Isolated cortical vein thrombosis after epidural anesthesia: report of three cases

Intracranial hypotension as a contributor to isolated cortical vein thrombosis

BACKGROUND

Isolated cortical vein thrombosis (ICVT), a rare type of cerebral venous thrombosis (CVT), is diagnostically challenging in some cases, and intracranial hypotension (IH) is known to cause CVT.

METHODS

In this study, we reviewed the clinical and imaging characteristics of ICVT in patients with IH caused by spinal cerebrospinal fluid leakage, based on a literature review and investigation of cases from our hospital.

RESULTS

Between January 1, 2007, and November 1, 2019, 735 patients were diagnosed with IH at our hospital; three patients developed ICVT (incidence ~ 0.4%, 3/735), and the literature review yielded an additional 23 cases. Therefore, 26 patients (mean age 35.9 ± 11.4 years old) were included in this study. The most common symptoms were headache (100.0%, 26/26), focal neurological deficits (53.8%, 14/26), and seizure (34.6%, 9/26). The initial headache was orthostatic in 96.2% (25/26) of patients, and 38.5% (10/26) of patients reported a change in the headache pattern following diagnosis of ICVT. Neuroimaging findings associated with ICVT included the cord sign (61.5%, 16/26) and parenchymal brain lesions (46.2%, 12/26), such as intracerebral hemorrhage (30.8%, 8/26), hemorrhagic infarcts (11.5%, 3/26), and localized edema (11.5%, 3/26). The percentage of patients who received anticoagulation and epidural blood patch therapy was similar (69.2% [18/26] vs. 65.4% [17/26]), and most patients recovered completely (92.3%, 24/26).

CONCLUSION

IH should be considered in the differential diagnosis in patients with ICVT. Knowledge of the relevant clinical and neuroimaging features is important to facilitate early diagnosis for favorable prognosis.

Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block.

METHODS

Medline, CINAHL and EMBASE databases were searched to identify postpartum cases of CVST following neuraxial block. The aim was to delineate the characteristics, presentation, investigations, and outcomes of postpartum women who presented with CVST.

RESULTS

Forty-nine articles with 58 case reports were identified. Forty-two women (72.4%) had an epidural attempted whilst 16 women (27.6%) received a spinal anaesthetic. Accidental dural puncture (ADP) was reported in 17 women (40.5%). Headache was the presenting symptom in 57 women (98.3%); 26 women (44.8%) also experienced seizures. Post-dural puncture headache was reported in 46 (79.3%) and an epidural blood patch was performed in 26 women (44.8%). Superior sagittal sinus, transverse sinus, and cortical veins were the most common sites of thrombosis. The median time to diagnosis was 6.5 days from delivery. Magnetic resonance imaging was the most common diagnostic neuro-imaging modality. Full neurological recovery was reported in 48 (82.8%), whilst neurological deficits were reported in six (10.3%) women.

DISCUSSION

The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.

Superior sagittal sinus thrombosis after spinal anesthesia

Superior sagittal sinus thrombosis is an uncommon phenomenon that could occur in patients with a risk for thrombosis. It has been reported after spinal anesthesia with persistent cerebrospinal fluid leak. The current case is a young 29-year-old man who was complaining of persistent headache after spinal anesthesia for varicocelectomy and a new onset of blurred vision with a sign of papilledema. The diagnosis was confirmed with magnetic resonance imaging and proved to be superior sagittal sinus thrombosis. He was started on anticoagulant therapy and showed gradual improvement. No previous case has been reported in the literature in a patient without prothrombotic status risk. Received 8th January 2020. Accepted 26th March 2020.

Isolated cortical vein thrombosis: case series

OBJECT

Isolated cortical vein thrombosis (ICVT) accounts for less than 1% of all cerebral infarctions. ICVT may cause irreversible parenchymal damage, rendering early and accurate diagnosis critical. This case series and literature review presents the clinical and radiological findings in 7 patients with ICVT, and highlights risk factors and imaging modalities that may be most beneficial in rendering an accurate and timely diagnosis.

METHODS

Patients with CT and MRI findings consistent with ICVT examined between January 2011 and June 2014 were included in this retrospective review.

RESULTS

Seven patients (5 females, 2 males), ranging in age from 11 months to 34 years, met the inclusion criteria. The most common clinical presentations were headaches (n = 4) and seizures (n = 3). The most common comorbidities noted in these patients were hypercoagulable states (n = 4) and intracranial hypotension (n = 3). Five patients had intraparenchymal involvement. CT suggested the correct diagnosis in 4 patients, and MRI confirmed the diagnosis in all 7 patients. All patients who received anticoagulation therapy (n = 5) experienced complete resolution of their symptoms.

CONCLUSIONS

The majority of these patients were adult females, consistent with published data. Seizures and headaches were the most common presenting symptoms. Hypercoagulable state and intracranial hypotension, both known risk factors for thrombosis, were the most commonly noted ICVT risk factors. Intraparenchymal involvement was prevalent in nearly all ICVT cases and presented as vasogenic edema, early intraparenchymal hemorrhage, or hemorrhagic venous infarction. Susceptibility-weighted imaging was the most sensitive imaging technique in diagnosing ICVT.

[Cerebral venous thrombosis after spinal anesthesia: case report]

INTRODUCTION

Cerebral venous thrombosis (CVT) is a rare, but serious complication after spinal anesthesia. It is often related to the presence of predisposing factors, such as pregnancy, puerperium, oral contraceptive use, and malignancies. Headache is the most common symptom. We describe a case of a patient who underwent spinal anesthesia who had postoperative headache complicated with CVT.

CASE REPORT

Male patient, 30 years old, ASA 1, who underwent uneventful arthroscopic knee surgery under spinal anesthesia. Forty-eight hours after the procedure, the patient showed frontal, orthostatic headache that improved when positioned supine. Diagnosis of sinusitis was made in the general emergency room, and he received symptomatic medication. In subsequent days, the headache worsened with holocranial location and with little improvement in the supine position. The patient presented with left hemiplegia followed by tonic-clonic seizures. He underwent magnetic resonance venography; diagnosed with CVT. Analysis of procoagulant factors identified the presence of lupus anticoagulant antibody. The patient received anticonvulsants and anticoagulants and was discharged eight days without sequelae.

DISCUSSION

Any patient presenting with postural headache after spinal anesthesia, which intensifies after a plateau, loses its orthostatic characteristic or become too long, should undergo imaging tests to rule out more serious complications, such as CVT. The loss of cerebrospinal fluid leads to dilation and venous stasis that, coupled with the traction caused by the upright position, can lead to TVC in some patients with prothrombotic conditions.

Cerebral venous thrombosis complicating severe preeclampsia in the postpartum period: a diagnostic challenge

A 26 year old primigravida with preeclampsia was diagnosed with a cerebral venous thrombosis 6 days following Cesarean section. The diagnosis was initially challenging due to the patient's history of migraines, the preeclampsia, multiple attempts at spinal anesthesia for Cesarean section, and a dural puncture while performing epidural blood patch.

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.

Isolated superficial sylvian vein thrombosis with long cord sign: case report and review of the literature

Isolated cortical vein thrombosis (ICVT) is extremely rare. Only single case or small series of ICVT have been reported; clinical details are still uncertain. We report a case of isolated superficial sylvian vein thrombosis with exceedingly long cord sign. A 14-year-old female with severe sudden onset headache visited our hospital. Fluid attenuated inversion recovery and echo-planar T2(*) susceptibility-weighted imaging (T2(*)SW) showed a long cord sign on the surface of the sylvian fissure. The patency of dural sinuses and deep cerebral veins were confirmed by magnetic resonance venography (MRV), and diagnosis of ICVT was made. She recovered completely without anticoagulant agents. To clarify the clinical characteristics of ICVT, we reviewed 51 ICVT cases in the literature. In many cases, T2(*)SW was the most useful examination to diagnose ICVT. In contrast with general cerebral venous thrombosis, MRV and conventional angiography were either supporting or useless. Anastomotic cortical veins were involved frequently; symptoms of gyri around the veins were common. It also suggested that ICVTs of the silent area might have been overlooked because of nonspecific symptoms, and more patients with ICVT may exist. In cases involving patients with nonspecific symptoms, the possibility of ICVT should be considered.

Isolated cortical vein thrombosis: a widely variable clinicoradiological spectrum

BACKGROUND/AIMS

The aim of this study is to highlight the variable clincoradiological spectrum of isolated cortical vein thrombosis (ICoVT), which seems to remain a challenge to clinicians.

CASES REPORTS

We reported 3 patients with this diagnosis. One presented with only an epileptic seizure, one with worsening headache, seizures, mental disorder, speech disturbance and right-sided weakness, and the other with seizures and fluctuating paralysis in her left-sided limbs. Brain images were manifested with a strand-like abnormal signal, a large hemorrhagic infarction and a continuously enlarged space-occupying massive edema, respectively.

CONCLUSIONS

Neurologic features and brain imaging of ICoVT are highly variable, which might be partly responsible for the underestimation of ICoVT. Clinical diagnosis should probably be evoked more often.