Are steroids useful to treat cerebral venous thrombosis?

Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain

BACKGROUND AND PURPOSE

The prognosis of untreated spinal arteriovenous malformations (SAVMs) is poor. Embolization plays an important role in the management of intramedullary SAVMs. Delayed aggravation due to spinal venous thrombosis following successful embolization has been reported; however, perioperative management strategies to prevent thrombosis have not been explored. We present our single-center experience of SAVM embolization and perioperative management, including anticoagulation.

MATERIAL AND METHODS

We retrospectively evaluated 18 patients with SAVMs who underwent transarterial embolization. Perioperative anticoagulation therapy was administered to selected patients. We compared the characteristics of the patients, including perioperative management procedures, between those with and without postoperative worsening following embolization.

RESULTS

Acute postoperative worsening within 1 week occurred in 4 (22.2%) patients. Of these, immediate worsening was observed in one patient as a procedure-related complication. Delayed worsening after 24 h was observed in 3 patients, caused by delayed venous thrombosis with severe back pain. Rescue anticoagulation for delayed worsening improved symptoms in two patients. A comparison between patients with and without acute postoperative worsening revealed significant differences in age (median 46.5 vs. 26.5 years, p = 0.009) and the presence of postoperative back pain (75.0% vs. 0%, p = 0.005); however, there was no significant difference in use of selective anticoagulation (p = 0.274).

CONCLUSION

The results of this study suggest that SAVM embolization can cause acute worsening due to postoperative venous thrombosis with severe back pain, which may be reversed by anticoagulation therapy. Back pain is an important finding that suggests venous thrombosis, and anticoagulation should be urgently administered.

High risk and low prevalence diseases: Cavernous sinus thrombosis

INTRODUCTION

Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation.

CONCLUSION

An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Reducing the global burden of cerebral venous thrombosis: An international research agenda

BACKGROUND

Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized.

AIMS

This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding.

SUMMARY OF REVIEW

This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion.

CONCLUSIONS

This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.

Cavernous Sinus Thrombosis

Cavernous sinus thrombosis is a potentially lethal subset of cerebral venous sinus thrombosis that may occur as a result of septic and aseptic etiologies. The overall incidence is estimated to be between 0.2 and 1.6 per 100,000 persons; and treatments include antibiotics, anticoagulation, corticosteroids, and surgery. Recent morbidity and mortality estimates are approximately 15% and 11%, respectively. Rapid identification and treatment are essential and may reduce the risk of poor outcome or death.

Glucocorticoids in the treatment of non-infectious superior ophthalmic vein thrombosis - Three cases and a review of the literature

Purpose

Superior ophthalmic vein thrombosis (SOVT) is a rare clinical entity, which can have a septic and an aseptic cause. Aseptic SOVT is typically treated with anticoagulation. Glucocorticoids are reserved for cases with concurrent orbital inflammation.We present three cases of SOVT due to carotid cavernous fistula not responding to standard treatment, subsequently successfully treated with glucocorticoids.

Observations

Three patients with various degrees of proptosis, ophthalmoplegia, orbital stasis and reduced vision are presented. One patient was confirmed to have isolated SOVT, while the other two had associated cavernous sinus thrombosis. All patients had underlying carotid-cavernous fistula without signs of infection. All patients were initially treated with parenteral anticoagulation. Two patients were treated with intraocular pressure-reducing medication. One of whom underwent canthotomy-cantholysis. Two patients experienced a gradual worsening of symptoms during treatment with anticoagulation, while one patient improved before deteriorating. All patients received additional treatment with glucocorticoids consisting of a three-day treatment with intravenous methylprednisolone 500 mg, followed by oral glucocorticoids resulting in total regression of symptoms. Two patients regained 20/20 vision, with some vision field defects, while the third patient regained 20/25 vision.

Conclusion and importance

The addition of glucocorticoids in the treatment of aseptic SOVT can lead to improvement of symptoms and a potentially better prognosis. However, the risk of complications of glucocorticoid treatment must be carefully considered on a case-by-case basis.

Stroke in Asia

BACKGROUND

There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition.

SUMMARY

In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis.

KEY MESSAGES

The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.

An Exploration of Anti-Inflammatory Therapy in Acute/Subacute Severe Cerebral Venous Thrombosis with Hereditary Protein C/S Deficiency: Case Series

Background

Inflammation was associated with the severity of severe cerebral venous thrombosis (CVT) on admission and poor prognosis at discharge. Hereditary protein C/S deficiency (hereditary PCD/PSD) not only promotes thrombosis but also activates the inflammatory response, further inducing venous thrombosis. However, conventional treatments such as standard anticoagulant/endovascular therapy (EVT) do not seem to improve prognosis. Anti-inflammatory therapy may be a new way to treat the disease.

Methods

We enrolled five patients with acute/subacute severe CVT with hereditary PCD/PSD from January 2020 to July 2022. In addition to standard anticoagulant therapy, all of them were given short-term methylprednisolone pulse therapy. Neurological deficit, increased intracranial pressure, venous recanalization, serum and cerebrospinal fluid (CSF) inflammatory markers and adverse events were retrospectively described before and after treatment and at 6 months after discharge.

Results

Inflammatory indexes of all patients were significantly elevated on admission. After methylprednisolone pulse therapy, serum inflammatory indexes including neutrophil-to-lymphocyte ratio (P=0.043); platelet-to-lymphocyte ratio (P=0.043); systemic immune inflammatory index (P=0.043); interleukin-6 (P=0.043) and hypersensitive C-reactive protein (P=0.022) reduced dramatically compared with baseline. CSF inflammatory indexes had a decreasing trend compared with baseline (P>0.05). In terms of venous recanalization, one patient achieved complete recanalization, four patients obtained partial recanalization. Compared with baseline on admission, the NIH Stroke Scale (NIHSS), modified Rankin Scale (mRS) and intracranial pressure were all considerably lower at discharge (P=0.029, P=0.041 and P=0.017). At 6-month follow-up, NIHSS and mRS further declined. During hospitalization and 6-month follow-up, none of the five patients experienced severe steroid-related adverse effects such as recurrence of venous thrombosis, spontaneous fracture or osteonecrosis, and gastroduodenal ulcer.

Conclusion

Acute/subacute severe CVT with hereditary PCD/PSD has high levels of inflammation. In addition to conventional anticoagulant therapy, early anti-inflammatory therapy using steroids may be necessary. Nevertheless, substantial randomized controlled trials with larger sample sizes are required for further investigation.

Case report: Delayed outflow obstruction of a DVA: A rare complication of brainstem cavernoma surgery

Introduction

Developmental venous anomalies (DVAs) are considered variants of normal transmedullary veins. Their association with cavernous malformations is reported to increase the risk of hemorrhage. Expert consensus recommends meticulous planning with MR imaging, use of anatomical “safe zones”, intraoperative monitoring of long tracts and cranial nerve nuclei, and preservation of the DVA as key to avoiding complications in brainstem cavernoma microsurgery. Symptomatic outflow restriction of DVA is rare, with the few reported cases in the literature restricted to DVAs in the supratentorial compartment.

Case

We present a case report of the resection of a pontine cavernoma complicated by delayed outflow obstruction of the associated DVA. A female patient in her 20's presented with progressive left-sided hemisensory disturbance and mild hemiparesis. MRI revealed two pontine cavernomas associated with interconnected DVA and hematoma. The symptomatic cavernoma was resected via the infrafacial corridor. Despite the preservation of the DVA, the patient developed delayed deterioration secondary to venous hemorrhagic infarction. We discuss the imaging and surgical anatomy pertinent to brainstem cavernoma surgery, as well as the literature exploring the management of symptomatic infratentorial DVA occlusion.

Conclusion

Delayed symptomatic pontine venous congestive edema is extremely rare following cavernoma surgery. DVA outflow restriction from a post-operative cavity, intraoperative manipulation, and intrinsic hypercoagulability from COVID-10 infection are potential pathophysiological factors. Improved knowledge of DVAs, brainstem venous anatomy, and “safe entry zones” will further elucidate the etiology of and the efficacious treatment for this complication.

Evaluating the Safety of Ultra-Low-Dose Estrogen Contraception in Sickle Cell Trait With Focus on Cerebral Venous Sinus Thrombosis

Ultra-low-dose combination estrogen-progestin contraceptive pills (OCP) have been marketed as being safer to use than previously higher estrogen-containing OCPs. While multiple large studies have shown a dose-dependent association between estrogen and deep vein thrombosis, there remains sparse guidance or data as to whether patients with sickle cell trait should avoid estrogen-containing OCPs regardless of the dosage. We present a case of a 22-year-old female with a history of sickle cell trait who had recently been started on an ultra-low-dose norethindrone-ethinyl estradiol-iron (1-20 mcg) that presented with headache, nausea, vomiting, and obtunded. Initial neuroimaging was significant for an extensive superior sagittal sinus thrombosis with extension into the confluence of dural venous sinuses, right transverse sinus, right sigmoid sinus, and right internal jugular vein which ultimately required systemic anti-coagulation. Her symptoms largely resolved within four days after starting anti-coagulation. She was discharged on day six to complete a six-month course of oral anti-coagulation. At her neurology follow-up three months later, the patient reported resolution of all symptoms. This study evaluates the safety of ultra-low-dose estrogen-containing contraceptive pills in the sickle cell trait population with special focus on cerebral sinus thrombosis.

Septic cavernous sinus thrombosis: A review

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

Cerebral venous thrombosis: Diagnosis and management in the emergency department setting

INTRODUCTION

Cerebral venous thrombosis (CVT) is an uncommon neurologic emergency associated with significant morbidity and mortality that can be difficult to differentiate from other conditions. It is important for the emergency clinician to be familiar with this disease as it requires a high index of suspicion, and early diagnosis and management can lead to improved outcomes.

OBJECTIVE

This narrative review provides an evidence-based update concerning the presentation, evaluation, and management of CVT for the emergency clinician.

DISCUSSION

CVT is due to thrombosis of the cerebral veins resulting in obstruction of venous outflow and increased intracranial pressure. Early recognition is important but difficult as the clinical presentation can mimic more common disease patterns. The most common patient population affected includes women under the age of 50. Risk factors for CVT include pregnancy, medications (oral contraceptives), inherited thrombophilia, prior venous thromboembolic event, malignancy, recent infection, and neurosurgery. CVT can present in a variety of ways, but the most common symptom is headache, followed by focal neurologic deficit, seizure, and altered mental status. Imaging studies such as computed tomography (CT) venography or magnetic resonance (MR) venography should be obtained in patients with concern for CVT, as non-contrast CT will be normal or have non-specific findings in most patients. Treatment includes anticoagulation, treating seizures and elevated ICP aggressively, and neurosurgical or interventional radiology consultation in select cases.

CONCLUSIONS

CVT can be a challenging diagnosis. Knowledge of the risk factors, patient presentation, evaluation, and management can assist emergency clinicians.

Cerebral venous thrombosis in adults

Summary. Thromboses of cerebral veins and/or sinuses (CVT) encompass a clinically rather heterogenous, relatively rare entity, which is nonetheless an important cause of stroke in the young. While until the mid of the last century the prognosis of CVT was thought to be poor or even fatal in the majority of cases, the advance and wider use of modern imaging technology since the early 1980s, together with the results of registries and population-based studies, revealed that CVT is more frequent and less life-threatening than previously assumed. However, because headache is frequently the only symptom, many oligosymptomatic cases might be overlooked. Both, CT- and MR-venography are suitable methods to confirm or rule out CVT, while the sensitivity of laboratory tests (D-dimer) alone is too low to rely on. Despite low evidence anticoagulation remains the treatment of choice during the acute phase and for secondary prevention.

Inflammation is correlated with severity and outcome of cerebral venous thrombosis

BACKGROUND

Few studies have suggested a relationship between inflammation and cerebral venous thrombosis (CVT). This retrospective study aimed to explore the changes in inflammation in different CVT stages and the correlation between inflammation and severity and outcome of CVT.

METHODS

In total, 95 suitable patients with CVT and 41 controls were compared. Patients with CVT were divided into three groups. The inflammatory factors studied included hypersensitive C-reactive protein (Hs-CRP), interleukin-6 (IL-6), and neutrophil-to-lymphocyte ratio (NLR) in the peripheral blood and immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin G (IgG) in the cerebrospinal fluid (CSF). The severity of CVT was evaluated with the modified Rankin Scale (mRS), the National Institutes of Health Stroke Scale (NIHSS), fundus condition, intracranial pressure (ICP), and complications on admission. The short-term outcome was evaluated with the mRS at discharge.

RESULTS

The following results were obtained: (1) Inflammatory factor levels in patients with CVT were higher than those in the controls. (2) Inflammatory factor levels in the acute and subacute stages were significantly higher than those in the chronic stage (all P < 0.05). (3) Serum NLR and CSF IgM levels were positively related to baseline degree of disability (odds ratio [OR], 1.279, 95% confidence interval [CI] 1.009-1.621, P = 0.042; OR 1.402, 95% CI 1.036-1.896, P = 0.028). The Hs-CRP level was positively correlated with the baseline occurrence of seizure (OR 1.040, 95% CI 1.001-1.080, P = 0.043). The baseline serum NLR (r = 0.244, P = 0.017), CSF IgA (r = 0.615, P < 0.001), CSF IgM (r = 0.752, P < 0.001), and CSF IgG (r = 0.248, P = 0.015) levels were positively associated with NIHSS. (4) The baseline NLR was significantly associated with high risk of poor outcome at discharge (OR 1.339, 95% CI 1.097-1.784, P = 0.007). Moreover, the ROC showed that NLR ≥ 4.205 could better predict the poor outcome at discharge. The data were analyzed using SPSS.

CONCLUSIONS

Inflammation may develop after CVT and gradually decrease during the course. Inflammation was significantly correlated with severity on admission and short-term poor outcome at discharge in CVT.

Management of Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare subtype of cerebrovascular disease representing 0.5% of strokes. The signs and symptoms of CVST are often nonspecific, and variable in duration, with the common results being delayed diagnosis and treatment. Increased awareness in the medical community and advancements in imaging modalities have produced faster diagnosis with improved patient outcomes. The preferred initial treatment is with a low molecular weight heparin. After the acute stage of CVST, treatment with a vitamin K antagonist (oral anticoagulant therapy) is recommended. Current evidence suggests that in the future, factor Xa inhibitor drugs may be used for long-term therapy.

Neurological Complications of Acute and Chronic Sinusitis

PURPOSE OF REVIEW

Acute and chronic sinusitis can give rise to a wide array of intracranial and orbital complications. These complications include brain abscess, subdural empyema, epidural abscess, meningitis, venous sinus thrombosis, frontal bone osteomyelitis, and orbital cellulitis and abscess. Despite numerous medical advances, these complications carry a risk of mortality and significant morbidity.

RECENT FINDINGS

Recent studies have shown improvement in both the mortality and the morbidity associated with the neurologic complications of acute and chronic sinusitis. However, there are still a large portion of patients with long-term sequelae, and the literature reports a morbidity rate of approximately 30%. The most common post-treatment morbidities include permanent changes in vision, seizures, and hemiparesis. Although the overall incidence of neurologic complications from a sinogenic source are rare, the potential long-term complications can be devastating making prompt diagnosis and treatment vital to improving outcomes.

Diagnosis and management of cerebral venous thrombosis

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

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology

BACKGROUND AND PURPOSE

Current guidelines on cerebral venous thrombosis (CVT) diagnosis and management were issued by the European Federation of Neurological Societies in 2010. We aimed to update the previous European Federation of Neurological Societies guidelines using a clearer and evidence-based methodology.

METHOD

We followed the Grading of Recommendations, Assessment, Development and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews and writing recommendations based on the quality of available scientific evidence.

RESULTS

We suggest using magnetic resonance or computed tomographic angiography for confirming the diagnosis of CVT and not routinely screening patients with CVT for thrombophilia or cancer. We recommend parenteral anticoagulation in acute CVT and decompressive surgery to prevent death due to brain herniation. We suggest preferentially using low-molecular-weight heparin in the acute phase and not 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 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 have suffered a previous CVT, 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.

CONCLUSIONS

Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of CVT.

Cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is an important cause of stroke in young adults. Data from large international registries published in the past two decades have greatly improved our knowledge about the epidemiology, clinical manifestations and prognosis of CVT. The presentation of symptoms is highly variable in this disease, and can range from a patient seen at the clinic with a 1-month history of headache, to a comatose patient admitted to the emergency room. Consequently, the diagnosis of CVT is often delayed or overlooked. A variety of therapies for CVT are available, and each should be used in the appropriate setting, preferably guided by data from randomized trials and well-designed cohort studies. Although deaths from CVT have decreased in the past few decades, mortality remains ∼5-10%. In this Review, we provide a comprehensive and contemporary overview of CVT in adults, with emphasis on advancements made in the past decade on the epidemiology and treatment of this multifaceted condition.

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology

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.

Clinical outcomes following corticosteroid administration in patients with delayed diagnosis of spinal arteriovenous fistulas

Background and purpose

There have been several previously reported cases of acute progression of myelopathic symptoms in patients with spinal arteriovenous fistula (SAVF) treated with intravenous methylprednisolone. This usually occurs during or immediately following steroid administration. We examined a small case series of patients with SAVF treated with epidural, oral, or intravenous steroids to determine the association between steroid administration and clinical outcomes in these patients.

Methods

Following Institutional Review Board approval, we conducted a retrospective review of patients with angiographically-confirmed SAVF who received intravenous, oral, or epidural corticosteroids for treatment of their symptoms. We studied patient-reported motor and sensory function following steroid administration using both the modified Rankin Scale and the Aminoff Motor Disability Scale.

Results

Twenty-one patients with SAVF were included in this study. Thirteen patients (61.9%) had intravenous methylprednisolone administered, four patients (19.0%) had epidural steroid injections, and six patients (28.6%) had oral prednisone. Among patients who received intravenous methylprednisolone, seven (53.8%) reported acute worsening of symptoms during or immediately following steroid administration. Among the patients receiving epidural steroids, none reported worsening and one patient reported short-term relief. Among the patients receiving oral steroids, one reported acute worsening of symptoms. Worsened deficits did not consistently resolve after steroid discontinuation.

Conclusions

Our study suggests that intravenous methylprednisolone can cause immediate worsening of motor and sensory symptoms when administered to patients with SAVF. Steroid administration should be avoided in patients with a myelopathy secondary to an untreated SAVF because neurological worsening may not be fully reversible.

Cavernous sinus thrombosis during pregnancy

Cavernous sinus thrombosis (CST) represents a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality. Rapid diagnosis and aggressive medical and surgical management are imperative for patients with CST. We present the case of a 24-year-old pregnant woman with intraorbital abscess and CST secondary to Streptococcus milleri. Surgical intervention included orbital abscess drainage and dental extraction, medical therapy included intravenous antibiotic, heparin, and methylprednisolone and an elective cesarean section was performed. The latter was the key point to resolution the disease.

Symptomatic Infratentorial Thrombosed Developmental Venous Anomaly: Case Report and Review of the Literature

BACKGROUND

Developmental venous anomalies (DVAs) are variations of normal transmedullary veins draining white and gray matter. In the vast majority of cases, DVAs are diagnosed incidentally and should be considered as benign entities. In extremely rare circumstances, DVAs may become symptomatic due to mechanical or flow-related etiologies. Thrombosis of the collector vein of a DVA is a rare type of a flow-related complication with only 29 cases reported in the literature, the majority of which are supratentorial. Infratentorial thrombosed DVAs are thus extremely rare and the few cases reported have typically caused symptoms due to venous ischemic infarctions.

SUMMARY

We report a case of an infratentorial DVA with a thrombosed drainage vein in a patient with nonhemorrhagic, noninfarcted venous congestive edema, which was successfully treated with high-dose glucocorticoids and short-term anticoagulation. We review the pertinent venous anatomy of the posterior fossa as well as the literature of symptomatic infratentorial thrombosed DVAs.

KEY MESSAGE

The presented case of an infratentorial thrombosed DVA with cerebellar and pontine venous congestive edema is extremely rare. A working knowledge of posterior fossa venous anatomy and possible pathomechanisms responsible for the rarely symptomatic lesion will aid in the timely and efficacious treatment of such lesions.

Neuro-Ophthalmological Emergencies

Neuro-ophthalmological emergencies constitute vision or life-threatening conditions if diagnosis and treatment are not promptly undertaken. Even with immediate therapy, these clinical entities carry a high rate of morbidity. They may present with diplopia, visual loss, and/or anisocoria. Arteritic anterior ischemic optic neuropathy is an ominous condition, which can cause permanent and severe vision loss, stroke, or aortic dissection, requiring immediate steroid therapy. Pituitary apoplexy may go unnoticed if only computed axial tomography is performed. Diseases affecting the cavernous sinus and orbital apex region, such as cavernous sinus thrombosis or mucormycosis, can give rise to simultaneous vision loss and diplopia and, if not treated, may extend to the brain parenchyma causing permanent neurological sequela. An isolated third nerve palsy may be the harbinger of a cerebral aneurysm, carrying a significant risk of mortality. Horner syndrome can be the initial presentation of a carotid dissection, an important cause of stroke in the young adult. The neurohospitalist should be familiar with the workup and management of neuro-ophthalmological emergencies.

Intracranial Infectious Aneurysm in Orbital Cellulitis

Infectious intracranial aneurysm and cavernous sinus thrombosis are rare complications of orbital cellulitis. We report the case of a 46-year-old male presenting with sinusitis and orbital cellulitis complicated by the development of an orbital mass. Following orbitotomy with debulking, the patient underwent bony orbital decompression for increasing proptosis postoperatively. While his exam stabilized, the patient developed complete ptosis and extraocular motor palsy in the contralateral eye after undergoing bilateral sinus debridement. Imaging was notable for the presence of a pseudoaneurysm of the internal carotid artery, which was treated with a stent. This report demonstrates rare complications of orbital cellulitis. These patients should be monitored carefully with noninvasive imaging studies, such as cerebral angiography, for early detection of vascular abnormalities that can progress rapidly.

Cerebral venous sinus thrombosis: update on diagnosis and management

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

Cerebral venous thrombosis-a primer for the haematologist

Cerebral venous thrombosis (CVT) is a condition that can affect all age groups and can often be difficult to diagnose and treat. The difficulties in diagnosis are mainly due to the non-specific presenting features of CVT, which can range from isolated headache and visual or auditory problems, to serious symptoms such as hemiparesis and coma. Therefore, it can present to various specialists including general physicians, obstetricians and neurologists. In recent years, more widespread use of cerebral imaging has led to the diagnosis being made more often. Since thrombosis is the key component, haematologists are consulted in the management of these patients including for identification of a causative factor for CVT. In this regard, the pivotal International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) has shed more light on its epidemiology and management options. This review aims to provide guidance to haematologists when faced with a patient with CVT, based on the currently available evidence.

Cerebral sinus venous thrombosis

Cerebral sinus venous thrombosis (CSVT) is a rare phenomenon that can be seen with some frequency in young patients. CSVT is a multifactorial condition with gender-related specific causes, with a wide clinical presentation, the leading causes differ between developed and developing countries, converting CSVT in a condition characterized by a highly variable clinical spectra, difficult diagnosis, variable etiologies and prognosis that requires fine medical skills and a high suspicious index. Patients who presents with CSVT should underwent to CT-scan venography (CVT) and to the proper inquiry of the generating cause. This disease can affect the cerebral venous drainage and related anatomical structure. The symptoms may appear in relation to increased intracranial pressure imitating a pseudotumorcerebri. Prognosis depends on the early detection. Correcting the cause, generally the complications can be prevented. Mortality trends have diminished, and with the new technologies, surely it will continue. This work aims to review current knowledge about CSVT including its pathogenesis, etiology, clinical manifestations, diagnosis, and treatment.

Evaluation and management of cerebral venous thrombosis

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.

Isolated cortical vein thrombosis: a rare cause of venous stroke with good prognosis after timely diagnosis and treatment

BACKGROUND

Isolated cortical vein thrombosis (ICoVT) is a rare condition representing approximately 6% of cerebral vein thromboses (CVT). In all its forms, CVT is more prevalent in women. ICoVT shares the same group of predisposing conditions typical of other CVT. It may thus be easily missed due to its non-specific clinical presentation and confounding radiological findings, which may lead to a delay in appropriate diagnosis and treatment.

METHODS

A comprehensive literature search was conducted to identify manuscripts discussing epidemiology, risk factors, clinical presentation, radiological techniques and presentation, management, and outcome in patients with ICoVT.

RESULTS

We identified 40 papers published between 1991 and 2012 that met our criteria for review.

DISCUSSION

MR techniques are essential in the diagnosis of this entity. Without appropriate therapy, these thromboses may extend bidirectionally and even compromise the dural sinuses. Correction of predisposing factors for venous thrombosis and anticoagulation is the therapy of choice for most patients. The overall prognosis with adequate and timely therapy is very good.

Cavernous sinus thrombosis: current therapy

Cavernous sinus thrombosis represents a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality. The prompt recognition and management of this problem is critical. However, most of the literature involves case-specific discussions. The purpose of this article was to review the literature and present current recommendations for the treatment of cavernous sinus thrombosis.