Cerebral venous thrombosis: imaging patterns

Prediction of Long-Term Poor Clinical Outcomes in Cerebral Venous Thrombosis Using Neural Networks Model: The BEAST Study

Introduction

Risk prediction models are commonly performed with logistic regression analysis but are limited by skewed datasets. We utilised neural networks (NNs) model to identify independent predictors of poor outcomes in cerebral venous thrombosis (CVT) due to the limitations of logistic regression (LR) analysis with complex datasets.

Methods

We evaluated 1309 adult CVT patients from the prospective BEAST (Biorepository to Establish the Aetiology of Sinovenous Thrombosis) study. The area under the receiver operating characteristic (AUROC) curve confirmed the goodness-of-fit of prediction models. The normalised importance (NI) of the NNs determines the significance of independent predictors.

Results

The stepwise logistic regression model found thrombolysis (OR 32.1; 95% CI 3.6-287.0; P=0.002), craniotomy (OR 6.9; 95% CI 1.3-36.8; P=0.02), and cerebral haemorrhage (OR 4.5; 95% CI 1.3-15.4; P=0.01) as predictors of poor clinical outcome with the AUROC of 0.71. Conversely, the NNs model identified major independent predictors of long-term poor clinical outcomes as cerebral haemorrhage (NI 100%) and thrombolysis (NI 98%), as well as trivial predictors of age (NI 2.8%) and altered mental status (NI 3.5%). The accuracy of the NNs model was 95.1% and 94.1% for self-learned randomly selected training and testing samples with an AUROC of 0.82. Positive and negative predictive values for poor outcomes were 13.2% and 97.1% for the LR model, compared with the NNs model of 18.8% and 98.7%, respectively.

Conclusion

Cerebral haemorrhage and thrombolysis was a strong independent predictor, whereas age merely impacts the long-term poor clinical outcome in adult CVT. Integrating unorthodox neural networks risk prediction model can improve decision-making as it outperforms conventional logistic regression with complex datasets.

Neuro-imaging in intracerebral hemorrhage: updates and knowledge gaps

Intracerebral hemorrhage (ICH) is characterized by hematoma development within the brain's parenchyma, contributing significantly to the burden of stroke. While non-contrast head computed tomography (CT) remains the gold standard for initial diagnosis, this review underscores the pivotal role of magnetic resonance imaging (MRI) in ICH management. Beyond diagnosis, MRI offers invaluable insights into ICH etiology, prognosis, and treatment. Utilizing echo-planar gradient-echo or susceptibility-weighted sequences, MRI demonstrates exceptional sensitivity and specificity in identifying ICH, aiding in differentiation of primary and secondary causes. Moreover, MRI facilitates assessment of hemorrhage age, recognition of secondary lesions, and evaluation of perihematomal edema progression, thus guiding tailored therapeutic strategies. This comprehensive review discusses the multifaceted utility of MRI in ICH management, highlighting its indispensable role in enhancing diagnostic accuracy as well as aiding in prognostication. As MRI continues to evolve as a cornerstone of ICH assessment, future research should explore its nuanced applications in personalized care paradigms.

Isolated Inferior Sagittal Sinus Thrombosis in Young Patient: Rare Case Report

Cerebral venous thrombosis (CVT) is a less common type of stroke, mostly in young patients. The majority of these cases are due to thrombosis of superior sagittal sinus and transverse sinus. Isolated thrombosis of the inferior sagittal sinus is very rare. Here, we report a 22-year-old male patient with no significant past medical history who presented to the emergency department of our hospital with a convulsion, decreased level of consciousness, and right side weakness. His laboratory investigations, including the coagulation profile, were normal. A non-contrast brain CT showed a 5 × 3 cm hematoma in the left parasagittal parietal lobe with no associated midline shift or intraventricular extension. The cerebral magnetic resonance (MR) angiogram did not show any underlying aneurysm or vascular lesion. However, the cranial MR venogram showed inferior sagittal sinus thrombosis, while other cranial veins and dural sinuses were patent. The patient was admitted to the hospital and managed with low-molecular-weight heparin and warfarin sequentially. He had significant improvement (consciousness and weakness have improved, and seizures are under control). This present case illustrates a rare case of isolated cerebral venous thrombosis and also reviews the known literature on this condition.

Development and Validation of a Clinical-Based Severity Scale for Patients with Cerebral Venous Thrombosis

Introduction

Cerebral venous thrombosis (CVT) is a rare subtype of stroke. However, existing scales were insufficient to evaluate the overall severity of CVT. The aim of this study is to develop and validate a CVT severity scale.

Methods

Items 1-11 were directly derived from NIHSS. New items were generated from a literature review and focus group discussion. A total of 170 CVT patients were prospectively recruited from 26 top tertiary hospitals in China Mainland from January 2021 to May 2022 to validate the CVT severity scale. The CVT severity scale, NIHSS, mRS and GCS were rated at admission. The lumbar puncture opening pressure was also recorded. Twenty randomly selected CVT patients were rated with the CVT severity scale again 24 hours later. The clinical outcome of CVT was evaluated by mRS at 6 months after baseline.

Results

We successfully established a CVT severity scale with 18 items. Exploratory factor analysis showed that 18 items were attributed to factor 1 (focal neurological deficits), factor 2 (diffuse encephalopathy), factor 3 (intracranial hypertension) and factor 4 (cavernous sinus syndrome). CVT severity scale was positively correlated with ICP, NIHSS and mRS, and negatively correlated with GCS at baseline. CVT severity scale >3 or factor 3 >2 indicated intracranial hypertension. CVT severity scale >10 indicated poor clinical outcome at 6 months of follow-up. Meanwhile, CVT severity scale showed high internal consistency and test-retest reliability.

Conclusion

The CVT severity scale included 18 items encompassing 4 domains of focal neurological deficits, diffuse encephalopathy, IH and cavernous sinus syndrome. CVT severity scale correlated well with ICP, NIHSS, mRS and GCS. Patients with CVT severity scale >10 can be defined as severe CVT. The CVT severity scale may serve as a valid and reliable tool for measuring the overall severity of CVT.

Increased cerebrospinal fluid pressure and nephrotic syndrome: A case report and literature review

OBJECTIVE

To analyze how nephrotic syndrome (NS) correlates to increased intracranial pressure (ICP), and to present a case of an adult patient whose initial manifestation of NS was cephalalgia, with the later identification of raised ICP.

METHODS

Data were retrospectively retrieved from the patient's record, and a literature search with the keywords "nephrotic syndrome", "intracranial hypertension" and "headache" was conducted in PubMed and Embase.

RESULTS

This is a rare description of co-occurrence of NS and raised ICP in a 48-year-old man, in which ICP normalizes after NS remits. There is no known cause for the raised ICP of our patient. Ten reports (n = 13) of concomitant occurrence of increased ICP and NS were described in the literature, both in children and adults. Cerebral venous thrombosis (CVT) was the most likely underlying cause for the majority of them. For one patient, the underlying cause was meningoencephalitis. Finally, in one case, the cause is unknown, but CVT was not discarded.

CONCLUSION

The early suspicion of elevated ICP is warranted in patients with new-onset headache and NS. It is possible that NS could both directly and indirectly lead to increased ICP through yet unknown mechanisms, although this direct causal relationship cannot be currently established.

Progressive Cerebral Venous Thrombosis with Cranial Nerve Palsies in an Adolescent African Girl & Associated Diagnostic Pitfalls: A Rare Case Report

Cerebral venous thrombosis (CVT) is a cerebrovascular disorder caused by complete or partial occlusion of the cerebral venous and sinus system. The etiology has been attributed to hypercoagulability and pro-thrombotic states, leading to raised intracranial pressures that often manifest as headaches and focal neurological deficits. However, the multifactorial nature of CVT can create a diagnostic conundrum for clinicians. We describe a unique case of a 16-year-old female who presented with convulsions, postictal confusion, and drowsiness followed by residual weakness of her extremities. She initially presented to the primary care center with headache, high-grade fever, and altered mental status and was empirically treated for pyogenic meningitis. The patient failed to improve with a week of antibiotics and was referred to the tertiary care center for urgent attention. On presentation, the patient developed VI and VII cranial nerve palsy. Subsequently, MRI images showed filling defects in the superior sagittal, right transverse, and sigmoid sinuses with right parietal gyral T1 hyperintensity and T2 hypo-intensity. She was diagnosed with septic CVT based on sinus venous thrombosis and venous infarction, probably secondary to meningococcal pneumonia. It can be challenging to distinguish between both conditions as their presentations overlap. Moreover, cranial nerve palsy is an infrequent manifestation of CVT, with unclear pathogenesis. We highlight the role of neuro-imaging in the early detection of CVT and bring to light the unfamiliar symptoms and a more varied clinical spectrum that may hinder the diagnosis in a limited-resource setting. Future research should be explicitly modeled to improve the diagnostic efficiency of CVT and improve outcomes in younger patient populations.

Imaging of Cerebral Venous Thrombosis

Cerebral venous thrombosis is a rare cause of stroke. Imaging is essential for diagnosis. Although digital subtraction angiography is still considered by many to be the gold standard, it no longer plays a significant role in the diagnosis of cerebral venous thrombosis. MRI, which allows for imaging the parenchyma, vessels and clots, and CT are the reference techniques. CT is useful in case of contraindication to MRI. After presenting the radio-anatomy for MRI, we present the different MRI and CT acquisitions, their pitfalls and their limitations in the diagnosis of cerebral venous thrombosis.