Cerebral venous sinus thrombosis risk factors

Sex Differences and Clinical Outcomes of Patients with Coronavirus Disease 2019 Infection and Cerebral Venous Sinus Thrombosis: A Systematic Review

Cerebral venous sinus thrombosis (CVST) is a rare neurovascular condition that has been observed in individuals with coronavirus disease 2019 (COVID-19). This systematic review aimed to explore the sex differences and characteristics of concurrent COVID-19 and CVST cases. A total of 212 CVST patients were included in the study. Women with CVST had a slightly higher mean age compared to men (47.359 years vs 46.08 years). Women were more likely to report symptoms such as fever (56.1%) and decreased sense of smell or taste (71.4%), while men more frequently experienced nausea or vomiting (55.6%), headache (62.9%), and seizures (72%). Notably, current smokers, who were predominantly men, had a higher occurrence of CVST. On the other hand, women had a higher likelihood of CVST risk factors such as oral contraceptive pill (OCP) use and autoimmune diseases. Treatment approaches also showed sex-based differences. Unfractionated heparin was administered more often to women with CVST (63.2%). The in-hospital mortality rate for CVST patients was 21.3%, with men having a significantly higher mortality rate than women (65.2% vs 34.8%, P = .027). Survival analysis revealed that factors such as smoking history, diabetes mellitus, hypertension, OCP use, COVID-19 symptoms, CVST symptoms, and the need for intubation significantly influenced survival outcomes. Understanding these sex differences in COVID-19-related CVST is crucial for accurate diagnosis and effective management, ultimately leading to improved patient outcomes. Our findings highlight the importance of considering sex as a factor in the evaluation and treatment of individuals with COVID-19 and concurrent CVST.

Translabyrinthine Craniotomy Is Associated with Higher Risk of Asymptomatic Dural Venous Sinus Thrombosis in Vestibular Schwannoma Resection

OBJECTIVE

Characterize the incidence, risk factors, and patient outcomes of dural venous sinus thrombosis identified on postoperative imaging after retrosigmoid or translabyrinthine craniotomy for vestibular schwannoma resection.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary academic referral center.

PATIENTS

Eighty-one patients 19 to 82 years of age with vestibular schwannomas, 58% female.

INTERVENTIONS

Retrosigmoid or translabyrinthine craniotomy with postoperative magnetic resonance imaging/magnetic resonance venography.

MAIN OUTCOME MEASURES

Association between operative approach, age, sex, body mass index, tumor size, dominant sinus, operative time, laterality, and perioperative cerebrospinal fluid (CSF) leaks with rate of thrombosis.

RESULTS

Translabyrinthine craniotomy was associated with the highest relative risk of thrombosis (odds ratios [OR] = 19.82, 95% confidence interval [CI] = 1.75-224, p = 0.007), followed by male sex (OR = 5.53, 95% CI = 1.63-18.8, p = 0.035). Other patient and demographic risk factors were not associated with increased rates of dural venous thrombosis, nor was there an association with postoperative CSF leak. 81% (25/31) of thrombi had resolved within 3 years of surgery.

CONCLUSIONS

Translabyrinthine approach and male sex most strongly predicted postoperative dural venous thrombosis after postauricular craniotomy for vestibular schwannoma resection.

PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED

Better understanding of risk factors and management of dural venous thrombosis after vestibular schwannoma surgery.

LEARNING OBJECTIVE

Characterize clinically significant risk factors for dural venous thrombosis in vestibular schwannoma surgery.

DESIRED RESULT

Identification of patient and operative risk factors for dural venous thrombosis.

LEVEL OF EVIDENCE

III.

INDICATE IRB OR IACUC

Exempt.

Cerebral Sinus Vein Thrombosis and Gender: A Not Entirely Casual Relationship

Cerebral sinus venous thrombosis (CSVT) is a relatively rare acute disorder of cerebral circulation, but it can potentially be associated with serious sequelae and a poor prognosis. The neurological manifestations associated with it are often not adequately taken into consideration given the extreme variability and nuances of its clinical presentation and given the need for radiological methods suitable for this type of diagnosis. CSVT is usually more common in women, but so far there are little data available in the literature on sex-specific characteristics regarding this pathology. CSVT is the result of multiple conditions and is therefore to be considered a multifactorial disease where at least one risk factor is present in over 80% of cases. From the literature, we learn that congenital or acquired prothrombotic states are to be considered extremely associated with the occurrence of an acute episode of CSVT and its recurrences. It is, therefore, necessary to fully know the origins and natural history of CSVT, in order to implement the diagnostic and therapeutic pathways of these neurological manifestations. In this report, we summarize the main causes of CSVT considering the possible influence of gender, bearing in mind that most of the causes listed above are pathological conditions closely linked to the female sex.

D-Dimer Level Associated with Amount of Sinus involvement Using Digital Subtraction Angiography on Cerebral Venous Thrombosis Patients

Background

Cerebral venous sinus thrombosis (CVST) is a form of the cerebrovascular disease characterized by varying degrees of obstruction of veins and cerebral sinuses caused by thrombus. Diagnosis is incredibly challenging due to the wide variety of symptoms and the distinct radiological aspects of affected vessels. In patients with venous thrombosis, the presence of D-Dimer is used as an indicator of the presence of endogenous fibrinolysis. D-Dimer is a by-product of fibrin polymer fragmentation.

Objective

To investigate the relationship between the level of D-Dimer and the number of sinuses in CVST by Digital Subtraction Angiography (DSA).

Methods

Retrospective data from September 2021 to September 2022 were used in this analytical observational with a cross-sectional study design. Chi-Square is used for data processing relationship analysis.

Results

Out of the 54 subjects with elevated levels of D-Dimer, 38 (70.4%) are females, whereas 16 (29.6%) are males. High levels of D-Dimer have been related to a greater risk of sinus thrombosis (p < 0.001). D-Dimer levels were similarly shown to rise in conjunction with the number of sinuses most severely damaged by thrombosis. The most common site for thrombosis to develop in this study were the left sigmoid and left transverse sinuses. Most risk factors were hormonal.

Conclusion

There is a statistically significant relationship between an increase in the D-Dimer level and the greater number of sinuses involved as determined by DSA in individuals diagnosed with CVST.

Paraneoplastic Syndromes in Neuro-Ophthalmology

Paraneoplastic neurological syndromes (PNS) occur in about 1 in 300 cases of cancer. The usual mechanism is that an antigen on the cancer sets off an immune response that then cross-reacts with a nervous system antigen. The presentation is usually with a subacute progressive neurological disorder. The management of these conditions is usually of both the underlying tumor and immunomodulation to suppress the autoimmune response. There are a number of these conditions that can present to the Neuro-Ophthalmology clinic, either as a discrete condition affecting vision or eye movements or as part of a more widespread neurological disorder. This article will discuss these conditions, their management and prognosis.

Cerebral venous sinus thrombosis caused by traumatic brain injury complicating thyroid storm: a case report and discussion

Introduction

Cerebral venous sinus thrombosis (CVST) is an uncommon cerebrovascular disease with diverse predisposing factors. We report a case of CVST caused by a thyroid storm induced by traumatic brain injury.

Case presentation

A 29-year-old male patient with a history of Graves’ disease with hyperthyroidism presented to our hospital with head trauma of cerebral contusion and laceration in both frontal lobes confirmed by admission CT scan. He received mannitol to lower intracranial pressure, haemostatic therapy, and antiepileptic treatment. Eight days later, he presented with signs of thyroid storms, such as tachycardia, hyperthermia, sweating and irritation, and his thyroid function tests revealed high levels of TPO-Ab, TR-Ab, TG-Ab, FT3 and FT4. Then, he entered a deep coma. His brain CT showed a thrombosis of multiple venous sinuses, along with the opening of peripheral collateral vessels, congestive infarction with haemorrhage and brain swelling. He regained consciousness after treatment with antithyroid drugs, anticoagulants, respiratory support and a regimen of sedation/analgesia. After a half-year follow-up, most of the patient’s blocked cerebral venous sinuses had been recanalized, but there were still some sequelae, such as an impaired fine motor performance of the right hand and verbal expression defects.

Conclusions

CVST can be induced by thyroid storms, and trauma-related thyroid storms can develop on the basis of hyperthyroidism. The purpose of this case report is to raise clinicians’ awareness and improve their ability to diagnose CVST early in patients with traumatic brain injury complicating thyroid storms to improve the neurological prognosis among similar patients.

Preseptal cellulitis and cerebral venous sinus thrombosis complication in a patient with diabetes mellitus

This was a rare case of preseptal cellulitis with an unexpected complication by cerebral venous sinus thrombosis. A 73-year-old woman with poorly controlled diabetes mellitus presented with a week history of swelling and redness on the left upper eyelid and right forehead, associated with poor oral intake, lethargy, and fever. She was generally lethargic with poor verbal response. She had cellulitis of the left upper eyelid and right forehead with the left upper eyelid necrosis. Computed tomography venography of the brain revealed thrombosis of the right transverse sinus, right sigmoid sinus, and right internal jugular vein. She later developed left upper eyelid and right forehead abscesses. Incision, drainage, and wound debridement were performed. She was treated with intravenous antibiotics and anticoagulant. After 1 week of treatment, the preseptal and forehead cellulitis had resolved. However, she passed away due to aspiration pneumonia with respiratory failure on day-13 of hospitalization.

Janus Kinase-2 V617F Mutation and Antiphospholipid Syndrome in Cerebral Sinus Venous Thrombosis: Natural History and Retrospective Bicenter Analysis

Background

Cerebral sinus venous thrombosis (CSVT) is a rare neurovascular entity, usually associated with acquired or genetic hypercoagulable states. In up to 30% of the cases it remains idiopathic. Bone marrow proliferation disorders that are associated with Janus Kinase 2 V617F mutation (JAK-2) are known causes of the systemic and cerebral thrombosis—at times despite normal blood counts—for which hematologic treatment exists. However, JAK-2 prevalence in the CSVT cases is not clear.

Methods

In this retrospective analysis, data of 236 patients with CSVT admitted to two tertiary centers between 2010 and 2020 were analyzed, with emphasis on laboratory and imaging data and clinical and interventional outcomes.

Results

A total of 236 patients were included in the analysis. The patients' median age was 42 years and the average age was 44 years (±19 years), with 59% female patients. JAK-2 positivity rate was 18% (among 77 patients tested for the mutation). Patients with normal blood counts on presentation comprised 36% of the JAK-2 positive cases. Other hypercoagulability states were also investigated, with the antiphospholipid syndrome (APLA) showing the highest prevalence (11%) followed by other etiologies including oral contraceptive use, Factor V Leiden, prothrombin mutation, and malignancy. Selected JAK-2, APLA, and prothrombin mutation cases showed a more severe clinical course.

Conclusion

JAK-2 mutation is underdiagnosed and its screening may be warranted in the cases of idiopathic CSVT, even despite normal blood counts, to allow disease-modifying treatment and blood cell count monitoring. JAK-2, APLA, and prothrombin mutation may be associated with a more complicated clinical course.

Frequency of Cerebral Venous Thrombosis in Dubai, UAE-A Multicenter, Retrospective Study

Background and Purpose

Cerebral venous thrombosis (CVT), also known as cerebral dural venous thrombosis, is not a very common cause of stroke. It has a diverse clinical presentation, with multiple predisposing factors and imaging findings. The incidence of CVT varies in different studies. We hypothesized that the incidence of CVT in Dubai is more than that reported in the West owing to dehydration caused by the high atmospheric temperature.

Methods

We retrospectively reviewed the medical records of all patients aged more than 13 years with appropriate International Classification of Diseases, 9th Revision, codes for the diagnosis of CVT from January 1, 2010 to December 31, 2018 from three major hospitals with an acute stroke service in Dubai, United Arab Emirates.

Results

We identified 138 patients who presented with CVT. The average frequency of CVT was 6.6 per 100,000 population. Fifty percent of the patients presented between May and September, which are considered the hottest months in the UAE. Headache was the most common presentation, followed by seizures. The most important risk factors were the use of oral contraceptive pills, anemia, and polycythemia. Our study showed a higher incidence of anemia, polycythemia, thrombophilia, and abnormal CT brain findings.

Conclusion

In our study, CVT was more common during the months of summer. Anemia and polycythemia were strongly associated with CVT. Public awareness about CVT, its higher incidence during summer months and strategies to avoid dehydration might be considered to reduce the incidence of CVT in summer months. However, larger studies are needed to confirm definite associations.

Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis

BACKGROUND

Consensus is currently lacking in the optimal treatment for blunt traumatic cerebral venous sinus thrombosis (tCVST). Anticoagulation (AC) is used for treating spontaneous CVST, but its role in tCVST remains unclear.

OBJECTIVE

To investigate the characteristics and outcomes of patients treated with AC compared with patients managed conservatively.

METHODS

We retrospectively reviewed patients who presented to a Level 1 trauma center with acute skull fracture after blunt head trauma who underwent dedicated venous imaging.

RESULTS

There were 137 of 424 patients (32.3%) presenting with skull fractures with tCVST on venous imaging. Among them, 82 (60%) were treated with AC while 55 (40%) were managed conservatively. Analysis of baseline characteristics demonstrated no significant difference in age, sex, admission Glasgow Coma Scale, admission Injury Severity Score, rates of associated intracranial hemorrhage, or neurosurgical interventions. New or worsening intracranial hemorrhage was seen in 7 patients treated with AC. Patients on AC had significantly lower mortality than non-AC (1% vs 15%; P = .003). There was no difference in the Glasgow Coma Scale or Glasgow Outcome Scale at last clinical follow-up. On follow-up venous imaging, patients treated with AC were more likely to experience full thrombus recanalization than non-AC (54% vs 32%; P = .012), and subsequent multiple regression analysis revealed that treatment with AC was a significant predictor of full thrombus recanalization (odds ratio, 5.18; CI, 1.60-16.81; P = .006).

CONCLUSION

Treatment with AC for tCVST due to blunt head trauma may promote higher rates of complete thrombus recanalization when compared with conservative management.

The Influence of Environmental Hypoxia on Hemostasis—A Systematic Review

Humans have been ascending to high altitudes for centuries, with a growing number of professional- and leisure-related sojourns occurring in this millennium. A multitude of scientific reports on hemostatic disorders at high altitude suggest that hypoxia is an independent risk factor. However, no systematic analysis of the influence of environmental hypoxia on coagulation, fibrinolysis and platelet function has been performed. To fill this gap, we performed a systematic literature review, including only the data of healthy persons obtained during altitude exposure (&lt;60 days). The results were stratified by the degree of hypoxia and sub-categorized into active and passive ascents and sojourns. Twenty-one studies including 501 participants were included in the final analysis. Since only one study provided relevant data, no conclusions regarding moderate altitudes (1,500–2,500 m) could be drawn. At high altitude (2,500–5,400 m), only small pathophysiological changes were seen, with a possible impact of increasing exercise loads. Elevated thrombin generation seems to be balanced by decreased platelet activation. Viscoelastic methods do not support increased thrombogenicity, with fibrinolysis being unaffected by high altitude. At extreme altitude (5,400–8,850 m), the limited data showed activation of coagulation in parallel with stimulation of fibrinolysis. Furthermore, multiple confounding variables at altitude, like training status, exercise load, fluid status and mental stress, prevent definitive conclusions being drawn on the impact of hypoxia on hemostasis. Thus, we cannot support the hypothesis that hypoxia triggers hypercoagulability and increases the risk of thromboembolic disorders, at least in healthy sojourners.

Pathogenesis of Two Faces of DVT: New Identity of Venous Thromboembolism as Combined Micro-Macrothrombosis via Unifying Mechanism Based on “Two-Path Unifying Theory” of Hemostasis and “Two-Activation Theory of the Endothelium”

Simple Summary

DVT is an intravascular blood clotting disorder that can be a life-threatening disease, particularly if it occurs in critically ill patients. Typically, distal DVT develops following a vascular injury associated with incidental trauma commonly involving lower extremities, which is transient and benign condition localized in the lower legs as solitary lesion. However, proximal/central DVT (i.e., venous thromboembolism) typically occurs in association with critical illnesses such as sepsis, diabetes, hypertension, cancer, autoimmune disease and others in the hospitalized patient, especially in the ICU. Recognition of different pathogenesis between distal DVT and proximal/central DVT is critically important because the prognosis is poorer in VTE. Its therapeutic approach should be different from distal DVT. The aim of this review is to identify the pathogenesis of two different types of DVT based on in vivo hemostatic mechanisms, which can explain their distinct phenotypes by clinical characteristics, laboratory data and imaging findings. An appropriate preventive measure can be put into the practice to avoid the onset of VTE. Additionally, should VTE be developed, proper and rational therapeutic regimen based on its pathogenesis can be designed for clinical trials to improve the outcome.

Abstract

Venous thrombosis includes deep venous thrombosis (DVT), venous thromboembolism (VTE), venous microthrombosis and others. Still, the pathogenesis of each venous thrombosis is not clearly established. Currently, isolated distal DVT and multiple proximal/central DVT are considered to be the same macrothrombotic disease affecting the venous system but with varying degree of clinical expression related to its localization and severity. The genesis of two phenotypes of DVT differing in clinical features and prognostic outcome can be identified by their unique hemostatic mechanisms. Two recently proposed hemostatic theories in vivo have clearly defined the character between “microthrombi” and “macrothrombus” in the vascular system. Phenotypic expression of thrombosis depends upon two major variables: (1) depth of vascular wall damage and (2) extent of the injury affecting the vascular tree system. Vascular wall injury limited to endothelial cells (ECs) in sepsis produces “disseminated” microthrombi, but intravascular injury due to trauma extending from ECs to subendothelial tissue (SET) produces “local” macrothrombus. Pathogen-induced sepsis activates the complement system leading to generalized endotheliopathy, which releases ultra large von Willebrand factor (ULVWF) multimers from ECs and promotes ULVWF path of hemostasis. In the venous system, the activated ULVWF path initiates microthrombogenesis to form platelet-ULVWF complexes, which become “microthrombi strings” that produce venous endotheliopathy-associated vascular microthrombotic disease (vEA-VMTD) and immune thrombocytopenic purpura (ITP)-like syndrome. In the arterial system, endotheliopathy produces arterial EA-VMTD (aEA-VMTD) with “life-threatening” thrombotic thrombocytopenic purpura (TTP)-like syndrome. Typically, vEA-VMTD is “silent” unless complicated by additional local venous vascular injury. A local venous vessel trauma without sepsis produces localized macrothrombosis due to activated ULVWF and tissue factor (TF) paths from damaged ECs and SET, which causes distal DVT with good prognosis. However, if a septic patient with “silent” vEA-VMTD is complicated by additional vascular injury from in-hospital vascular accesses, “venous combined micro-macrothrombosis” may develop as VTE via the unifying mechanism of the “two-path unifying theory” of hemostasis. This paradigm shifting pathogenetic difference between distal DVT and proximal/central DVT calls for a reassessment of current therapeutic approaches.

Admission Dehydration Status Portends Adverse Short-Term Mortality in Patients with Spontaneous Intracerebral Hemorrhage

The impact of dehydration at admission of patients with spontaneous intracerebral hemorrhage (ICH) on short-term mortality remains ambiguous due to scarce data. All of the consecutive patients with spontaneous ICH, who were referred to our neurovascular center in 2018/19, were assessed for hydration status on admission. Dehydration was defined by a blood urea-to-creatinine ratio > 80. In a cohort of 249 patients, 76 patients (31%) were dehydrated at the time of admission. The following factors were significantly and independently associated with increased 30-day mortality in multivariate analysis: “signs of cerebral herniation” (p = 0.008), “initial midline shift > 5 mm” (p < 0.001), “ICH score > 3” (p = 0.007), and “admission dehydration status” (p = 0.007). The results of the present study suggest that an admission dehydration status might constitute a significant and independent predictor of short-term mortality in patients with spontaneous ICH.

Concomitant central venous sinus thrombosis and subdural hematoma in acute promyelocytic leukemia: middle meningeal artery embolization enables safe anticoagulation. Illustrative case

BACKGROUND

Acute promyelocytic leukemia (APL) has long been associated with coagulation disorders. The proposed mechanism is a combination of fibrinolysis, proteolysis, platelet dysfunction, thrombocytopenia, and possibly disseminated intravascular coagulation. Hemorrhagic complications are prominent.

OBSERVATIONS

In this case, a 25-year-old female with newly diagnosed APL developed extensive cerebral venous thrombosis (CVT) and was initiated on a protocol with idarubicin and all-trans retinoic acid. The general recommendation for treating CVT is anticoagulation to stabilize the existing thrombus and prevent propagation. The patient was initiated on a heparin drip, but her clinical course was complicated by subdural hemorrhage (SDH) and epidural hemorrhage in the setting of thrombocytopenia. Anticoagulation was held, and her CVT propagated on follow-up imaging. To restart anticoagulation for CVT with a limited risk of SDH, the authors pursued middle meningeal artery (MMA) embolization. The patient was transitioned to apixaban and discharged to home.

LESSONS

MMA embolization enables safe anticoagulation in patients with concomitant CVT and SDH. The authors report the complex clinical course and effective management of this rare clinical scenario.

Septic cavernous sinus thrombosis: A review

Septic cavernous sinus thrombosis (SCST) is a rare, yet severe, process typically arising from infections of the paranasal sinuses (predominately ethmoid and/or sphenoid sinusitis) and less commonly, otogenic, odontogenic, and pharyngeal sources. Clinical symptoms of SCST arise from obstruction of venous drainage from the orbit and compression of the cranial nerves within the cavernous sinus. In the preantibiotic era SCST was considered universally fatal (80-100%); however, with the introduction of antibiotics the overall incidence, morbidity, and mortality of SCST have greatly declined. In spite of dramatic improvements, morbidity and mortality remain high, with the majority of patients experiencing neurological sequalae, highlighting the severity of the disease and the need for prompt recognition, diagnosis, and treatment. Here we review of the literature on SCST with a focus on the current recommendations and recent evidence for diagnostic and medical management of this condition.

Gender Differences in Risk Factor Profile and Clinical Characteristics in 89 Consecutive Cases of Cerebral Venous Thrombosis

Gender has been shown to be an important variable in cerebral venous thrombosis (CVT) risk and significantly influences its clinical manifestations and outcome. The aim of our study was to investigate the gender-specific risk factor profile and clinical picture of this rare cerebrovascular disorder.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 89 consecutive cases of CVT at a tertiary neurology clinic in Târgu Mures, Romania, between June 2009 and January 2021 to analyze the gender-related differences in etiology, clinical presentation, and outcome.

RESULTS

Women comprised 62.5% of the cohort. Females were significantly younger than males (37.3 years versus 48.8 years, respectively, p = 0.001), and the main risk factors were hormone related in 37.9% of the cases, followed by primary thrombophilia (34.4%), smoking (25.8%), obesity (17.2%), infections (17.2%), mechanical factors (17.2%), cancer (8.6%), systemic autoimmune disorders (8.6%), and hematological disorders (8.6%). In male patients, the main risk factors were smoking (41.9%), primary thrombophilia (29%), infections (22.6%), heavy alcohol consumption (16.1%), and venous thromboembolism in the medical history (12.9%). Frequency of headache was higher in females than in males (75.9% versus 67.7%), whereas frequency of coma (6.5% in males versus 1.7% in females) and dizziness (19.4% in males versus 10.3% in females) was higher in males. CVT onset was acute in 41.4% of females and 38.7% of males. The Rankin score at discharge was significantly lower in females compared with males (0.6 versus 1.6), reflecting a more favorable short-term outcome. Mortality was 6.4% in males and 1.7% in females.

CONCLUSIONS

CVT is a multifactorial disorder that has a broad spectrum of risk factors with important gender-related differences in clinical manifestation and prognosis. Female patients, especially those with hormone-related risk factors, have a more favorable outcome than male patients.

Cerebral Venous Sinus Thrombosis in a Child With Idiopathic Nephrotic Syndrome: A Case Report and Review of the Literature

Cerebral venous sinus thrombosis is a rare and serious complication of nephrotic syndrome. A case of a five-year-old boy with nephrotic syndrome is described here. On the fourth day of admission, the child developed an occasional cough. A percutaneous renal biopsy was conducted to characterize the frequent-relapse nephrotic syndrome that was developed. After suspension of oral anticoagulants, the patient developed mild dizziness, headache, and vomiting. The child was diagnosed with intracranial venous sinus thrombosis based on data obtained using head computed tomography and magnetic resonance imaging. He recovered after receiving heparin and warfarin anticoagulants. We summarized the case and reviewed the literature here, showing that early diagnosis and treatment have a significant impact on the prognosis of this complication.

Endoplasmic reticulum stress and oxidative stress contribute to neuronal pyroptosis caused by cerebral venous sinus thrombosis in rats: Involvement of TXNIP/peroxynitrite-NLRP3 inflammasome activation

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke, which is life-threatening in severe cases. However, considerably less attention has been concentrated on the mechanism of neural cell damage after CVST. This study aims to investigate the role of endoplasmic reticulum stress, oxidative stress, and pyroptosis in a well-established rodent model of CVST. Rat brains were harvested at 0 h, 6 h, days 1, days 3, days 7, and days 14 post-CVST for measurement of corresponding indexes. Endoplasmic reticulum stress sensors (including protein kinase RNA-like ER kinase (PERK) and inositol-requiring enzyme-1α (IRE1α)), oxidative stress markers (thioredoxin-interacting protein (TXNIP) and peroxynitrite), NLRP3, caspase p20, IL-1β, and gasdermin D (GSDMD, an indicator of pyroptosis) were separately evaluated by Western-blot and Immunohistochemistry/Immunofluorescence. Co-immunoprecipitation and Fluorescent double-labeling were employed to probe into the relationship between TXNIP/peroxynitrite and NLRP3 inflammasome. In the damaged cortex region, profuse p-PERK, p-IRE1α, TXNIP were produced and predominantly localized in neurons accompanied by a small amount expressed in microglia and astrocytes. The levels of 3-nitrotyrosine (3-NT, as a footprint of peroxynitrite), NLRP3, caspase p20, IL-1β, and GSDMD were distinctly elevated post-CVST and cellular localization of peroxynitrite, NLRP3, caspase p20, and IL-1β was largely observed in neurons and/or microglia. Importantly, sites of enhanced TXNIP and 3-NT immunoreactivity were colocalized with increased NLRP3 staining, indicating the involvement of TXNIP and peroxynitrite in NLRP3 inflammasome activation and subsequent pyroptosis. Besides, co-immunoprecipitation also hinted that there might be an interaction or causality between TXNIP/peroxynitrite and NLRP3 inflammasome. We concluded that endoplasmic reticulum stress and oxidative stress may jointly lead to neuronal NLRP3 inflammasome activation and pyroptosis after CVST.

Cerebral Venous Thrombosis: Review of Diagnosis, Follow-Up, Late Complications and Potential Pitfalls

Cerebral venous thrombosis is a less common but relevant cause of stroke in adults. The clinical manifestations are nonspecific leading frequently diagnostic delays, so imaging findings are is of vital importance. Conventional imaging modalities, namely computed tomography and magnetic resonance imaging (MRI), allow identification of the thrombus and parenchymal involvement due to venous congestion to a variable degree, but this entity may appears as a nonexpected finding in a nonvenographic study. computed tomography and MRI venographies allow noninvasive confirmation of the diagnosis and adequate characterization of the extent of the thrombus and acute complications, both of them being robust diagnostic techniques. MR venography also can be done without the use of contrast media, which is especially important in certain clinical situations. Cerebral venous thrombosis needs follow-up, and imaging plays a key role in detection of late complications of the disease, including dural arteriovenous fistulas and intracranial hypertension due to veno-occlusive disease. Knowledge of other diseases and conditions that may mimic a thrombus is needed to avoid wrong diagnosis. In this article, we conduct a pictorial comprehensive review of cerebral venous thrombosis, including also the technical aspects of different imaging modalities, diagnosis and acute complications, follow-up, late complications and potential imaging mimics.

Association of admission clinical predictors and functional outcome in patients with Cerebral Venous and Dural Sinus Thrombosis

OBJECTIVES

Cerebral venous sinus thrombosis (CVST) is a rare subtype of stroke that most commonly affects younger women. While most patients treated with anticoagulation therapy have good outcomes, a significant number go on to experience disability. The primary aim of this study was to identify objective, easily reproducible, clinical admission predictors of poor outcome at discharge in patients with CVST.

PATIENTS AND METHODS

This was a retrospective cohort study of adult CVST patients admitted at our comprehensive stroke center between April 2004 and December 2017. The medical records of patients with a CVST discharge diagnosis code were reviewed for diagnosis confirmation and extraction of clinical and demographic admission data. Multivariable logistic regression was used to build predictive models of objective, standardized examination signs and adjusted for confounders. The primary endpoint was modified Rankin Scale score at discharge defined as good outcome (0-2) and poor outcome (3-6). Mortality was the secondary endpoint.

RESULTS

A total of 176 CVST patients were identified. Most patients were white (91 %) and female (65 %). The median age was 40 years old. Headache was the most commonly reported symptom (74 %). Intracranial hemorrhage (ICH) was present in 27 % of patients, venous infarct occurred in 22 % of the patients, and 12 % had both. Age (OR = 1.03, 95 % CI 1.01-1.05), abnormal level of consciousness (OR = 4.38, 95 % CI 1.86-8.88), and focal motor deficits (OR = 3.49, 95 % CI 1.49-8.15) were found to be predictive of poor functional outcome. Pre-hospitalization infections (OR = 5.22, 95 % CI 1.51-18.07) and abnormal level of consciousness (OR = 9.22, 95 % CI 2.34-36.40) were significant predictors of mortality. The predictive effect remained significant after adjusting by median PTT level, presence of intracranial hemorrhage, and venous infarct.

CONCLUSIONS

Age, abnormal level of consciousness, and focal motor deficits identified at admission are independently associated with poor outcome in CVST patients. These frequently prevalent, easily reproducible examination signs represent the first step to develop a clinical prediction tool toward stratifying CVST patients with poor prognosis at admission.

Cerebral Venous Thrombosis, Seasonal Trends, and Climatic Influence: A Region-SpecificStudy

Background and Purpose:

Studies looking at seasonal variation on cerebral venous thrombosis (CVT) are few with conflicting conclusions. In this region-specific study, we looked for climatic influence and seasonal trends on the incidence of CVT.

Methods:

Imaging proven adult CVT cases treated over a period of 18 years from a specific geographical location with similar seasons and climatic conditions were studied. Metrological parameters prepared using 30 years of data was used. Quantum geographical information system (QGIS software) and SPSS v 22 were used for patient plotting and analysis.

Results:

Total of 970 cases were studied. The incidence was significantly higher in summer 411 (42.3%) compared with autumn 317 (32.7%) and winter 242 (25.05); P = 0.038. This trend was consistent across all the 18 years in time series analysis. Mean age was 33.5 years (range 18–88 years). A significant majority 673 (69.4%) were below 40 years of age; P = 0.012. Females constituted 394 (40.6%) of cases. Postpartum CVT cases constituted 237 (30%). Interaction analysis showed younger age (<40 years) were more vulnerable for CVT in summer; P = 0.009. There was no seasonal influence on postpartum CVT. Apart for a weak positive correlation between rain fall (r = 0.18, P < 0.01); humidity and cloud cover was not influencing the incidence.

Conclusions:

Higher ambient temperatures were consistently associated with higher incidence of CVT. This is the largest region-specific study on CVT in the world. These results may be applicable to other regions with similar climatic conditions.

Prognostic value of JAK2V617F mutation in pseudotumor cerebri associated with cerebral venous sinus thrombosis

OBJECTIVES

To examine the clinical characteristics and prognosis of cerebral venous sinus thrombosis (CVST) that presented as pseudotumor cerebri (PTC) patients with JAK2V617F mutation.

METHODS

Medical records of all consecutive patients that presented with PTC and a JAK2V617F mutation who were treated were retrospectively reviewed. Data regarding demographics and ocular presenting symptoms and signs, neurological signs, hematological factors treatment, and prognosis were collected.

RESULTS

The most common presenting symptoms were headache (5 patients, 83.3%) and visual obscurations (5 patients, 83.3%). CVST of the sagittal sinus and sigmoid sinus were the most common site of thrombus. Platelet count and hemoglobin count were higher than normal during follow-up. There was significant change in the disk edema degree as well as decline in retinal nerve fiber layer (RNFL) thickness (P < 0.001, P < 0.001, Matched pairs). There was no significant change in visual acuity (VA) or mean deviation (MD) during follow-up (P = 0.95, 0.64, respectively, Matched pairs).

CONCLUSIONS

Pseudotumor cerebri resulting from CSVT in our patients with JAK2V617F mutation was frequent in young patients and needed medical and surgical treatment, without improvement in visual functions and in third caused poor visual outcome. Therefore, we believe that a screening test for JAK2V617F mutation should be considered for patients with CVST without known risk factor presenting with PTC, especially when sagittal sinus or sigmoid sinus involvement or thrombocytosis or high hemoglobin are found upon presentation. This might lead to more aggressive management which may improve the visual prognosis of those young patients.

Incidence of Dural Venous Sinus Thrombosis in Patients with Glioblastoma and Its Implications

OBJECTIVE

Glioblastoma (GBM) is associated with increased risk of developing dural venous sinus thrombosis (DVST), which often goes undiagnosed as symptoms are readily attributed to tumor. The purpose of this study was to investigate the incidence of DVST, potential predictive features on imaging, complications, its effect on survival, and time of greatest risk for developing DVST.

METHODS

A retrospective search of patients with GBM who had surgery followed by chemotherapy and/or radiation therapy between 2009 and 2015 at our institution was performed. Magnetic resonance imaging studies of the brain were reviewed on volumetric postgadolinium T1-weighted sequences for DVST. Tumors were characterized using the Visually Accessible REMBRANDT (Repository for Molecular Brain Neoplasia Data) Images classification, and identified thromboses were tracked for propagation, regression, or resolution. Statistical analyses were directed at identifying clinical predictors and survival differences between the DVST and no-DVST groups.

RESULTS

In total, 163 cases totaling 1637 scans, were reviewed; 12 patients (7.4%) developed DVST, of whom 11 presented with thrombus before any treatment. Tumor invasion of dural sinuses and greater T1/fluid-attenuated inversion recovery ratios were significantly associated with thrombus development (P = 0.02 and P = 0.02, respectively). In patients who developed DVST, thrombosis was more likely to develop ipsilateral to tumor side (P = 0.01) and was associated with a greater likelihood of developing extracranial venous thromboembolism (P = 0.012). There were no venous infarcts and no significant difference in survival between groups (P = 0.83).

CONCLUSIONS

Patients with GBM have increased risk of developing DVST, independent of surgical treatment or chemoradiation. DVST presence does not affect survival. Tumor invasion of dural sinuses and greater T1/fluid-attenuated inversion recovery ratio on preoperative imaging were the most significant predictors of DVST development.

Mechanical Thrombectomy with Intraoperative Local Thrombolysis Versus Mechanical Thrombectomy with Continuous Thrombolysis for Treatment of Cerebral Venous Sinus Thrombosis: A Systematic Review of 82 Cases

OBJECTIVE

The first-line treatment of cerebral venous sinus thrombosis (CVST) is systemic anticoagulation. However, patients with severe or a clinically worsening condition might benefit from mechanical thrombectomy (MT) combined with intraoperative thrombolysis (IOT) or MT with continuous thrombolytic infusion (CTI). The present study compared the efficacy and safety of these 2 endovascular therapeutic methods by performing a systematic review of the literature.

METHODS

The present systematic review was conducted to identify all cases of CVST treated with MT+IOT or MT+CTI/MT+IOT+CTI reported in PubMed and Ovid. The recanalization rates, outcomes, operation-related complications, sequelae, and postoperative hemorrhage rates were evaluated.

RESULTS

A total of 28 studies, including 82 patients, met the inclusion criteria. Alone, MT+IOT was performed in 42 patients (51%), and MT+CTI/MT+IOT+CTI was performed in 40 patients (49%). Overall, outcomes data were available for 69 patients, of whom 57 (82%) had had a good outcome and 12 (18%) had had a poor outcome or had died. Recanalization data were available for 68 patients. Of these patients, 28 (41%) had had complete recanalization, 40 (59%) had had partial, and no patient had had no recanalization. Operation-related complications occurred in 5 patients (6%), and 3 patients (4%) developed postoperative intracerebral hemorrhage. However, no significant differences were found in the recanalization rate or prognosis between the MT+IOT and MT+CTI/MT+IOT+CTI groups.

CONCLUSIONS

The results from our review suggest that MT with local thrombolysis is relatively safe, with no significant differences in efficacy and safety between MT+IOT alone and MT+CTI/MT+IOT+CTI. However, randomized controlled studies are required to provide a definitive answer on its use for CVST.

Global epidemiology and patterns of cerebral venous thrombosis: a systematic review and meta-analysis protocol

INTRODUCTION

Venous thrombosis can affect all veins in the body including cerebral veins, where it causes cerebral venous thrombosis (CVT). CVT is an aetiology of stroke, particularly in children and young adults. Its clinical features vary widely according to the occluded vessel. Data concerning the epidemiology of CVT are scant. This protocol for a systematic review and meta-analysis aims to critically synthesise data concerning prevalence, incidence, risk factors, anatomical patterns, diagnostic and therapeutic delays, and mortality rate of CVT in the global population.

METHODS AND ANALYSIS

MEDLINE, EMBASE and ISI Web of Science databases will be searched for relevant abstracts of studies published between 1 January 1990 and 31 October 2017, without language restriction. After the screening of abstracts, study selection, data extraction and assessment of risk of bias, we will assess studies individually for heterogeneity. Random effects meta-analysis will then be used to pool studies judged to be clinically homogenous. Funnel plot analysis and Egger's test will be used to detect publication bias. Results will be presented according to economic level of the various countries (high-income vs low/middle-income countries).

ETHICS AND DISSEMINATION

Since the current study will be based on published data, ethical approval is not required. This review is expected to provide relevant data to help in evaluating the global burden of CVT. The final report of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017074266.

Diagnosis and management of cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is rare and accounts for 0.5% of all strokes. Its clinical presentation is variable and diagnosis requires a high index of clinical suspicion in conjunction with neuroradiological diagnostic support. Treatment options are limited and are mostly based on consensus. Therefore, familiarity with international guidelines is important. Outcome is often good and most patients make a full recovery, although a small proportion suffers death or disability. Here, we describe the clinical features, risk factors, acute imaging features, management and complications of CVT.

Cerebral venous sinus thrombosis: A diagnostic challenge in a rare presentation

Cerebral venous sinus thrombosis (CVST) is an uncommon, life-threatening condition with a variable clinical presentation that makes it a challenge of diagnosis. A 39-year-old male patient presented to the hospital with complete loss of conscious and admitted to Medical Intensive Care Unit for investigation without any obvious history that was difficult for diagnosis. In this case, the patient presented with coma that is a rare presentation of CVST with no obvious clinical history and he was male patient that means he is free of all gender-specific risk factors of CVST. The brain computed tomography (CT) scan showed hypodense lesion in the left upper parietal region with no hemorrhage. The lesion was low-signal intensity (SI) on T1WIs and high SI on T2WIs and restricted on diffusion-weighted images like arterial infarctions, but magnetic resonance angiography (MRA) was normal that excluded arterial infarction. Gadolinium-enhanced MR venography (MRV) showed the filling defect of CVST. CVST can be present by a mysterious clinical presentation that makes it as a challenge of diagnosis even by medical imaging by CT and MR imaging (MRI). A combination of MRI and MRV is the best, noninvasive, and nonionizing imaging modality for the diagnosis of CVST.

Stent retriever thrombectomy combined with local thrombolytic therapy for cerebral venous sinus thrombosis: A case report

The present study reports the effect of successful treatment of cerebral venous sinus thrombosis (CVST) with stent retriever thrombectomy combined with local thrombolytic therapy. Medical records of 29 patients were retrospectively analyzed following a diagnosis of CVST with magnetic resonance venography (MRV) or digital subtraction angiography (DSA). Systemic anticoagulation was the initial treatment in all patients following admission. In group A, stent retriever thrombectomy combined with local thrombolytic therapy was performed on 14 patients who met the criteria of endovascular therapy. Stent-assisted angioplasty was also performed when patients presented with venous sinus stenosis. A total of 15 patients in group B received systemic anticoagulant treatment. Subsequently, warfarin was administered orally for 3 to 12 months as a continuous anticoagulant therapy. International normalized ratio was monitored when patients were receiving anticoagulant therapy. Additionally, clinical presentation, decision to escalate therapy, recanalization, Glasgow Coma Scale, modified Rankin Scale (mRS) and the clinical outcome was assessed. A total of 14 patients (9 female patients, 5 male patients), with ages ranging from 17 to 57 years, met the criteria of endovascular therapy. The clinical symptoms of 12 patients had improved after receiving endovascular therapy and only 2 patients suffered from intracranial hemorrhage following the procedure. Complete recanalization of venous sinus was exhibited in 10/14 (71.4%) patients in group A when compared with 1/15 (6.7%) patients in group B. mRS were improved in the 12-month follow-up in groups A and B when compared with that at admission. In the present study, patients with acute CVST treated with stent retriever thrombectomy combined with local thrombolytic therapy had a favorable outcome. To conclude, the present study provides a treatment option in treating CVST, particularly for patients that present with evident cortical venous outflow stasis or deteriorate neurology, despite appropriate anticoagulant therapy.

Red cell distribution width and the risk of cerebral vein thrombosis: A case-control study

BACKGROUND

Red cell distribution width (RDW) is a marker of cardiovascular diseases and venous thromboembolism, but its role in cerebral vein thrombosis (CVT) is unknown.

AIMS

To investigate whether high values of RDW are associated with an increased risk of CVT.

METHODS

A case-control study of CVT patients (≥18years-old) referred to our center contrasted with healthy individuals. Odds ratios (ORs) were calculated for RDW values >90th percentile by multivariable logistic regression and adjusted for demographic characteristics, hemorheological parameters, renal function, fibrinogen and CRP. Quartiles based on the distribution of RDW values were used in an additional model to assess a dose-response relationship. The risk of CVT associated with the combined presence of high RDW and either thrombophilia abnormalities or oral contraceptive use was also estimated.

RESULTS

143 cases (median age 36years, 18-79) and 352 controls (42years, 18-80) were investigated. RDW values >90th percentile (>14.6%) were associated with an increased risk of CVT (OR 2.44, 95% CI 1.39-4.28). The association remained after further adjustment for hemorheological parameters (OR 3.73, 95% CI 1.72-8.09), inflammatory markers (OR 3.77, 95% CI 1.72-8.25) and renal function (OR 3.62, 95% CI 1.53-8.55). The risk appeared restricted to these extreme levels (>14.6%), as there was no graded association between values of RDW and CVT risk over quartiles. There was a synergistic effect on the risk of CVT for the combination of high RDW and thrombophilia abnormalities (OR 33.20, 95% CI 6.95-158.55) or oral contraceptive use (OR 37.99, 95% CI 8.78-164.45).

CONCLUSIONS

Values of RDW >90th percentile are associated with CVT.

Optic Nerve

Optic nerve diseases arise from many different etiologies including inflammatory, neoplastic, genetic, infectious, ischemic, and idiopathic. Understanding some of the characteristics of the most common optic neuropathies along with therapeutic approaches to these diseases is helpful in designing recommendations for individual patients. Although many optic neuropathies have no specific treatment, some do, and it is those potentially treatable or preventable conditions which need to be recognized in order to help patients regain their sight or develop a better understanding of their own prognosis. In this chapter several diseases are discussed including idiopathic intracranial hypertension, optic neuritis, ischemic optic neuropathies, hereditary optic neuropathies, trauma, and primary tumors of the optic nerve. For each condition there is a presentation of the signs and symptoms of the disease, in some conditions the evaluation and diagnostic criteria are highlighted, and where possible, current therapy or past trials are discussed.

Cerebral Venous Sinus Thrombosis May Follow a Seasonal Pattern

BACKGROUND

Several studies have demonstrated seasonal and temporal variations in the incidence of arterial stroke; however, for cerebral venous sinus thrombosis (CVST), such study seems lacking. The main aim of this study was to investigate whether there is any seasonal variation for CVST, and association between CVST occurrence and temperature.

METHODS

This retrospective study was conducted from January 2004 to July 2015 in 2 referral centers for the patients with cerebrovascular disorders. One hundred and sixty-six consecutive patients with a hospital admission or discharge diagnosis of definite CVST were included. The incidence of CVST was compared between high-temperature and low-temperature months.

RESULTS

The mean age of patients was 36.71 ± 12.44 and 130 (78.31%) subjects were female. The highest frequency of CVST was seen in 3 months of July to September (1.69/month per year); and the lowest frequency of CVST was seen from December to April (.83/month per year). Additionally, there was a significant correlation between the mean average of temperature in each month and the frequency of CVST occurrence (r = .60, P = .03). Moreover, we found a cluster of patients, mostly females, in whom CVST occurred in cold months and accompanied visible cerebral infarct with higher occurrence of seizure, focal neurological deficit, and loss of consciousness.

CONCLUSIONS

It seems that the incidence of CVST increases in high-temperature months of the year and dehydration and ensuing consequences may play an important role in such augmentation; however, the visible cerebral infarct is again more observed in low-temperature months.

Coexistence of High Fibrinogen and Low High-density Lipoprotein Cholesterol Levels Predicts Recurrent Cerebral Venous Thrombosis

BACKGROUND

Cerebral venous thrombosis (CVT) may lead to serious neurological disorders; however, little is known about the risk factors for recurrent CVT. Our aim was to determine the association between elevated fibrinogen and decreased high-density lipoprotein cholesterol (HDL-C) levels with recurrent CVT.

METHODS

This retrospective cohort study included participants if they had a first episode of objectively defined CVT and were admitted to Xuan Wu Hospital, Capital Medical University from August 2005 to September 2009. Demographic and clinical variables were collected, as well as laboratory parameters, including plasma fibrinogen and HDL-C. Patients with CVT were followed for recurrent symptomatic CVT. Follow-up was through the end of September 2010. Potential predictors of recurrence were analyzed using Cox survival analysis.

RESULTS

At the end of the follow-up, 95 patients were eligible for the study. Twelve of 95 patients (12.6%) had recurred CVT. The median time of recurrence was 7 months (range: 1-39 months). Eight of these 12 (66.7%) experienced recurrence within the first 12 months after their initial CVT. The recurrence rate of CVT was 2.76 per 100 patient-years. Multivariate Cox regression analysis demonstrated that the coexistence of high fibrinogen (>4.00 g/L) and low HDL-C (<1.08 mmol/L) levels at baseline was the only independent predictor for recurrent CVT (hazard ratio: 4.69; 95% confidence interval: 1.10-20.11; P < 0.05). Of the twelve patients with recurrent CVT in our study, 7 (58.3%) had high fibrinogen plus low HDL-C levels. All 7 of these patients took warfarin for 3-12 months, and 6 of 7 had recurrent CVT after the discontinuation of anticoagulant treatment.

CONCLUSIONS

Concomitant high fibrinogen and low HDL-C levels may be associated with recurrence of CVT. The effect of potential risk factors related to atherothrombosis on recurrent CVT should be closely monitored.

Septic cerebral venous sinus thrombosis

Septic cerebral venous sinus thrombosis, once a common and deadly disease, has fortunately become rare now. Not only that the incidence has fallen significantly after the antibiotic era, the morbidity and mortality has also decreased substantially. Cavernous sinus thrombosis is by far the commonest form of septic cerebral venous sinus thrombosis. Due to its rare occurrence, a lot of current generation clinicians have not encountered the entity in person. Despite all the advances in diagnostic modalities, a high index of clinical suspicion remains the mainstay in prompt diagnosis and management of this potentially lethal condition. Keeping this in view, the authors have reviewed the subject including the old literature and have summarized the current approach to diagnosis and management. Septic cavernous thrombosis is a fulminant disease with dramatic presentation in most cases comprised of fever, periorbital pain and swelling, associated with systemic symptoms and signs. The preceding infection is usually in the central face or paranasal sinuses. The disease rapidly spreads to contralateral side and if remains undiagnosed and untreated can result in severe complications or even death. Prompt diagnosis using radiological imaging in suspected patient, early use of broad spectrum antibiotics, and judicial use of anticoagulation may save the life and prevent disability. Surgery is used only to treat the nidus of infection.

Factor V Leiden, factor V Cambridge, factor II GA20210, and methylenetetrahydrofolate reductase in cerebral venous and sinus thrombosis: A case-control study

Background:

Factor V G1691A (FV Leiden), FII GA20210, and methylenetetrahydrofolate reductase (MTHFR) C677T mutations are the most common genetic risk factors for thromboembolism in the Western countries. However, there is rare data in Iran about cerebral venous and sinus thrombosis (CVST) patients. The aim of this study was to evaluate the frequency of common genetic thrombophilic factors in CVST patients.

Materials and Methods:

Forty consequently CVST patients from two University Hospital in Isfahan University of Medical Sciences aged more than 15 years from January 2009 to January 2011 were recruited. In parallel, 51 healthy subjects with the same age and race from similar population selected as controls. FV Leiden, FII GA20210, MTHFR C677T, and FV Cambridge gene mutations by polymerase chain reaction technique were evaluated in case and control groups.

Results:

FV Leiden, FII GA20210, and FV Cambridge gene mutations had very low prevalence in both case (5%, 2%, 0%) and control (2.5%, 0%, 0%) and were not found any significant difference between groups. MTHFR C677T mutations was in 22 (55%) of patients in case group and 18 (35.5%) of control group (P = 0.09).

Conclusion:

This study showed that the prevalence of FV Leiden, FII GA20210, and FV Cambridge were low. Laboratory investigations of these mutations as a routine test for all patients with CVST may not be cost benefit.

Structural brain lesions in inflammatory bowel disease

Central nervous system (CNS) complications or manifestations of inflammatory bowel disease deserve particular attention because symptomatic conditions can require early diagnosis and treatment, whereas unexplained manifestations might be linked with pathogenic mechanisms. This review focuses on both symptomatic and asymptomatic brain lesions detectable on imaging studies, as well as their frequency and potential mechanisms. A direct causal relationship between inflammatory bowel disease (IBD) and asymptomatic structural brain changes has not been demonstrated, but several possible explanations, including vasculitis, thromboembolism and malnutrition, have been proposed. IBD is associated with a tendency for thromboembolisms; therefore, cerebrovascular thromboembolism represents the most frequent and grave CNS complication. Vasculitis, demyelinating conditions and CNS infections are among the other CNS manifestations of the disease. Biological agents also represent a risk factor, particularly for demyelination. Identification of the nature and potential mechanisms of brain lesions detectable on imaging studies would shed further light on the disease process and could improve patient care through early diagnosis and treatment.

Photothrombosis combined with thrombin injection establishes a rat model of cerebral venous sinus thrombosis

OBJECTIVE

Cerebral venous sinus thrombosis (CVST) is a rare but life-threatening disease and an animal model for in-depth study of CVST is needed. This study aimed to develop a rat model suitable for studying clinically relevant aspects of CVST and investigating its dynamic pathophysiological changes during a 7-day period.

METHOD

A photothrombosis method was used to create a rat sinus-vein thrombosis model. A spot size-adjustable Diode Pumped Solid State laser (DPSS) combined with thrombin injection occluded the rostral and caudal superior sagittal sinus (SSS). The model was used to evaluate pathophysiological changes at different time points over 7 days. Evans Blue dye injection was used to detect alterations in blood-brain barrier (BBB) permeability. Brain water content was also measured. Moreover, we examined changes in brain infarct volume, neurological function, as well as histology after induction of CVST.

RESULT

CVST in rats significantly altered BBB permeability, consistent with the development of brain edema. It was accompanied by an increase in brain infarct volume and deficits in neurological function that began on day 1, peaked on day 2, and typically improved by day 7 due to the neuroprotective effects of angiogenesis and gliocyte proliferation.

CONCLUSION

In this study, we describe a rat model that produces clinically relevant pathophysiology and pathology that will facilitate evaluation of therapeutic regimens for CVST. Furthermore, our results indicate a period of optimal clinical intervention for patients with CVST, which may reduce the probability of dependency and death.

Association Between Anemia and Cerebral Venous Thrombosis: Case-Control Study

BACKGROUND AND PURPOSE

Anemia is often considered to be a risk factor for cerebral venous thrombosis (CVT), but this assumption is mostly based on case reports. We investigated the association between anemia and CVT in a controlled study.

METHODS

Unmatched case-control study: cases were adult patients with CVT included in a single-center, prospective database between July 2006 and December 2014. Controls were subjects from the control population of the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) study. Anemia was defined according to World Health Organization criteria: nonpregnant women hemoglobin<7.5 mmol/L, pregnant women<6.9 mmol/L, and men<8.1 mmol/L. We used logistic regression analysis, adjusting for age, sex, malignancy, oral contraceptive use, and pregnancy/puerperium.

RESULTS

We included 152 cases and 2916 controls. Patients with CVT were younger (mean age, 40 versus 48 years) and more often women (74% versus 53%) than controls. Anemia was more frequent in cases (27.0%) than in controls (6.5%; P<0.001). Anemia was associated with CVT, both in univariate analysis (odds ratio, 5.3; 95% confidence interval [CI], 3.6-7.9) and after adjustment for potential confounders (adjusted odds ratio, 4.4; 95% CI, 2.8-6.9). Hemoglobin as a continuous variable was inversely associated with CVT (adjusted odds ratio per 1 mmol/L change 0.53; 95% CI, 0.42-0.66). Stratification by sex showed a stronger association between anemia and CVT in men (adjusted odds ratio, 9.9; 95% CI, 4.1-23.8) than in women (3.6; 95% CI, 2.1-6.0).

CONCLUSION

Our data suggest that anemia is a risk factor for CVT.

Heparin Resistance and Anticoagulation Failure in a Challenging Case of Cerebral Venous Sinus Thrombosis

We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus. She was started on systemic anticoagulation and underwent mechanical clot removal and catheter-directed endovascular thrombolysis with limited success. Complicating the intensive care unit care was the development of heparin resistance, with an inability to reach the target partial thomboplastin time (PTT) of 60 to 80 seconds. At her peak heparin dose, she was receiving >35 000 units/24 h, and her PTT was subtherapeutic at <50 seconds. Deficiency of ATIII was suspected as a possible etiology of her heparin resistance. Fresh frozen plasma was administered for ATIII level repletion. Given her high thrombogenic risk and challenges with conventional anticoagulation regimens, we transitioned to argatroban for systemic anticoagulation. Heparin produces its major anticoagulant effect by inactivating thrombin and factor X through an AT-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and the AT. A deficiency of AT leads to a hypercoagulable state and decreased efficacy of heparin that places patients at high risk of thromboembolism. Heparin resistance, especially in the setting of critical illness, should raise the index of suspicion for AT deficiency. Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.

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.

Oral Direct Thrombin Inhibitor as an Alternative in the Management of Cerebral Venous Thrombosis: A Series of 15 Patients

Background

Cerebral vein thrombosis is a rare cause of stroke with significant risk of death and long-term dependency. Anticoagulation has been associated with better long-term prognosis, and vitamin K antagonists are usually prescribed in this setting.

Aim

The aim of this study was to present a series of 15 cerebral vein thrombosis patients treated with dabigatran.

Methods

Retrospective study of clinical, imaging, and follow-up characterization of all patients admitted with cerebral vein thrombosis and treated with dabigatran in a tertiary neurology department between June 2011 and December 2013 was conducted. Complications and adverse effects were recorded. Modified Rankin Scale was used to assess clinical severity; excellent outcome was defined as modified Rankin Scale at six-months of 0 to 1. Recanalization was assessed with an angiographic method (computer tomography, magnetic resonance imaging, or digital subtraction angiography).

Results

Eighteen patients were admitted for cerebral vein thrombosis. Dabigatran was started in 11 patients, and warfarin was started in 7. Four patients on warfarin were switched to dabigatran because of adverse effects at 0·5, 1, 3·5, and 4 months. A total of 15 patients were treated with dabigatran with median follow-up time of 19 months. Excellent outcome was observed in 87% of patients and recanalization in 80%.

Conclusions

We report the largest series of cerebral vein thrombosis patients treated with dabigatran. Clinical outcome was excellent in most patients and not different from other studies. Dabigatran could possibly be considered an alternative to warfarin; nevertheless, further prospective assessment with randomized controlled studies is warranted.

Cerebral venous sinus thrombosis may be associated with hepatitis B virus infection: a preliminary finding

OBJECTIVE

To assess the clinical significance of hepatitis B virus (HBV) infection in patients with cerebral venous sinus thrombosis (CVST).

METHODS

Twenty-two patients with CVST confirmed by magnetic resonance venography (MRV) or digital subtraction angiography (DSA) and 743 controls with ischemic stroke confirmed by magnetic resonance imaging (MRI) were analyzed retrospectively.

RESULTS

Among all researches, HBV surface antigen (HBsAg)-positive rate was high. Six of the 22 (27.3%) confirmed cases had HBsAg. However, HBsAg-positive rate in patients with ischemic stroke was only 45 of the 743 cases (6.1%), closed to the average prevalence in China (∼ 8.6%), but much lower than the positive rate in CVST patients (27.3 vs 6.1%, P  =  0.002). Odd ratio (OR) value between HBsAg-positive CVST patients (27.3%) and HBsAg-positive ischemic stroke patients (6.1%) was 5.78. The OR value between HBsAg-positive CVST patients (27.3%) and average prevalence of HBV infection in China (8.6%) was nearly 3.99. It meant that HBV infection might be a risk factor for CVST. However, there existed no statistically significant difference in HBV surface antibody (HBsAb), HBV e antigen (HBeAg), HBV e antibody (HBeAb), and HBV central antibody (HBcAb)-positive rate. The HBV surface antigen (HBsAg)-positive CVST patients did not show worse liver function. Most of them were inactive HBV carriers.

CONCLUSION

Hepatitis B virus infection may be a risk factor for CVST.

Low levels of tissue factor pathway inhibitor increase the risk of cerebral venous thrombosis

Background:

Decreased concentration of tissue factor pathway inhibitor (TFPI) is a risk factor for development of deep venous thrombosis and coronary heart disease, but there is no evidence for the relationship between TFPI and cerebral venous and sinus thrombosis (CVST). The aim of this study was to determine the level of TFPI in healthy population and in patients with CVST.

Materials and Methods:

We determined the plasma level of TFPI in 20 patients with CVST (cases) and 31 healthy volunteer subjects (as control group) by enzyme linked immunoassay method. We also examined the association between TFPI and the risk of CVST. Continuous variables were compared between groups using Student's t test, and odds ratio was calculated by multiple logistic regression analysis.

Results:

The mean TFPI was significantly lower in the CVST group compared with the control group (8.60 ± 4.05 ng/mL; 14.6 ± 8.6 ng/mL; P = 0. 005), respectively. The odds ratio for CVST associated with low (<25^th percentile) levels of TFPI was 5.429 (95% CI, 1.487-19.82, P = 0.012).

Conclusion:

Our investigation demonstrates that reduced TFPI may be one of the risk factors of CVST and associated with increasing the risk of developing CVST.

Neurological disorders and inflammatory bowel diseases

Extraintestinal manifestations occur in about one-third of patients living with inflammatory bowel disease (IBD) and may precede the onset of gastrointestinal symptoms by many years. Neurologic disorders associated with IBD are not frequent, being reported in 3% of patients, but they often represent an important cause of morbidity and a relevant diagnostic issue. In addition, the increasing use of immunosuppressant and biological therapies for IBD may also play a pivotal role in the development of neurological disorders of different type and pathogenesis. Hence, we provide a complete and profound review of the main features of neurological complications associated with IBD, with particular reference to those related to drugs and with a specific focus on their clinical presentation and possible pathophysiological mechanisms.