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Mahal S, Yadav T, Panda S, Garg PK, Khera PS, Tiwari S. Multimodality imaging in cerebral venous thrombosis: a synopsis for emergency radiologist. Jpn J Radiol 2024; 42:437-449. [PMID: 38212513 DOI: 10.1007/s11604-023-01522-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/02/2023] [Indexed: 01/13/2024]
Abstract
Cerebral venous thrombosis (CVT) is an uncommon but potentially fatal condition which presents with a wide range of symptoms. Some of these presenting features are vague thus contributing to the delay in diagnosis. A prompt diagnosis and initiation of appropriate therapy are therefore of paramount importance. In this pictorial, we have tried to illustrate the direct and indirect imaging features of CVT in detail on multiple imaging modalities, along with the potential pitfalls of imaging.
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Affiliation(s)
- Sayani Mahal
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India.
| | - Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Pushpinder Singh Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
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Arsovska AA, Venketasubramanian N. Use of MLC901 in cerebral venous sinus thrombosis: Three case reports. World J Clin Cases 2024; 12:346-353. [PMID: 38313657 PMCID: PMC10835695 DOI: 10.12998/wjcc.v12.i2.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/17/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVT) is rare cause of cerebrovascular disease. The incidence is 0.5% of all stroke. The majority of affected patients are young adults (mean age: 35-40 years) with mild to moderate disabilities. Poor outcome with severe disability is seen in 13% of cases. Early diagnosis and treatment are important for good outcomes and preventing complications. Treatment options are limited and mostly based on consensus. NeuroAiD II™ (MLC901; Moleac Pte, Ltd, Singapore) has a potential beneficial role in post-stroke recovery, by aiding the natural brain recovery process. CASE SUMMARY MLC901 consists of nine natural herbal ingredients. Studies have shown its safety profile and aid in post stroke recovery. The aim of this case series was to demonstrate the potential role of MLC901 in stroke recovery of patients with cerebral venous sinus thrombosis (CVST) who received MLC901 in addition to standard of care. The prescribed dose of MLC901 is 400 mg/cap two capsules, three times a day. Data from these patients were prospectively collected at baseline and at monthly visits, for a duration of 3 mo. Outcome measures included adherence to therapy, side effects, National Institutes of Health Stroke Scale, Glasgow Coma Scale, modified Rankin Scale, and the Short Orientation-Memory-Concentration Test. MLC901 was well tolerated and no side effects were reported. All patients were stable with improved condition. CONCLUSION This case series highlights the potential therapeutic effects of MLC901 on CVST and provides support for further studies.
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Affiliation(s)
- Anita Ante Arsovska
- Department of Urgent Neurology, University Clinic of Neurology, University Ss. Cyril and Methodius-Faculty of Medicine, Skopje 1000, North Macedonia
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Mishra AK, Shukla R, Chaurasia RN, Verma A. Descriptive Study of Headache as the Most Common Presenting Feature of Cerebral Venous Thrombosis. Cureus 2023; 15:e43007. [PMID: 37674961 PMCID: PMC10477085 DOI: 10.7759/cureus.43007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE To study the etiology and clinical characteristics of cerebral venous thrombosis (CVT) patients with a detailed description of headache as a presenting feature. INTRODUCTION CVT is an infrequent type of stroke with protean clinical manifestations. The most common presenting symptom in CVT is headache (>85%), followed by seizures and focal neurological deficits. METHODS A total of 32 consecutive and confirmed patients of CVT were recruited after obtaining informed consent. CVT was diagnosed based on clinical and imaging parameters. Data regarding etiology, clinical symptoms, and signs with special mention of headache pattern, onset, site, character, severity (based on the visual analog scale), aggravating and relieving factors, as well as sinus involvement were recorded. RESULTS A total of 32 patients (16 males and 16 females) with a mean age of 31.56 (SD = 14.31) years were recruited, out of which 31 patients (96.87%) presented with headaches. The mode of onset of headache was acute in 19.35%, sub-acute in 67.75%, and chronic in 12.9% of patients. Location was holocranial in 38.71%, hemicranial in 29.03%, frontal in 22.58%, and occipital in 9.68% of patients. Headache was severe in 38.7% and moderate in 61.3% of patients. Character was throbbing in 67.74%, heaviness in 25.8%, and band-like in 6.46% of patients. Headache was aggravated on bending forward in 58.06%, movement in 35.48%, coughing in 32.26%, straining in 25.8%, and standing in 16.12% of patients. The relieving factors of headache were lying down in 45.16%, sleeping in 45.16%, and sitting quietly in 9.86% of patients. CONCLUSION CVT should be suspected in patients presenting with new-onset holocranial or hemicranial headaches of increasing intensity, thereby requiring early imaging and appropriate management.
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Affiliation(s)
- Ashutosh K Mishra
- Department of Neurology, All India Institute of Medical Sciences, Raebareli, IND
| | - Ruchi Shukla
- Department of Ophthalmology, All India Institute of Medical Sciences, Raebareli, IND
| | - Rameshwar N Chaurasia
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Archana Verma
- Department of Neurology, All India Institute of Medical Sciences, Raebareli, IND
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Zhao Y, Su X, Liu Z, Zhou C, Yu J, Wang X, Zhou L, Shi Z, Liu L, Lu H, Zhao P, Li Z, Bu K, Guo L, Liu X. Effect of intracranial venous collaterals on neurological outcomes in cerebral venous thrombosis. J Clin Neurosci 2022; 102:95-100. [PMID: 35763987 DOI: 10.1016/j.jocn.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 06/04/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Abstract
This study identifies predictors of favourable intracranial venous collaterals and the effect of intracranial venous collaterals on outcomes and recanalization in patients with cerebral venous thrombosis (CVT). Data of 61 patients with CVT were retrospectively reviewed. Venous collateralization was defined as expanded cortical vein formation through different drainage pathways. Recanalization grades were classified into complete or partial recanalization based on images obtained during hospitalisation and follow-up. Independent predictors of collateral formation and poor prognosis were investigated via univariate and binary logistic regression analyses. The effects of different intracranial venous collaterals on recanalization in patients with CVT were assessed. A risk prediction nomogram for prognosis was constructed. Age ≤ 35 years (odds ratio (OR) = 7.067; 95% confidence interval (CI) = 1.776-28.277; P = 0.006) and male sex (OR = 5.490; 95% CI = 1.205-25.004; P = 0.028) were independent predictors of favourable venous collaterals. Venous collaterals were associated with early recanalization (P = 0.017) and not with long-term recanalization (P = 0.252). Male sex (OR = 0.047; 95% CI = 0.003-0.651; P = 0.023), subacute onset (OR = 0.026; 95% CI = 0.002-0.367; P = 0.007), and good collateral grade (OR = 0.168; 95% CI = 0.029-0.985; P = 0.048) were independent factors of favourable neurological outcomes at discharge. Haemorrhage on computed tomography at admission (OR = 10.868; 95% CI = 2.082-56.733; P = 0.005) was inversely correlated with prognosis. These findings suggested that male patients under 35 years of age are more likely to have favourable venous collaterals and good outcomes. Venous collaterals are significantly associated with early recanalization. These findings highlight the importance of venous collateral evaluation in patients with CVT.
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Affiliation(s)
- Yanying Zhao
- Department of Psychosomatic Medicine, The Second Hospital of Hebei Medical University, 215 West Heping Road, Shijiazhuang, Hebei 050000, China; Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Xudong Su
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Zengpin Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Cunhe Zhou
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Jianghua Yu
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Xiaopeng Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Lixia Zhou
- Department of Radiology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Zhaoxia Shi
- Department of Radiology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Lin Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Honglin Lu
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Pandi Zhao
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Zhongzhong Li
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Kailin Bu
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Li Guo
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China
| | - Xiaoyun Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, 215 West, Heping Road, Shijiazhuang, Hebei 050000, China; Neuroscience Research Center, Medicine and Health Institute, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang, Hebei 050000, China.
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Jain RS, Sripadma PV, Tejwani S. Clinical Characteristics, Etiology, Recanalization Rates and Neurological Outcomes in CVT: A Prospective Cohort Study. Ann Indian Acad Neurol 2022; 25:229-234. [PMID: 35693659 PMCID: PMC9175402 DOI: 10.4103/aian.aian_718_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/25/2021] [Accepted: 10/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Recanalization rates in cerebral venous thrombosis (CVT) and its effect on neurological outcome have been debated worldwide and are inadequately addressed in studies from India. Our objective was to study the clinical profile of CVT and determine recanalization rates with its predictors and its effect on outcome. Methods A prospective single centre cohort study on 101 patients with radiologically confirmed acute CVT between October 2018 and June 2021 was conducted. Anticoagulation was given for 3-12 months or lifelong for thrombophilias. Recanalization status of vessels was assessed between 3-6 months and at 12 months after ictus. Outcome was defined as favorable (mRS 0-1) or unfavorable. Patients with atleast one CT/MR venogram on follow up were included. Results Of the 101 enrolled patients, 83 completed study protocol. Mean age of patients was 34.2 ± 11.7 years. Clinical characteristics included headache (75.9%),seizure (66.2%), altered mentation(20.4%) with clustering of cases during summers. Transverse- sigmoid sinuses were predominantly involved (66.2 %) followed by superior sagittal sinus (SSS,65.0%).Commonest etiologies were thrombophilia (27.7%) and postpartum state (15.6%). Complete recanalization was achieved in 67.4%, partial in 26.5% and no recanalization in 6.02% at end of 12 months. Recanalization rates improved from 83.09% between 3-6 months to 93.9 % at 12 months. Median time to last follow-up was 12months and at last follow up 95.1% had favorable mRS with recurrence in two patients with raised factor VIII levels. Conclusion Recanalization occurred in more than 90% of CVT patients. Isolated superior sagittal sinus thrombosis and age <50 years were predictors of complete recanalization. Most patients, except few achieved a favorable mRS.
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Affiliation(s)
| | - P V Sripadma
- Department of Neurology, SMS Medical College, Jaipur, Rajasthan, India
| | - Shankar Tejwani
- Department of Neurology, SMS Medical College, Jaipur, Rajasthan, India
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KAVAK S, BATMAZ İ, ŞENOCAK A, HALİSÇELİK M, GÜL Y, ŞANLI C, BULU G, ÇİM B, ÇELİK KAVAK E. Cerebral Vein Sinus Thrombosis in Obstetrics and Gynecology Practice. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.934151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Amaç. Serebral Ven Sinüs Trombozu (SVST) çok çeşitli ve nonspesifik semptomlarla kendini gösteren ve farklı etiyolojilere bağlı olarak ortaya çıkan klinik bir durumdur. Tanısı kolayca konulamayan nadir bir hastalıktır. SVST gelişen olgularda, jinekolojik ve obstetrik nedenlerin araştırılmasını amaçladık.
Gereç ve Yöntemler. Fırat Üniversitesi Tıp Fakültesi Hastanesi’ne Kasım 2010 ile Kasım 2020 tarihleri arasında nörolojik şikayetlerle başvuran, yapılan değerlendirmede SVST tanısı konulan olgular ile obstetrik/jinekolojik nedenlerle SVST gelişen kadınlar, retrospektif olarak incelendi. Kadınların başvuru şikâyetleri, nöroradyolojik bulguları ve uygulanan tedaviler kayıtlardan tespit edildi. Verilerin değerlendirmesinde tanımlayıcı istatistik kullanıldı.
Bulgular. Çalışmanın yapıldığı dönemde 166 olguya SVST tanısı konuldu. Olguların 105’i kadın (% 63,2) ve 61’i erkek (% 36,8) idi. 15 olguda (% 9) obstetrik ve jinekolojik nedenlere sekonder SVST geliştiği tespit edildi. En sık semptom baş ağrısı (%80) ve en sık bulgu papil ödemi (%20) ile birlikte hemiparezi (%13,3) ve hemipleji (%6,7) olarak tespit edildi. Çalışmaya dâhil edilen altı olgu (%40) puerperal dönemde idi. Bunlardan iki olgu (%13,3) vaginal yolla, dört olgu (%26,7) ise sezaryenle doğum yapmıştı. Olgulardan beş tanesi (%33,3) gebe idi. Gebelerin tamamı gebeliğin 3. trimesterinde bulunuyordu. Bir olguda (%6,7) mastoidit geliştiği ve 4 ay öncesinde vaginal yolla doğum yaptığı tespit edildi. Bir olgunun puerperal dönemde olduğu ve eşlik eden sinüzit enfeksiyonu bulunduğu (%6,7), ayrıca aile öyküsünde postpartum derin trombozu varlığı tespit edildi. İki olgunun (% 13,3) kombine oral kontraseptif (OKS) kullandığı, bunlardan birinde MTHFR homozigot mutasyon varlığı ve homosistein yüksekliği tespit edildi. Olguların tamamı değerlendirildiğinde 7 olguda (%46,7) kalıtsal trombofili tanısı mevcuttu.
Sonuç. SVST olgularında gebelik, puerperal dönem ve OKS kullanımı başta olmak üzere, obstetrik ve jinekolojik nedenler %10’a yakın yer tutar ve değerlendirme sırasında göz önünde bulundurulmalıdır.
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Affiliation(s)
| | | | | | | | - Yeliz GÜL
- UNIVERSITY OF HEALTH SCIENCES, ELAZIĞ HEALTH RESEARCH CENTER
| | - Cengiz ŞANLI
- UNIVERSITY OF HEALTH SCIENCES, ELAZIĞ HEALTH RESEARCH CENTER
| | - Gülay BULU
- UNIVERSITY OF HEALTH SCIENCES, ELAZIĞ HEALTH RESEARCH CENTER
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Significance of recanalization of sinuses and resolution of parenchymal lesion in cerebral venous sinus thrombosis. J Clin Neurosci 2020; 77:175-180. [PMID: 32354649 DOI: 10.1016/j.jocn.2020.04.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/19/2020] [Indexed: 11/22/2022]
Abstract
In cerebral venous sinus thrombosis (CVST), the degree of recanalization may determine resolution of parenchymal lesion and clinical outcome. The aim of our study was to evaluate the relationship of recanalization with resolution of MRI lesion and clinical outcome. The patients with CVST diagnosed on the basis of magnetic resonance venography (MRV) were included prospectively. Risk factors, clinical features, and MRI and MRV findings were noted. MRI and MRV were repeated at 6 months and the change in parenchymal lesion and grade of recanalization (I, II, III) were noted. Patients were evaluated clinically at three and six months. Complete recovery was considered if modified Rankin Scale (mRS) score was 0. Thirty-three CVST patients were included, 12 (36.4%) of whom were females. Recanalization occurred in 29 (87.9%), which was complete (grade III) in 6 (21%). Sigmoid sinus (52%) recanalized more frequently. Resolution of parenchymal lesion on repeat MRI occurred in 13.3% (4/30) patients, and they had no sequelae. Degree of recanalization was not related to resolution of neurological sequelae, MRI lesion at follow up and burden of thrombosis at baseline. Varying degree of recanalization occurred in 87.9% patients with CVST, and resolution of parenchymal lesion occurred in 13.3%. Clinical outcome however was not related to recanalization.
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Kalita J, Singh VK, Jain N, Misra UK, Kumar S. Cerebral Venous Sinus Thrombosis Score and its Correlation with Clinical and MRI Findings. J Stroke Cerebrovasc Dis 2019; 28:104324. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/11/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023] Open
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Canedo-Antelo M, Baleato-González S, Mosqueira AJ, Casas-Martínez J, Oleaga L, Vilanova JC, Luna-Alcalá A, García-Figueiras R. Radiologic Clues to Cerebral Venous Thrombosis. Radiographics 2019; 39:1611-1628. [DOI: 10.1148/rg.2019190015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Background and Purpose- The role of recanalization of the occluded dural sinus or vein in the outcome of patients with cerebral venous thrombosis (CVT) is not established. We aimed to systematically review, in patients with CVT, (1) the recanalization rate and its association with (2) clinical outcome and (3) CVT recurrence. Methods- Systematic search in MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane Library, and clinicaltrials.gov (inception to September 2017). We considered cohort studies reporting the recanalization rate in adult patients with CVT treated with anticoagulation. Reported rates of venous recanalization at the last follow-up, functional outcome defined using the modified Rankin scale at last follow-up dichotomized for favorable (0-1) and unfavorable (2-6) outcome, and recurrence rate of CVT according to recanalization status were extracted independently by 2 authors. Meta-analyses of proportions were performed using Freeman-Tukey double arcsine transformation. Functional outcomes according to the recanalization status were compared using meta-analysis and ordinal logistic regression. We conducted sensitivity analyses for time to assessment of recanalization and study quality. Results- Four hundred sixty-eight studies were identified, and 19 studies were included. (1) We found report of 694 patients with recanalization in the follow-up among 818 cases of CVT. The overall pooled proportion of patients achieving recanalization was 85% (95% confidence interval, 80-89; I2=58%). In studies with higher methodological quality, the recanalization rate was 77% (95% confidence interval, 70-82; I2=0%). (2) There was a significant increase in the chance of favorable outcome (modified Rankin scale, 0-1) in patients with recanalization with a pooled odds ratio of 3.3 (95% confidence interval, 1.2-8.9; I2=32%) in the random effects meta-analysis and a common odds ratio of 3.3 (95% confidence interval, 1.7-6.3) in the ordinal logistic regression. (3) Data on CVT recurrence according to recanalization was scarce. Conclusions- The overall rate of recanalization in patients receiving anticoagulation was 85%, but exclusion of severe patients from follow-up imaging is a plausible source of bias. Lack of venous recanalization was associated with worse clinical outcome.
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Affiliation(s)
- Diana Aguiar de Sousa
- From the Department of Neurosciences and Mental Health (D.A.d.S., P.C., J.M.F.).,J. Ferro Lab, Instituto de Medicina Molecular, Lisbon, Portugal (D.A.d.S., P.C., J.M.F.).,Institute of Anatomy (D.A.d.S., L.L.N.)
| | - Lia Lucas Neto
- Department of Neuroradiology (L.L.N.), Hospital de Santa Maria, Lisbon, Portugal.,Institute of Anatomy (D.A.d.S., L.L.N.)
| | - Patrícia Canhão
- From the Department of Neurosciences and Mental Health (D.A.d.S., P.C., J.M.F.).,J. Ferro Lab, Instituto de Medicina Molecular, Lisbon, Portugal (D.A.d.S., P.C., J.M.F.).,Neurology Clinic (P.C., J.M.F.), University of Lisbon, Portugal
| | - José M Ferro
- From the Department of Neurosciences and Mental Health (D.A.d.S., P.C., J.M.F.).,J. Ferro Lab, Instituto de Medicina Molecular, Lisbon, Portugal (D.A.d.S., P.C., J.M.F.).,Neurology Clinic (P.C., J.M.F.), University of Lisbon, Portugal
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Brunori M, Lazzari I, Recinella G, Puddu G, Zoli M. Persistent headache: a case of post-traumatic cerebral venous thrombosis. Br J Hosp Med (Lond) 2019; 80:478-479. [DOI: 10.12968/hmed.2019.80.8.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mattia Brunori
- 4th Year Resident, Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola- Malpighi University Hospital, Bologna, Italy
| | - Ilaria Lazzari
- 4th Year Resident, Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola- Malpighi University Hospital, Bologna, Italy
| | - Guerino Recinella
- 4th Year Resident, Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola- Malpighi University Hospital, 40138, Bologna, Italy
| | - Giovanni Puddu
- Specialty Doctor, Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola- Malpighi University Hospital, Bologna, Italy
| | - Marco Zoli
- Professor of Internal Medicine, Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
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Improvement in the Prognosis of Cerebral Venous Sinus Thrombosis over a 22-Year Period. Can J Neurol Sci 2019; 45:44-48. [PMID: 29334037 DOI: 10.1017/cjn.2017.236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cerebral venous thrombosis is a rare cause of stroke, with a number of well-defined risk factors. However, there exist few studies that describe trends in the prognosis of this disease over time. METHODS A retrospective study was performed on patients diagnosed with cerebral venous thrombosis at the University of Alberta Hospital during two time periods: 1988-1998 (21 patients) and 1999-2009 (40 patients). Signs and symptoms, risk factors, imaging findings, etiologies, treatment modalities, and status at discharge were examined. RESULTS Headache, nausea and vomiting, focal motor deficit, and seizure were the most common signs and symptoms, and active hormonal contraception was the most commonly identified risk factor between the two cohorts. Hematoma and hyperdense sinuses were the most commonly identified CT findings between groups. Thrombophilia and the use of hormonal contraception were the most frequently identified etiologies between the two cohorts. Treatment was similar, with the majority of patients in both cohorts receiving unfractionated heparin as first-line therapy. Patients in the 1999-2009 cohort were significantly less likely to have a severe deficit or be dead at discharge (odds ratio [OR]=0.178; 95% confidence interval [CI 95%]=0.051, 0.625) and were more likely to have a favorable modified Rankin Scale score of 0 or 1 at discharge (OR=7.98; CI 95%=1.79, 35.71). CONCLUSIONS Our data indicate a reduction in severe residual symptoms at discharge and improved functional status at discharge for patients presenting with cerebral venous thrombosis from 1999 to 2009, as compared with 1988-1998.
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Ding J, Zhou D, Hu Y, Elmadhoun O, Pan L, Ya J, Geng T, Wang Z, Ding Y, Ji X, Meng R. The efficacy and safety of Batroxobin in combination with anticoagulation on cerebral venous sinus thrombosis. J Thromb Thrombolysis 2018; 46:371-378. [PMID: 30062617 DOI: 10.1007/s11239-018-1718-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cerebral venous sinus thrombosis (CVST) is an uncommon subtype of stroke with highly variable clinical presentation. Although anticoagulation with heparin and/or warfarin remains the standard treatment for CVST, treatment failure is still common. This study aims to evaluate the safety and efficacy of Batroxobin in combination with anticoagulation on CVST control. In this retrospective study, a total of 61 CVST patients were enrolled and divided into Batroxobin (n = 23) and control (n = 38) groups. In addition to the same standard anticoagulation in control, patients in the treatment group received Batroxobin 5 BU intravenous infusion (10 BU for the first time) every other day, for a total of three infusions. A higher recanalization rate was found in Batroxobin group (adjusted OR [95% CI] of 2.5 [1.1-5.0], p = 0.028) compared to the control group, especially in patients with high levels of fibrinogen (adjusted OR [95% CI] of 4.7 [1.4-16.7], p = 0.015). Statistically significant differences between the two groups were seen regarding the levels of thrombin time, fibrinogen and D-dimer at each cut-off time point (all p < 0.01). Compared with baseline, NIHSS scores at discharge showed significant improvement in the Batroxobin group [0(0, 4.25)-5(2, 11), p = 0.036]. No significant difference in mRS scores was found between the two groups at discharge or at 6-month outpatient follow-up (all p > 0.05). Additionally, Batroxobin did not increase the risk of intracranial hemorrhage. We conclude that Batroxobin is a potentially safe and effective adjunct therapeutic agent promoting CVST recanalization especially in patients with high level of fibrinogen.
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Affiliation(s)
- Jiayue Ding
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Da Zhou
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Yanyu Hu
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Omar Elmadhoun
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, 48201, USA
- Department of Anesthesiology and Critical Care, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, 02215, USA
| | - Liqun Pan
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Jingyuan Ya
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Tingting Geng
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Zhongao Wang
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Yuchuan Ding
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Xunming Ji
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China
| | - Ran Meng
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China.
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14
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Saigal G, Ezuddin NS, Vega GDL. Neurologic Emergencies in Pediatric Patients Including Accidental and Nonaccidental Trauma. Neuroimaging Clin N Am 2018; 28:453-470. [DOI: 10.1016/j.nic.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Rashad S, Niizuma K, Sato-Maeda M, Fujimura M, Mansour A, Endo H, Ikawa S, Tominaga T. Early BBB breakdown and subacute inflammasome activation and pyroptosis as a result of cerebral venous thrombosis. Brain Res 2018; 1699:54-68. [PMID: 29981290 DOI: 10.1016/j.brainres.2018.06.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/23/2018] [Accepted: 06/24/2018] [Indexed: 02/04/2023]
Abstract
Cerebral venous thrombosis (CVT) is a rare form of cerebral stroke that causes a variety of symptoms, ranging from mild headache to severe morbidity or death in the more severe forms. The use of anti-coagulant or thrombolytic agents is the classical treatment for CVT. However, the development of new therapies for the treatment of the condition has not been the focus. In this study, we aimed to analyze the pathophysiology of CVT and to identify the pathways associated with its pathology. Moreover, mechanisms that are potential drug targets were identified. Our data showed the intense activation of immune cells, particularly the microglia, along with the increase in macrophage activity and NLRP3 inflammasome activation that is indicated by NLRP3, IL-1β, and IL-18 gene and caspase-1 upregulation and cleavage as well as pyroptotic cell death. Leukocytes were observed in the brain parenchyma, indicating a role in CVT-induced inflammation. In addition, astrocytes were activated, and they induced glial scar leading to parenchymal contraction during the subacute stage and tissue loss. MMP9 was responsible primarily for the BBB breakdown after CVT and it is mainly produced by pericytes. MMP9 activation was observed before inflammatory changes, indicating that BBB breakdown is the initial driver of the pathology of CVT. These results show an inflammation driven pathophysiology of CVT that follows MMP9-mediated BBB breakdown, and identified several targets that can be targeted by pharmaceutical agents to improve the neuroinflammation that follows CVT, such as MMP9, NLRP3, and IL-1β. Some of these pharmaceutical agents are already in clinical practice or under clinical trials indicating a good potential for translating this work into patient care.
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Affiliation(s)
- Sherif Rashad
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Neurosurgical Engineering and Translational Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Neurosurgical Engineering and Translational Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Neurosurgical Engineering and Translational Neuroscience, Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan.
| | - Mika Sato-Maeda
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Ahmed Mansour
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shuntaro Ikawa
- Department of Project Programs, Institute of Development, Aging and Cancer (IDAC), Tohoku University, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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16
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Rezoagli E, Martinelli I, Poli D, Scoditti U, Passamonti SM, Bucciarelli P, Ageno W, Dentali F. The effect of recanalization on long-term neurological outcome after cerebral venous thrombosis. J Thromb Haemost 2018; 16:718-724. [PMID: 29341411 DOI: 10.1111/jth.13954] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Indexed: 12/01/2022]
Abstract
Essentials The role of cerebral venous thrombosis (CVT) recanalization on neurologic outcome is still debated. We studied a large cohort of 508 CVT patients with 419 patient years of radiological follow-up. Recanalization rate is high during the first months after CVT and neurologic outcome is favorable. High recanalization grade of CVT independently predicts good neurological outcome. SUMMARY Background Studies with limited sample size and with discordant results described the recanalization time-course of cerebral venous thrombosis (CVT). The neurological outcome after a first episode of CVT is good, but the role of recanalization on neurological dependence is still debated. Objectives The aim of the study is to assess the recanalization rate after cerebral venous thrombosis (CVT) and its prognostic role in long-term neurological outcome. Patients/Methods In a retrospective observational multicenter cohort study, patients with an acute first episode of CVT with at least one available imaging test during follow-up were enrolled. Patency status of the vessels was categorized as complete, partial or not recanalized. Neurological outcome was defined using the modified Rankin scale (mRS) as good (mRS = 0-1) or poor (mRS = 2-6). Results Five-hundred and eight patients (median [IQR] age, 39 [28.5-49] years; 26% male) were included. Complete or partial recanalization was not differently represented in patients undergoing scans at different periods of time (from 28-day to 3 month-period up to a 1-3 year-period). mRS at the time of follow-up imaging was available in 483 patients; 92.8% of them had a mRS of 0-1. CVT recanalization (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.59-4.13) was positively associated, whereas cancer (OR, 0.29; 95% CI, 0.09-0.88), and personal history of venous thromboembolism (VTE) (OR, 0.36; 95% CI, 0.14-0.92) were negatively associated as independent predictors of favorable (mRS = 0-1) outcome at follow-up. Conclusions Most patients with a first CVT had complete or partial recanalization at follow-up. Recanalization was independently associated with a favorable neurological outcome.
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Affiliation(s)
- E Rezoagli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Anesthesia Center for Critical Care Research, Boston, USA
| | - I Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - D Poli
- Thrombosis Centre, Department of Heart and Vessels, University of Florence, Florence, Italy
| | - U Scoditti
- Thrombosis Centre, Department of Heart and Vessels, University of Florence, Florence, Italy
- Department of Neurology, University of Parma, Parma, Italy
| | - S M Passamonti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - P Bucciarelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - W Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - F Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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17
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Long B, Koyfman A, Runyon MS. Cerebral Venous Thrombosis: A Challenging Neurologic Diagnosis. Emerg Med Clin North Am 2017; 35:869-878. [PMID: 28987433 DOI: 10.1016/j.emc.2017.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Headache is a common emergency department chief complaint. Although most are benign, emergency physicians must rapidly identify and manage the uncommon, sometimes subtle, presentation of headache from a life-threatening cause. Cerebral venous thrombosis imparts significant morbidity and mortality, and can be a challenging diagnosis. It most commonly occurs in those under 50 years of age with thrombosis of the cerebral veins/sinuses. Diagnosis is frequently delayed. The disease can present with 1 or more clinical syndromes, including intracranial hypertension with headaches, focal neurologic deficits, seizures, and encephalopathy. Diagnosis requires imaging. Treatment includes stabilization, management of complications, and anticoagulation.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas HealthCare System, Medical Education Bldg., Third floor, 1000 Blythe Blvd, Charlotte, NC 28203, USA
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18
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Gazioglu S, Eyuboglu I, Yildirim A, Aydin CO, Alioglu Z. Cerebral venous sinus Thrombosis: Clinical Features, Long-Term outcome and recanalization. J Clin Neurosci 2017; 45:248-251. [PMID: 28802797 DOI: 10.1016/j.jocn.2017.07.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
Recanalization and prognosis of cerebral venous sinus thrombosis (CVST) are generally considered to be good, and various factors have been reported to be associated with recanalization in previous studies. Fifty patients diagnosed with CVST between September 2007 and July 2016 were analyzed retrospectively. Modified Rankin scale (mRS) scores at six months and results of follow-up imaging of patients with at least six months follow-up were also reviewed for the assessment of long term outcome, recanalization rates and factors associated with recanalization. The mean age of the patients (39 female, 11 male) was 34.6±11.2years (17-69). Of the 50 patients enrolled, 31 (62%) had at least six months follow-up with available data and 26 (83.9%) of these had favorable outcomes (mRS 0-1) at six months. Complete recanalization was observed in 15 patients (48.4%), partial recanalization in 14 (45.2%) and no recanalization in 2 (6.5%). Univariate analysis revealed that complete recanalization rates were higher in female patients (p=0.013) and lower in patients with multiple thrombosis in more than one dural sinus (p=0.03). The prognosis and recanalization rates of CVST were good, and complete or partial recanalization of venous sinuses was not associated with clinical outcome.
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Affiliation(s)
- Sibel Gazioglu
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080 Trabzon, Turkey.
| | - Ilker Eyuboglu
- Department of Radiology, Karadeniz Technical University Medical Faculty, 61080 Trabzon, Turkey
| | - Ahmet Yildirim
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080 Trabzon, Turkey
| | - Cigdem Ozen Aydin
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080 Trabzon, Turkey
| | - Zekeriya Alioglu
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080 Trabzon, Turkey
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19
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Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, de Sousa DA, Stam J. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology. Eur Stroke J 2017; 2:195-221. [PMID: 31008314 DOI: 10.1177/2396987317719364] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/13/2017] [Indexed: 12/21/2022] Open
Abstract
The current proposal for cerebral venous thrombosis guideline followed the Grading of Recommendations, Assessment, Development, and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews of all available evidence and writing recommendations and deciding on their strength on an explicit and transparent manner, based on the quality of available scientific evidence. The guideline addresses both diagnostic and therapeutic topics. We suggest using magnetic resonance or computed tomography angiography for confirming the diagnosis of cerebral venous thrombosis and not screening patients with cerebral venous thrombosis routinely for thrombophilia or cancer. We recommend parenteral anticoagulation in acute cerebral venous thrombosis and decompressive surgery to prevent death due to brain herniation. We suggest to use preferentially low-molecular weight heparin in the acute phase and not using direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations due to very poor quality of evidence concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that in women who suffered a previous cerebral venous thrombosis, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular weight heparin should be considered throughout pregnancy and puerperium. Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of cerebral venous thrombosis.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | | | - Patrícia Canhão
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Matteo di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University, Naples, Italy.,Unit of Cell and Molecular Biology in Cardiovascular Diseases, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Alberto Maino
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Florian Masuhr
- Department of Neurology, Bundeswehrkrankenhaus, Berlin, Germany
| | - Diana Aguiar de Sousa
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
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20
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Dempfle AK, Harloff A, Schuchardt F, Bäuerle J, Yang S, Urbach H, Egger K. Longitudinal Volume Quantification of Deep Medullary Veins in Patients with Cerebral Venous Sinus Thrombosis. Clin Neuroradiol 2017; 28:493-499. [DOI: 10.1007/s00062-017-0602-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/22/2017] [Indexed: 12/17/2022]
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21
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Schuchardt F, Hennemuth A, Schroeder L, Meckel S, Markl M, Wehrum T, Harloff A. Acute Cerebral Venous Thrombosis: Three-Dimensional Visualization and Quantification of Hemodynamic Alterations Using 4-Dimensional Flow Magnetic Resonance Imaging. Stroke 2017; 48:671-677. [PMID: 28179559 DOI: 10.1161/strokeaha.116.015102] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 11/14/2016] [Accepted: 12/12/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral venous thrombosis (CVT) affects venous hemodynamics and can provoke severe stroke and chronic intracranial hypertension. We sought to comprehensively analyze 3-dimensional blood flow and hemodynamic alterations during acute CVT including collateral recruitment and at follow-up. METHODS Twenty-two consecutive patients with acute CVT were prospectively included and underwent routine brain magnetic resonance imaging (MRI) and 4-dimensional flow MRI at 3 T for the in vivo assessment of cerebral blood flow. Neurological and MRI follow-up at 6 months was performed in 18 patients. RESULTS Three-dimensional blood flow visualization and quantification of large dural venous sinuses and deep cerebral veins was successfully performed in all patients. During acute CVT, we observed abnormal flow patterns including stagnant flow, flow acceleration in stenoses, and change of flow directions. In patients with complete recanalization, flow trajectories resembled those known from previously published 4-dimensional flow MRI data in healthy adults. There was a trend toward a relationship between occluded segments and cerebral lesions (not significant). Furthermore, patients with versus without cerebral lesions showed increased mean (0.08±0.09 versus 0.005±0.014 m/s) and peak velocities (0.18±0.21 versus 0.006±0.02 m/s) within partially thrombosed left and right transverse sinuses (P<0.05) at baseline. CONCLUSIONS Four-dimensional flow MRI was successfully applied for the 3-dimensional visualization and quantification of venous hemodynamics in patients with CVT and provided new dynamic information regarding vessel recanalization. This technique seems promising to investigate the contribution of hemodynamic parameters and collaterals in a larger cohort to identify those at risk of stroke.
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Affiliation(s)
- Florian Schuchardt
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL.
| | - Anja Hennemuth
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL
| | - Laure Schroeder
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL
| | - Stephan Meckel
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL
| | - Michael Markl
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL
| | - Thomas Wehrum
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL
| | - Andreas Harloff
- From the Department of Neurology (F.S., L.S., T.W., A. Harloff) and Department of Neuroradiology (S.M.), University Medical Centre, Freiburg, Germany; Fraunhofer MEVIS, Bremen, Germany (A. Hennemuth); and Department of Radiology, Feinberg School of Medicine (M.M.) and Department of Biomedical Engineering, McCormick School of Engineering (M.M.), Northwestern University, Chicago, IL
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22
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Abstract
PURPOSE OF REVIEW Although recent trials of intervention for acute ischemic stroke have been positive, similar benefit in acute cerebral venous thrombosis (CVT) remains largely unclear. This review aims to summarize the existing evidence regarding the management of CVT, including anticoagulation and endovascular therapy. RECENT FINDINGS The mainstay of treatment in CVT is systemic anticoagulation even in the setting of intracerebral hemorrhage. Nonrandomized studies and case series suggest that endovascular therapy in CVT is relatively safe, and can improve outcomes in the small subset of CVT patients with neurologic deterioration despite anticoagulation. SUMMARY Despite a generally favorable prognosis, one in four patients with CVT develop neurological deterioration in the acute phase. Predisposing factors include a neurological deficit or seizures at onset, deep venous thrombosis, venous infarctions, or intracranial hemorrhage with mass effect and an underlying thrombophilia. More randomized trials are needed to compare the benefits of anticoagulation and endovascular therapy.
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23
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Carducci C, Colafati GS, Figà-Talamanca L, Longo D, Lunardi T, Randisi F, Bernardi B. Cerebral sinovenous thrombosis (CSVT) in children: what the pediatric radiologists need to know. Radiol Med 2016; 121:329-41. [PMID: 27025499 DOI: 10.1007/s11547-016-0630-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 01/18/2023]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a relatively uncommon and potentially life-threatening condition in childhood, occurring in various clinical settings. Nowadays, however, it is increasingly diagnosed as related to many causes, likely due to greater clinical awareness and improvement of neuroradiologic techniques. The prompt diagnosis is an important goal to significantly reduce the risk of acute complications and long-term sequelae. The purpose of this narrative overview is to provide a useful educational tool in daily clinical practice for radiologists with a broad perspective of CSVT including a discussion of more common potential pitfalls related to misinterpretation of images in children. This paper will also review the normal venous anatomy, its variants, risk factors that contribute to cause CSVT (neonates with their specific causes of CSVT are not included in this review) and the practical imaging feature of cerebral sinovenous thrombosis on MRI and CT. Finally, a brief overview of frequent and severe CSVT conditions in children with key points in imaging is shown.
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Affiliation(s)
- Chiara Carducci
- Neuroradiology Unit, Department of Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
| | | | - Lorenzo Figà-Talamanca
- Neuroradiology Unit, Department of Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Daniela Longo
- Neuroradiology Unit, Department of Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Tommaso Lunardi
- Neuroradiology Unit, Department of Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Francesco Randisi
- Neuroradiology Unit, Department of Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Bruno Bernardi
- Neuroradiology Unit, Department of Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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24
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Arauz A, Vargas-González JC, Arguelles-Morales N, Barboza MA, Calleja J, Martínez-Jurado E, Ruiz-Franco A, Quiroz-Compean A, Merino JG. Time to recanalisation in patients with cerebral venous thrombosis under anticoagulation therapy. J Neurol Neurosurg Psychiatry 2016; 87:247-51. [PMID: 25802120 DOI: 10.1136/jnnp-2014-310068] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/27/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Few studies have investigated the rates of recanalisation after cerebral venous thrombosis (CVT). Our objective was to investigate the recanalisation rate and to identify predictors of recanalisation in patients with CVT. METHODS We included 102 patients with confirmed first-ever, non-septic CVT. All patients received anticoagulation for 12 months or until complete recanalisation. To assess recanalisation, patients underwent MR venography every 3 months until partial or complete recanalisation or for 12 months after diagnosis. We conducted two parallel analyses of complete recanalisation versus partial and no recanalisation versus any recanalisation. As a secondary objective we explored the influence of recanalisation on outcome and recurrent events. We calculated the probability of recanalisation using Kaplan-Meier analysis and conducted multivariate analysis using a Cox model. RESULTS The mean age of patients was 33.5±11 years (80 (78.4%) women). Survival analysis indicated that 50% of the patients had any recanalisation (grades I, II and III) by 64 days and complete recanalisation (grade III) by 169 days. Adjusted Cox proportional model revealed that age <50 years (HR=11.5 95% CI=1.58 to 84.46, p=0.01) and isolated superior sagittal sinus thrombosis (HR=0.39, 95% CI=0.14 to 1.04, p=0.05) predict complete recanalisation, while age <50 years (HR=4.79; 95% CI=1.69 to 13.5, p=0.003) predicts any recanalisation. Patients with complete recanalisation had a greater chance of good functional outcome (HR=5.17; 95% CI=2.8 to 9.53, p<0.001). CONCLUSIONS We found that recanalisation occurs over time, until month 11. Complete recanalisation may influence functional outcome.
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Affiliation(s)
- Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | | | - Nayelli Arguelles-Morales
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | - Miguel A Barboza
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | - Juan Calleja
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | - Elizabeth Martínez-Jurado
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | - Angélica Ruiz-Franco
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | - Alejandro Quiroz-Compean
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, Mexico
| | - José G Merino
- Neurology Department, Johns Hopkins Community Physicians, Bethesda, Maryland, USA
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Alnasser Alsukhni R, Ghoubari MS, Aboras Y, Almohamad Alkhalifa K. Delirium as presenting symptom of neuro-Behcet’s disease. SAGE Open Med Case Rep 2016; 4:2050313X16661641. [PMID: 27579169 PMCID: PMC4989586 DOI: 10.1177/2050313x16661641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 06/14/2016] [Indexed: 11/16/2022] Open
Abstract
Objectives: Behcet’s disease is a multisystemic disorder. Most of its clinical manifestations are due to thrombosis or vasculitis. There is a predominance of mucocutaneous and ocular lesions; neurological manifestations are minority. However, this could be the first problem that leads a patient to seek medical help. Methods: We report a 30-year-old female with rapidly progressive headaches and confusion. Brain magnetic resonance imaging showed bilateral thalamic T2 hyperintense lesions and hemorrhage. Directed inquiry revealed recurrent oral ulcers and three miscarriages. During hospitalization, the patient developed a deep venous thrombosis. Results: After exclusion of other differential diagnoses, the diagnosis of Behcet’s disease was established. Conclusion: Behcet’s disease is a protean disease. Hence it should be in mind in patients with otherwise unexplained signs and symptoms, especially in endemic countries, and treatment decision should not be witheld in critical cases if no alternative diagnosis is plausible.
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Affiliation(s)
- Rana Alnasser Alsukhni
- Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
| | | | - Yasmin Aboras
- Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
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Krieger DA, Dehkharghani S. Magnetic Resonance Imaging in Ischemic Stroke and Cerebral Venous Thrombosis. Top Magn Reson Imaging 2015; 24:331-352. [PMID: 26636639 DOI: 10.1097/rmr.0000000000000067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Imaging is indispensable in the evaluation of patients presenting with central nervous system emergencies. Although computed tomography (CT) is the mainstay of initial assessment and triage, magnetic resonance imaging (MRI) has become vital in expanding diagnostic capabilities, refining management strategies, and developing our understanding of disease processes. Ischemic stroke and cerebral venous thrombosis are 2 areas wherein MRI is actively revolutionizing patient care. Familiarity with the imaging manifestations of these 2 disease processes is crucial for any radiologist reading brain MR studies. In this review, the fundamentals of image interpretation will be addressed in-depth. Furthermore, advanced imaging techniques which are redefining the role of emergency MRI will be outlined, with a focus on the pathophysiological mechanisms that underlie image interpretation. In particular, emerging data surrounding the use of MR perfusion imaging in acute stroke management portend dramatic shifts in neurointerventional management. To this end, a review of the recent stroke literature will hopefully enhance the radiologist's role in both meaningful reporting and multidisciplinary teamwork.
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Affiliation(s)
- Daniel A Krieger
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Division of Neuroradiology, Atlanta, Georgia
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Herweh C, Griebe M, Geisbüsch C, Szabo K, Neumaier-Probst E, Hennerici MG, Bendszus M, Ringleb PA, Nagel S. Frequency and temporal profile of recanalization after cerebral vein and sinus thrombosis. Eur J Neurol 2015; 23:681-7. [PMID: 26667584 DOI: 10.1111/ene.12901] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/01/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The temporal course of recanalization and its association with clinical outcome were analysed in our patients with cerebral sinus and/or venous thrombosis (CSVT) and follow-up magnetic resonance imaging (MRI). METHODS Between January 1998 and September 2014 all patients from our institutions with CSVT were systematically analysed. Baseline data, treatment characteristics and follow-up MRI were retrospectively recorded. The status of recanalization was assessed as complete (CRec), partial (PRec) or failed recanalization. Clinical follow-up was measured with the modified Rankin Scale. Excellent outcome was defined as modified Rankin Scale 0-1. RESULTS Ninety-nine patients were identified; 97% of these patients were treated with oral anticoagulation (OAC) and the median (min-max) time of OAC was 7 months (1-84). CRec was achieved in 57.6% (57/99), PRec in 29.3% (29/99) and only 13 (13.1%) patients did not recanalize. The median (min-max) time to PRec was 4 months (0.25-14) and to CRec 6 months (2-34). Median time to last clinical follow-up was 8 months (1-88); 91.8% (89/99) had an excellent outcome at last clinical follow-up and only 2.1% (2/99) died. Only thrombosis of the superior sagittal sinus was independently associated with successful recanalization (odds ratio 16, 95% confidence interval 2-138). No severe haemorrhagic complications and no recurrence of CSVT occurred within clinical follow-up. No association of outcome and recanalization status was found. CONCLUSIONS The recanalization rate of CSVT under OAC was high and the median time to CRec was 6 months. Thrombosis of the superior sagittal sinus is a positive predictor of recanalization. Outcome in this cohort was excellent but no significant association of outcome and recanalization status was found.
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Affiliation(s)
- C Herweh
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - M Griebe
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - C Geisbüsch
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - K Szabo
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - E Neumaier-Probst
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - M G Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - M Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - S Nagel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Abstract
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.
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Ladner TR, Davis BJ, He L, Mawn LA, Mocco J. Transorbital superior ophthalmic vein sacrifice to preserve vision in ocular hypertension from aseptic cavernous sinus thrombosis. BMJ Case Rep 2014; 2014:bcr-2014-011454. [PMID: 25355742 DOI: 10.1136/bcr-2014-011454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Aseptic cavernous sinus thrombosis (CST) is rare and may clinically masquerade as a carotid cavernous fistula. Conventional management includes oral anticoagulation, but cases of ocular hypertension affecting vision may require more aggressive intervention. We report a case of a woman with spontaneous bilaterally occluded cavernous sinuses with elevated intraocular pressure (IOP), which resolved immediately following unilateral superior ophthalmic vein (SOV) sacrifice. She was subsequently placed on oral anticoagulants. By 4 months postoperatively her IOP was normalized and her vision had improved. Repeat angiography demonstrated stable venous filling, with some mild improvement of flow through the cavernous sinus. Coil-mediated sacrifice of the SOV might be an effective means to relieve ocular hypertension and preserve vision in the setting of aseptic CST.
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Affiliation(s)
- Travis R Ladner
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Brandon J Davis
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Lucy He
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Louise A Mawn
- Department of Ophthalmology and Visual Sciences, Vanderbilt University, Nashville, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
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Geisbüsch C, Lichy C, Richter D, Herweh C, Hacke W, Nagel S. [Clinical course of cerebral sinus venous thrombosis. Data from a monocentric cohort study over 15 years]. DER NERVENARZT 2014; 85:211-20. [PMID: 24469382 DOI: 10.1007/s00115-013-4000-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Thrombosis of cerebral veins or sinuses (CVST) is a rare condition. In a monocentric retrospective cohort study the clinical characteristics, risk factors, radiological findings as well as course and prognosis of patients over the past 15 years were examined. METHODS Between January 1998 and March 2013 all patients who were treated as inpatients for CVST at the department of neurology of the University of Heidelberg were systematically registered in a database. Along with all relevant clinical data the modified Rankin scale (MRS) was used to measure the clinical severity. A follow-up visit was performed at three time points. The odds ratios (OR) were calculated to establish predictors of good outcome (MRS 0-2), mortality at discharge and at follow-up. Significant variables after univariate analysis were tested for independency in a multivariate logistic regression model. RESULTS A total of 143 patients were included in the study. The median age was 43 years (range 17-74 years) and 67.4 % of patients were female. The most common symptoms were headache (70.6 %), seizures (50.4 %) and paresis (37.8 %). The most prominent clinical risk factor was oral contraception (40.4 %). The two most common localizations of thrombosis were the transversal sinus with the sigmoid sinus (66.4 %) and the sagittal superior sinus (47.6 %). On admission 42.7 % of patients suffered additionally from intracerebral hemorrhage and 12.6 % from congestive infarction. Of the patients 9.5 % (10 out of 105) showed a pathologically reduced activated protein C (APC) resistance and 8.4 % (6 out of 94) a prothrombin mutation. All patients were initially treated with heparin and 88.7 % were switched to cumarin during the course of the disease. The median duration of anticoagulation was 15.75 months (range 1-121 months). On discharge 77.7 % had a good outcome and the in-hospital mortality was 4.7 %. The median time to follow-up in 108 patients was 36 months (range 3-132 months), 74.1 % of patients had a good outcome (MRS 0-2) and 18.5 % died. Independent predictors of in-hospital mortality were MRS on admission (OR 2.2, 95 % CI 1.03-4.7) and of mortality at follow-up the presence of a malignant disease (OR 50.2, 6-423) and intracerebral hemorrhage on admission (OR 10.3, 1.7-62.6). DISCUSSION The results of this study are in line with previously published data on CVST. The most prominent clinical risk factors for CVST were female gender and oral contraception. At discharge from hospital and 3 years after CVST approximately 75 % of patients achieved a good clinical outcome. A severe clinical syndrome and the presence of an intracerebral hemorrhage on admission were independent predictors of mortality.
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Affiliation(s)
- C Geisbüsch
- Neurologische Klinik, Universität Heidelberg, INF 400, 69120, Heidelberg, Deutschland
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Wu X, Wu W, Wu J, Zhang HL. A 72-year-old man presenting with progressive lower limb weakness and unconsciousness. Thrombosis of the vein of Galen. Ann Saudi Med 2014; 34:450. [PMID: 25827706 PMCID: PMC6074565 DOI: 10.5144/0256-4947.2014.450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | - Hong-Liang Zhang
- Dr. Hong-Liang Zhang, Department of Neurology, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China, T: +86-13756536356, F: +86-431-88782362,
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Abstract
PURPOSE OF REVIEW Thrombosis of the dural sinus and/or cerebral veins (CVT) is a rare but potentially devastating type of stroke that tends to occur in young adults, especially women. In this article, the abbreviation CVT refers to either cerebral venous thrombosis or dural sinus thrombosis. The purpose of this review is to review the most up-to-date literature on the epidemiology, diagnosis, management, and prognosis of CVT. In addition, illustrative cases that represent the spectrum of CVT are provided. RECENT FINDINGS CVT represents about 0.5% of all strokes and can be challenging to diagnose because headache, rather than focal neurologic symptoms, is the prominent feature. The diagnosis is confirmed with MRI and magnetic resonance venogram (MRV). The mainstay of acute management is anticoagulation, although, in the cases of severe hemorrhagic conversion of a venous infarction, endovascular mechanical thrombectomy may be potentially lifesaving. The evaluation of underlying causes from transient triggers, eg, pregnancy, oral contraceptives, or infection, versus chronic triggers, eg, cancer and thrombophilia, will often influence the duration of anticoagulation. The outcomes after CVT are generally favorable, and the risk of recurrence is low. SUMMARY CVT is an important diagnosis to keep in mind when evaluating patients with headache in the emergency department, and it is important that it not be overlooked because it is treatable.
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Wu X, Wu W, Wu J, Zhang HL. Diagnosis: Thrombosis of the vein of Galen. Ann Saudi Med 2014; 34:450-450. [PMCID: PMC6074553 DOI: 10.5144/0256-4947.2014.450a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Xiujuan Wu
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
| | - Wei Wu
- Department of Neurosurgery, the First Hospital of Jilin University, Jilin University, Changchun, China
| | - Jiang Wu
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
| | - Hong-Liang Zhang
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
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Affiliation(s)
- Deepak Gulati
- From the Department of Neurology, University Hospitals of Cleveland/Case Medical Center, OH (D.G., S.S.); and Departments of Neurology and Stroke Units, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
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Wang J, Ji X, Ling F, He X. Comparison of anticoagulation and thrombolysis treatments in a rat model of superior sagittal sinus thrombosis. Int J Neurosci 2013; 124:532-41. [PMID: 24195615 DOI: 10.3109/00207454.2013.862245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Superior sagittal sinus thrombosis (SSST) is a form of cerebral venous sinus thrombosis (CVST) routinely treated with anticoagulation therapy. Anticoagulation and thrombolysis treatment effects on neurological function, venous recanalization and brain edema were compared after SSST in rats. Male Sprague-Dawley rats underwent non-fatal SSST induction and were divided into no treatment (control), anticoagulation (heparin), carotid artery thrombolysis and local thrombolysis groups (each n = 50). Within each group, an equal number of rats (n = 10) were treated with anticoagulation and thrombolysis at day 3 or weeks 1, 2, 3 or 4 following SSST. Magnetic resonance venography (MRV) was conducted within 24 h of anticoagulation and thrombolysis treatments to determine recanalization, structural abnormalities and cerebral edema quantitated by wet-dry methods. Neurological function (Rotarod test) and histological abnormalities were compared. Severe brain edema, flattened gyri and coronal swelling were observed following SSST. Recanalization rates in carotid artery and local thrombolysis were higher than in anticoagulation (both p < 0.001). Carotid artery and local thrombolysis brain water contents were 79.6±0.1% and 79.2±0.1%, respectively, significantly lower than 83.9±0.1% and 84±0.1% in anticoagulation and controls, respectively (all p < 0.05), after treatments at day 3 following SSST. Increasing SSST onset to treatment time worsened neurological function ( p < 0.05). Maximum treatment benefits were observed <2 weeks post-SSST using local thrombolysis and, to a lesser extent, carotid artery thrombolysis. Thrombolysis may produce better functional outcomes if employed early rather than as a second-line treatment following anticoagulant failure.
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Affiliation(s)
- Jianzhen Wang
- 1Department of Neurosurgery, General Hospital of Chinese People's Armed Police Forces, Beijing, China
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Ciron J, Godenèche G, Vandamme X, Rosier MP, Sharov I, Mathis S, Larrieu D, Neau JP. Obstetrical outcome of young women with a past history of cerebral venous thrombosis. Cerebrovasc Dis 2013; 36:55-61. [PMID: 23921093 DOI: 10.1159/000351507] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 04/12/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study was designed to review the obstetrical outcome of a consecutive series of cerebral venous thrombosis (CVT) affecting fertile women over a long period of time. METHODS From a computerized database of four hospitals of a French region (Poitou-Charentes), we selected patients admitted to hospital for CVT between January 1995 and February 2012. All the case notes were re-examined by two neurologists to confirm the initial diagnosis of CVT. The criterion of inclusion in our study was the occurrence of CVT in a woman ≤ 40 years of age. All the patients were recontacted by telephone in September 2012 and could be seen in an outpatient clinic. The data of interest were: occurrence of subsequent pregnancies, outcome of these pregnancies, their possible complications, their management with respect to preventive medication, details on the birth and the neonate. RESULTS Out of 190 consecutive patients hospitalized for CVT, 62 women aged ≤ 40 years were included (mean age 27.2 ± 6.7 years at the time of their cerebrovascular event). The mean duration of follow-up was 89.5 ± 60.6 months (median: 76 months). There were 45 pregnancies in 24 of the women. Among these 45 pregnancies, 1 was in progress, 24 were completed resulting in normal children, whereas 20 were terminated (5 voluntary abortions, 14 miscarriages and 1 medical abortion). During the pregnancies recorded, there was one recurrence of CVT and no extra-CVT. Various management strategies were adopted, depending on the identified cause(s) for CVT and the medical history of the patient. CONCLUSIONS Our study confirms that the occurrence of a CVT in young women is not a contraindication for subsequent pregnancy. However, it points to a high incidence of miscarriage. Apart from this fact, there is no increase in materno-fetal complications during pregnancy and childbirth, and the neonates are healthy. The risk of recurrence of a CVT or extra-CVT during subsequent pregnancy is low but most of patients were on preventive antithrombotic medication.
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Affiliation(s)
- Jonathan Ciron
- Department of Neurology, CHU La Milétrie, Poitiers, France
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Weimar C, Masuhr F, Hajjar K. Diagnosis and treatment of cerebral venous thrombosis. Expert Rev Cardiovasc Ther 2013; 10:1545-53. [PMID: 23253278 DOI: 10.1586/erc.12.126] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dural sinus or cerebral venous thrombosis (CVT) is a frequently unrecognized cause of stroke affecting predominantly young women. Typical clinical signs include headache, visual problems and seizures. Both computed tomography and magnetic resonance venous angiography are suitable for the detection of CVT, although magnetic resonance angiography is more sensitive to detect small cortical venous thrombosis. Evidence for efficacy of initial treatment with heparin in acute CVT comes from two randomized placebo-controlled studies that together included 79 patients. Although not evidence-based, postacute treatment with oral anticoagulation is recommended for up to 12 months after CVT. Long-term anticoagulation is recommended only in patients suffering from a severe coagulopathy or with recurrent CVT.
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Affiliation(s)
- Christian Weimar
- Department of Neurology and Stroke Center, University Duisburg-Essen, Hufelandstr. 55, 45122 Essen, Germany.
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Cerebral sinovenous thrombosis in pediatric practice. Pediatr Radiol 2013; 43:173-88. [PMID: 23212594 DOI: 10.1007/s00247-012-2486-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 07/09/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) in the pediatric population is a relatively uncommon yet under-appreciated and potentially life-threatening neurological condition. Early symptoms and signs are often vague and the clinician requesting a cranial imaging study might not even suspect sinovenous thrombosis. If left undiagnosed, or if the diagnosis of CSVT is delayed, progressive neurological deterioration, coma and death can follow. The purpose of this review is to highlight pertinent development of the cerebral venous system, discuss the causal factors of cerebral sinovenous thrombosis in the pediatric population, review practical imaging strategies using cranial sonography augmented with color and pulsed Doppler, unenhanced brain CT, CT venography, cerebral MRI, and MR venography (MRV). Finally, this review will illustrate the imaging features of sinovenous thrombosis, including a discussion of the common causes of false-positive and false-negative CT and MRI studies.
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Missori P, Domenicucci M, Sassun TE, Tarantino R, Peschillo S. Alterations in the intracranial venous sinuses in spontaneous nontraumatic chronic subdural hematomas. J Clin Neurosci 2012; 20:389-93. [PMID: 23219821 DOI: 10.1016/j.jocn.2012.02.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 02/10/2012] [Accepted: 02/14/2012] [Indexed: 11/26/2022]
Abstract
Occlusion of the cerebral venous system is frequently associated with intraparenchymal or subarachnoid hemorrhage. There are few reports of cerebral venous thrombosis associated with nontraumatic chronic subdural hematoma (CSH). We aimed to evaluate the intracranial venous system in patients with spontaneous nontraumatic CSH and to identify alterations in their venous sinuses. In this study, eight patients with spontaneous, nontraumatic CSH were followed for a 7-year period (mean: 2.2 years, range: 1-7 years). Neuroradiological images were taken at the onset of symptoms and during follow-up. Venous angiography or magnetic resonance venography was used to evaluate the cerebral venous system of patients. In all patients, medical or surgical treatments were based on clinical symptoms. In seven of the eight patients, the CSH was in the left hemisphere, whereas one patient had bilateral CSH. In one of the eight patients, thrombosis of the transverse sinus and sigmoid sinus was found, but recanalization was observed at follow-up. In a further three patients, the superior sagittal sinus, the straight sinus, and the vein of Galen were markedly reduced in diameter compared to normal or were not visible at presentation, but normal flow was observed at follow-up. In the remaining four patients, the transverse sinus was not observed at symptom onset or during long-term follow-up. A nontraumatic CSH can occur secondary to a venous thrombosis or it can be associated with the inability to image some of the venous sinuses. Venous flow was restored at long-term follow-up. Increased intravenous pressure is thought to be the pathogenic factor that causes a nontraumatic CSH.
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Affiliation(s)
- Paolo Missori
- Department of Neurology and Psychiatry, Neurosurgery, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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Tait C, Baglin T, Watson H, Laffan M, Makris M, Perry D, Keeling D. Guidelines on the investigation and management of venous thrombosis at unusual sites. Br J Haematol 2012; 159:28-38. [PMID: 22881455 DOI: 10.1111/j.1365-2141.2012.09249.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 06/25/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Campbell Tait
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
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43
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Pakter GJ. Bilateral optic disc swelling as a presenting sign of superior sagittal sinus thrombosis. BMJ Case Rep 2012; 2012:bcr-2012-006814. [PMID: 22987907 DOI: 10.1136/bcr-2012-006814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The case of a 59-year-old Caucasian man who presented with a 6-week history of intermittent blurring of vision and diplopia is reported. Fundoscopy revealed asymmetrical, bilateral optic disc swelling with peripapillary haemorrhages. An initial CT scan and D-dimer level were reported as normal. A subsequent MRI revealed a recanalising superior sagittal sinus thrombosis. Cerebral venous sinus thrombosis is a rare and potentially fatal condition. The author suggests that it should be part of the differential diagnosis of bilateral optic disc swelling and that a normal unenhanced CT scan and D-dimer would not rule out this potentially devastating condition.
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Affiliation(s)
- Grant Jason Pakter
- Department of Ophthalmology, Calderdale and Huddersfield NHS Trust, Huddersfield Royal Infirmary, Huddersfield, UK.
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Verma R, Patil TB, Kumar N. Early recanalisation of cerebral venous sinus thrombosis in an unusual case associated with severe protein S deficiency. BMJ Case Rep 2012; 2012:bcr-2012-006496. [PMID: 22847569 DOI: 10.1136/bcr-2012-006496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An inherited or acquired deficiency of protein S leads to a prothrombotic state, with predisposition to venous thrombosis. We describe a case of cerebral venous sinus thrombosis (CVST) associated with acquired protein S deficiency and recanalisation within 15 days of anticoagulation. A 38-year-old man presented with recurrent headache, vomiting, altered sensorium and one episode of transient left hemiparesis. Magnetic resonance venography showed poor flow in the deep cerebral venous sinuses with extensive collateral venous channel formation, which resolved after 15 days of anticoagulation, along with clinical improvement. Serum protein S activity was found to be markedly low (16% of biological reference). CVST should be suspected in a patient with acute features of raised intracranial pressure or focal neurological deficit, and a patient without obvious clinical predisposition for a prothrombotic state should be evaluated for underlying thrombophilic states like protein S deficiency.
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Affiliation(s)
- Rajesh Verma
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India.
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45
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Caprio F, Bernstein RA. Duration of anticoagulation after cerebral venous sinus thrombosis. Neurocrit Care 2012; 16:335-42. [PMID: 22189571 DOI: 10.1007/s12028-011-9661-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cerebral venous sinus thrombosis (CVST) often occurs in young patients and is treated with acute and then long-term oral anticoagulation. It is important to decide when to discontinue anticoagulation, as lifelong anticoagulation exposes the patient to considerable cumulative risk. However, a lack of high quality studies makes choosing a duration of anticoagulation after CVST difficult. In this article, we review the evidence for different treatment durations in several common clinical scenarios of CVST. In addition, when no direct evidence is available, we discuss and extrapolate from the more comprehensively studied situation of systemic venous thromboembolic disease. Recommendations are graded using standard criteria for the level of evidence.
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Affiliation(s)
- Frances Caprio
- Department of Neurology, Stroke Program, Feinberg School of Medicine of Northwestern University, 710 North Lake Shore Drive, Abbott Hall 11th Floor, Chicago, IL 60611, USA
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46
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Agarwal N, Tolia A, Hansberry DR, Duffis EJ, Barrese JC, Gandhi CD, Prestigiacomo CJ. Current differential diagnoses and treatment options of vascular occlusions presenting as bilateral thalamic infarcts: a review of the literature. J Neurointerv Surg 2012; 5:419-25. [DOI: 10.1136/neurintsurg-2012-010352] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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47
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Einhäupl K, Stam J, Bousser MG, De Bruijn SFTM, Ferro JM, Martinelli I, Masuhr F. EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. Eur J Neurol 2011; 17:1229-35. [PMID: 20402748 DOI: 10.1111/j.1468-1331.2010.03011.x] [Citation(s) in RCA: 300] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed as a result of the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis and symptomatic therapy including control of seizures and elevated intracranial pressure. METHODS We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence but consensus was clear we stated our opinion as good practice points. RESULTS AND CONCLUSIONS Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous LMWH or with dose-adjusted intravenous heparin (level B recommendation). Concomitant intracranial haemorrhage (ICH) related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulant therapy after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with "mild" thrombophilia, such as heterozygous factor V Leiden or prothrombin G20210A mutation and high plasma levels of factor VIII. Indefinite AC should be considered in patients with recurrent episodes of CVST and in those with one episode of CVST and 'severe' thrombophilia, such as antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without large ICH and threatening herniation (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. However, in severe cases with impending herniation craniectomy can be used as a life-saving intervention (good practice point).
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Affiliation(s)
- K Einhäupl
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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48
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Chalmers E, Ganesen V, Liesner R, Maroo S, Nokes T, Saunders D, Williams M. Guideline on the investigation, management and prevention of venous thrombosis in children*. Br J Haematol 2011; 154:196-207. [DOI: 10.1111/j.1365-2141.2010.08543.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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49
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Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M, deVeber G, Ferro JM, Tsai FY. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:1158-92. [PMID: 21293023 DOI: 10.1161/str.0b013e31820a8364] [Citation(s) in RCA: 1139] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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50
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Dlamini N, Billinghurst L, Kirkham FJ. Cerebral venous sinus (sinovenous) thrombosis in children. Neurosurg Clin N Am 2011; 21:511-27. [PMID: 20561500 PMCID: PMC2892748 DOI: 10.1016/j.nec.2010.03.006] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cerebral venous sinus (sinovenous) thrombosis (CSVT) in childhood is a rare, but underrecognized, disorder, typically of multifactorial etiology, with neurologic sequelae apparent in up to 40% of survivors and mortality approaching 10%. There is an expanding spectrum of perinatal brain injury associated with neonatal CSVT. Although there is considerable overlap in risk factors for CSVT in neonates and older infants and children, specific differences exist between the groups. Clinical symptoms are frequently nonspecific, which may obscure the diagnosis and delay treatment. While morbidity and mortality are significant, CSVT recurs less commonly than arterial ischemic stroke in children. Appropriate management may reduce the risk of recurrence and improve outcome, however there are no randomized controlled trials to support the use of anticoagulation in children. Although commonly employed in many centers, this practice remains controversial, highlighting the continued need for high-quality studies. This article reviews the literature pertaining to pediatric venous sinus thrombosis.
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Affiliation(s)
- Nomazulu Dlamini
- The Hospital For Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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