatic SSST and concomitant PE.

CLINICAL PRESENTATION

A 30-year-old man presented with altered mental status after a motorcycle collision, and subsequently developed respiratory distress. Computed tomography (CT) scanning of the head revealed multiple calvarial and skull base fractures, contusions, and hemorrhages. Air was noted within the superior sagittal sinus, indicating a fracture involving the sinus and suggesting thrombus formation. A chest CT scan obtained at the time of presentation revealed a PE in the right pulmonary artery. The patient had no personal or family history of hypercoagulability, and all coagulation study results were within normal limits. Work-up revealed no evidence of long bone fractures or deep venous thrombosis. Initial intervention involved placement of an external ventricular drain, brain tissue oxygen saturation probe, internal jugular venous oxygen saturation monitor, arterial line, and central venous line with extensive treatment of all abnormal values according to established standards. Ultimately, pentobarbital coma was initiated for persistently elevated intracranial pressure (ICP) refractory to conservative measures. Aggressive pulmonary resuscitation was required to maintain adequate oxygenation. Anticoagulation was begun 3 weeks after admission.

CONCLUSION

Our patient had good neurological recovery. This report highlights the possibility of acute PE in the setting of traumatic SSST.

Anticoagulation for cerebral venous sinus thrombosis

BACKGROUND

Treatment of cerebral venous sinus thrombosis with anticoagulants has been controversial. Anticoagulants may prevent new venous infarcts, neurologic deterioration and pulmonary embolism but may also promote haemorrhages.

OBJECTIVES

To assess the effectiveness and safety of anticoagulant therapy in patients with confirmed cerebral venous sinus thrombosis.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched August 2010), MEDLINE (1950 to August 2010), EMBASE (1980 to August 2010) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers and reference lists of relevant articles, and contacted authors.

SELECTION CRITERIA

Unconfounded randomised controlled trials in which anticoagulant therapy was compared with placebo or open control in patients with cerebral venous sinus thrombosis (confirmed by intra-arterial contrast, or venography with magnetic resonance, or venography with computed tomography imaging).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted outcomes for each of the two treatment groups (anticoagulant treatment and control). The outcome data for each patient were analysed in the treatment group to which the patient was originally allocated (intention-to-treat analysis). We calculated a weighted estimate of the treatment effects across trials (relative risk, absolute risk reduction).

MAIN RESULTS

We included two small trials involving 79 patients. One trial (20 patients) examined the efficacy of intravenous, adjusted dose unfractionated heparin. The other trial (59 patients) examined high dose, body weight adjusted, subcutaneous, low-molecular weight heparin (nadroparin). Anticoagulant therapy was associated with a pooled relative risk of death of 0.33 (95% confidence interval (CI) 0.08 to 1.21) and of death or dependency of 0.46 (95% CI 0.16 to 1.31). The absolute reduction in the risk of death or dependency was 13% (95% CI 30% to -3%). No new symptomatic intracerebral haemorrhages were observed. One major gastro-intestinal haemorrhage occurred after anticoagulant treatment. Two control patients (placebo) had a diagnosis of probable pulmonary embolism (one fatal).

AUTHORS' CONCLUSIONS

Based upon the limited evidence available, anticoagulant treatment for cerebral venous sinus thrombosis appeared to be safe and was associated with a potentially important reduction in the risk of death or dependency which did not reach statistical significance.

Cerebral venous thrombosis in a Mexican multicenter registry of acute cerebrovascular disease: the RENAMEVASC study

BACKGROUND

Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular disease that is usually not mentioned in multicenter registries on all-type acute stroke. We aimed to describe the experience on hospitalized patients with CVT in a Mexican multicenter registry on acute cerebrovascular disease.

METHODS

CVT patients were selected from the RENAMEVASC registry, which was conducted between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging, and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed.

RESULTS

Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%), contraceptive use (18%), and pregnancy (12%) were the main risk factors in women. In 67% of men, CVT was registered as idiopathic, but thrombophilia assessment was suboptimal. Longitudinal superior sinus was the most frequent thrombosis location (78%). Extensive (>5 cm) venous infarction occurred in 36% of patients. Only 81% of patients received anticoagulation since the acute phase, and 3% needed decompressive craniectomy. Mechanical ventilation (13.6%), pneumonia (10.2%) and systemic thromboembolism (8.5%) were the main in-hospital complications. The 30-day case fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox proportional hazards model, only age <40 years was associated with a mRS score of 0 to 2 (functional independence; rate ratio, 3.46; 95% CI, 1.34-8.92).

CONCLUSIONS

The relative frequency of CVT and the associated in-hospital complications were higher than in other registries. Thrombophilia assessment and acute treatment was suboptimal. Young age is the main determinant of a good short-term outcome.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Forget me not

A 37-year-old man presented with a facial abscess that progressed to external ophthalmoplegia and proptosis. Neuroimaging was consistent with cavernous sinus thrombosis. The diagnosis, management options, and management controversies of septic cavernous sinus thrombosis are discussed, including neuroimaging, antibiotic choice, and the role of corticosteroids and anticoagulation.

A review of therapeutic strategies for the management of cerebral venous sinus thrombosis

OBJECT

Although initially described in the 19th century, cerebral venous sinus thrombosis (CVST) remains a diagnostic and therapeutic dilemma. It has an unpredictable course, and the propensity for hemorrhagic infarction produces significant consternation among clinicians when considering anticoagulation. It is the purpose of this review to analyze the evidence available on the management of CVST and to provide appropriate recommendations.

METHODS

A thorough literature search was conducted through MEDLINE and PubMed, with additional sources identified through cross-referencing. A classification and level of evidence assignment is provided for recommendations based on the American Heart Association methodologies for guideline composition.

RESULTS

Of the publications identified, the majority were isolated case reports or small case series. Few prospective trials have been conducted. Existing data support the use of systemic anticoagulation as an initial therapy in all patients even in the presence of intracranial hemorrhage. Chemical and/or mechanical thrombectomy, in conjunction with systemic anticoagulation, is an alternative strategy in patients with progressive deterioration on heparin therapy or in those who are moribund on presentation. Mechanical thrombectomy is probably preferred in patients with preexisting intracranial hemorrhage.

CONCLUSIONS

Effective treatments exist for the management of CVST, and overall outcomes are more favorable than those for arterial stroke. Further research is necessary to determine the role of individual therapies; however, the rarity of the condition poses a significant limitation.

Intracranial dural sinus thrombosis: novel use of a mechanical thrombectomy catheter and review of management strategies

Management of intracranial dural sinus thrombosis with involvement of multiple sinuses is complex, often involving not only the primary problem (thrombosis) but acute adverse events consequent to the disease. We highlight the novel use of an endovascular device (typically for suction thrombectomy in the peripheral vascular system) used in our patient with a life-threatening multi-sinus thrombosis. As there is no standard treatment yet for cranial sinus thrombosis, our review of the literature highlights some effective management strategies. A 35-year-old woman developed associated complications of cranial sinus thrombosis that included intracranial hypertension caused by an expanding intracranial hematoma, pulmonary embolism treated by placement of filters in superior and inferior vena cava to eliminate intra- and extracranial sources of emboli, and procedure-related retroperitoneal hematoma that necessitated peripheral vascular intervention. After failure of several common devices during mechanical thrombolysis, a thrombectomy catheter (typically for peripheral vascular intervention to aide in the clot removal) was used. Our case highlights the fine balance of anticoagulation and thrombolysis and the proactive, aggressive approach used by our multispecialty team to manage concurrent factors.

Spontaneous superior sagittal sinus thrombosis secondary to type II heparin-induced thrombocytopenia presenting as an acute subarachnoid hemorrhage

Cerebral sinus thrombosis is a rare cause of spontaneous subarachnoid hemorrhage. The development of cerebral sinus thrombosis as a complication of heparin-induced thrombocytopenia is even rarer. In this paper, we present a 59-year-old patient admitted to our service with cerebral sinus thrombosis secondary to type II heparin-induced thrombocytopenia. We also review the literature in regard to the incidence, pathophysiology and management of this rare clinicopathological entity.

Cerebral venous thrombosis: an update

Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular disease that can occur at any age, including in neonates, and it accounts for 0.5% of all stroke. The widespread use of neuroimaging now allows for early diagnosis and has completely modified our knowledge on this disorder. CVT is more common than previously thought and it is recognised as a non-septic disorder with a wide spectrum of clinical presentations, numerous causes, and usually a favourable outcome with a low mortality rate. MRI with T1, T2, fluid-attenuated inversion recovery, and T2* sequences combined with magnetic resonance angiography are the best diagnostic methods. D-dimer concentrations are raised in most patients but normal D-dimers do not rule out CVT, particularly in patients who present with isolated headache. Heparin is the first-line treatment, but in a few cases more aggressive treatments, such as local intravenous thrombolysis, mechanical thrombectomy, and decompressive hemicraniectomy, may be required.

Cerebral venous thrombosis: a review

BACKGROUND

Cerebral venous thrombosis (CVT) is less frequent than arterial thrombosis, presents in an atypical fashion, and is an uncommon cause of stroke. Although the functional outcome from CVT is better than arterial strokes, the outcome of CVT remains unpredictable and may lead to sequelae or even death if not recognized and treated early.

REVIEW SUMMARY

The clinical presentations, time of onset, and neuroimaging findings vary. Symptoms include headache, seizures, neurologic deficits, and altered consciousness. Causes include hematologic disorders, hypercoagulable states, pregnancy, and contraceptive medications. Treatment of this infrequent condition remains controversial and includes heparin infusions, intrasinus thrombolysis, and other endovascular procedures.

CONCLUSION

Further clinical trials are needed to address optimal treatment of this infrequent but potentially serious condition.

Causes and predictors of death in cerebral venous thrombosis

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.

Differential diagnosis of patients with intracranial sinus venous thrombosis related isolated intracranial hypertension from those with idiopathic intracranial hypertension

In patients presenting with intracranial hypertension without hydrocephalus, mass lesions, and with normal cerebrospinal fluid (CSF) composition (pseudotumor cerebri syndrome), the diagnosis of intracranial sinus venous thrombosis (ISVT) has crucial etiological, therapeutic and prognostic implications. Utilizing two well-defined groups of pseudotumor cerebri patients, one with magnetic resonance imaging (MRI) or angiography confirmed ISVT (17 patients) and the other in whom ISVT has been excluded (idiopathic intracranial hypertension [IIH], 27 patients), we investigated the characteristics that might be helpful in distinguishing them. No clinical or auxiliary findings differed between the ISVT and IIH groups except for female gender and lower CSF protein level, which were significantly associated with the latter. While the syndrome pseudotumor cerebri could be due to multiple causes including ISVT, the term IIH should be restricted for patients with isolated intracranial hypertension attributable to no other neurological or systemic disease. Since CT frequently misses ISVT, patients with pseudotumor cerebri syndrome should undergo MRI and MR venography before being labeled as IIH. We conclude that Modified Dandy's Diagnostic Criteria of pseudotumor cerebri, formulated prior to MRI era, can no longer be applied for the diagnosis of IIH.

Cerebral Venous Thrombosis

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.

Cerebral Venous Thrombosis

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.

A sticky situation

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.

Anticoagulation for cerebral sinus thrombosis

BACKGROUND

Treatment of cerebral sinus thrombosis with anticoagulants has been controversial. Anticoagulants may prevent new venous infarcts, neurologic deterioration, and pulmonary embolism but may also promote haemorrhages.

OBJECTIVES

To review the available evidence regarding the effectiveness and safety of anticoagulant therapy in patients with confirmed cerebral sinus thrombosis.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 18 March 2002). We also searched MEDLINE (1966-Oct 2001), EMBASE (1980-Feb 2002) and the Cochrane Controlled Trials Register (Cochrane Library, 2002 Issue 1) and contacted authors to identify additional published and unpublished studies.

SELECTION CRITERIA

Unconfounded randomised controlled trials in which anticoagulant therapy was compared with placebo or open control in patients with cerebral sinus thrombosis (confirmed by intra-arterial contrast or magnetic resonance angiography).

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted outcomes for each of the two treatment groups (anticoagulant treatment and control). The outcome data for each patient are analysed in the treatment group to which the patient was originally allocated ('intention to treat' analysis). A weighted estimate of the treatment effects across trials (relative risk, absolute risk reduction) is calculated using the Cochrane statistical software.

MAIN RESULTS

Two small trials involving 79 patients fulfilled the inclusion criteria. One trial (20 patients) examined the efficacy of intravenous, adjusted dose unfractionated heparin. The other trial (59 patients) examined high dose, body weight adjusted, subcutaneous, low-molecular weight heparin (Nadroparin). Anticoagulant therapy was associated with a pooled relative risk of death of 0.33 (95 % CI 0.08 to 1.21) and of death or dependency of 0.46 (95 % CI 0.16 to 1.31). No new symptomatic intracerebral haemorrhages were observed. One major gastro-intestinal haemorrhage occurred after anticoagulant treatment. Two control patients (placebo) had a diagnosis of probable pulmonary embolism (one fatal).

REVIEWER'S CONCLUSIONS

Based upon the limited evidence available, anticoagulant treatment for cerebral sinus thrombosis appeared to be safe and was associated with a potentially important reduction in the risk of death or dependency which did not reach statistical significance.

Cerebral venous sinus thrombosis: a diagnostic challenge

BACKGROUND

Cerebral venous sinus thrombosis (CVT) is a potentially serious but treatable disorder that has been underdiagnosed in the past. Delay in diagnosis and treatment of this disorder has resulted in the death of one of our patients.

AIM

To review the local experience with CVT in order to identify factors that may allow diagnosis and appropriate treatment decisions to be made more readily in the future.

METHODS

A retrospective review of all cases of CVT diagnosed or treated at Auckland Hospital between 1990 and 1999.

RESULTS

Twenty-five cases of CVT were identified. The number of cases diagnosed increased from less than one per year in 1990-94 to eight in 1999. Clinical signs at presentation included headache (96%), focal neurological deficits (60%), seizures (40%) and papilloedema (43%). Delayed diagnosis after admission to hospital occurred in two young women presenting with neurological symptoms during pregnancy or puerperium, in two cases in whom focal symptoms were not explained by negative computed tomography and in five cases presenting with intracerebral haemorrhage. Twenty patients received anticoagulant therapy and their condition remained stable or improved after treatment.

CONCLUSIONS

The diagnosis of CVT should be considered in women with any neurological symptoms during pregnancy or puerperium and in all cases of unexplained intracerebral haemorrhage. CVT should also be considered in cases of recent onset and progressive headache, particularly when associated with focal neurological symptoms or signs, seizures or papilloedema. Magnetic resonance imaging with magnetic resonance venography is the investigation of choice. Anticoagulation with heparin remains the mainstay of treatment, even in the presence of intracerebral haemorrhage.

Cerebral venous thrombosis in young adults: 2 Case reports

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.

Superior sagittal sinus thrombosis induced by thyrotoxicosis. Case report

There is a wide variety of disorders associated with thrombosis of the superior sagittal sinus (SSS), including infectious disease. noninfectious conditions such as vasculitis and hypercoagulable states, and complications arising from pregnancy or use of oral contraceptive medications. Despite these well-defined associations, approximately 25% of the cases remain idiopathic. In this article the authors describe a patient who was found to have SSS thrombosis while experiencing a thyrotoxic phase of Graves disease. The patient presented with intracerebral hemorrhage, subarachnoid hemorrhage, seizure, coma, a raised fibrinogen concentration, low protein C activity, and atrial fibrillations. Thrombolysis was successfully performed despite the coexistence of thrombosis and intracranial hemorrhage. Patients with thyrotoxicosis and a diffuse goiter may be predisposed to the development of SSS thrombosis, as a result of hypercoagulation and stasis of local venous blood flow. In the present case, a patient in whom thrombosis coexisted with intracranial hemorrhage was successfully treated using thrombolytic therapy.

Heparin and oral anticoagulants in the treatment of brain ischemia

The use of heparin, heparin analogues, and oral anticoagulation in the treatment of brain ischemia remains controversial. We review the mechanism of action of the heparins and warfarin as well as the data regarding their efficacy and complications in patients with ischemic stroke and venous sinus thrombosis. None of these drugs have proven effective for all forms of cerebral ischemia. Further studies examining the efficacy of anticoagulants in different stroke subgroups will be necessary in order to clarify optimal clinical practice.