Systemic lupus erythematosus complicated with cerebral venous sinus thrombosis : a report of two cases

Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers

BACKGROUND

Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19.

AIMS

This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19.

CONCLUSION

A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.

An Uncommon Case of Celiac Disease and Deep Cerebral Venous Sinus Thrombosis

Celiac disease is an enteropathy characterized by malabsorption related with gluten intolerance and immune-mediated pathogenesis. It may manifest with gastrointestinal features like diarrhea, abdominal pain, weight loss, and anemia. Besides, it can manifest with various extraintestinal features like ataxia, neuropathy, stroke, or sometimes venous sinus thrombosis. Being of autoimmune origin, relation with systemic lupus erythematosus has also been reported. Herein, we present a rare case of a young patient with celiac disease who presented with fever, headache, and altered sensorium and was found to have meningitis with deep cerebral venous sinus thrombosis.

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

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Neuropsychiatric involvement in systemic lupus erythematosus: A review

The neuropsychiatric involvement in systemic lupus erythematosus (NPSLE) is a challenge for clinicians, both at a diagnostic and therapeutic level. Although in 1999 the American College of Rheumatology (ACR) proposed a set of definitions for 19 NPSLE syndromes, with the intention of homogenizing the terminology for research purposes and clinical practice, the prevalence of NPSLE varies widely according to different series and is estimated to be between 37 and 95%. This is due to multiple factors such as the unalike definitions used, the diverse design of the studies, type of population, race, type and severity of symptoms, and follow-up of the different cohorts of patients with SLE. In recent years, some authors have tried excluding minor neuropsychiatric manifestations in order to try to reduce this wide variation in the prevalence of NPSLE since they are very prevalent in the general population; others authors have developed various models for the attribution of neuropsychiatric events to SLE that can assist clinicians in this diagnostic process, and finally, some authors developed and validated in 2014 a new algorithm based on the definitions of the ACR that includes the evaluation of the patient's lupus activity together with imaging techniques and the analysis of cerebrospinal fluid (CSF), with the aim of trying to differentiate the true neuropsychiatric manifestations attributable to SLE. In 2010, the European League Against Rheumatism (EULAR) developed recommendations for the management of NPSLE. We found abundant literature published later where, in addition to the recommendations for the management of the 19 NPSLE syndromes defined by the ACR, additional recommendations are given for other neurological and/or psychiatric syndromes, conditions, and complications that have been associated to SLE in recent years. We review below the diagnostic and therapeutic management of the different entities.

Clinical Characteristics of Cerebral Venous Sinus Thrombosis in Patients with Systemic Lupus Erythematosus: A Single-Centre Experience in China

Clinical characteristics of systemic lupus erythematosus (SLE) patients complicated with cerebral venous sinus thrombosis (CVST) between 2000 and 2013 were analyzed through this retrospective, single-centre study. Of 4747 hospitalized SLE patients, 17 (0.36%, 12 females, average age 30) had CVST. Headache (88.2%) was the most common neurological symptom followed by nausea or vomiting (47.1%), conscious disturbance (41.2%), edema of eyelids or conjunctiva (35.3%), blurred vision or diplopia (35.3%), and seizure (35.3%). Increased intracranial pressure (ICP) occurred in 13 cases (76.5%). Magnetic resonance venography (MRV) detected thrombosis in the transverse (82.4%), sigmoid (52.9%), and sagittal (35.3%) sinuses, with frequent (70.6%) multiple sinus occlusions. Compared to SLE patients without CVST, SLE patients with CVST had a higher prevalence of thrombocytopenia and positive antiphospholipid antibodies and a higher SLE disease activity index (SLEDAI) score. 13 patients achieved improvement following glucocorticoids and immunosuppressants treatment, as well as anticoagulants, while 3 patients died at the hospital. CVST is relatively rare in SLE and tends to occur in active lupus patients. Intracranial hypertension is common but nonspecific clinical feature, so MRV evaluation is necessary to establish a diagnosis. Aggressive treatment for the rapid control of SLE activity combined with anticoagulants can improve the prognosis.

Cerebral venous thrombosis as a complication of neuropsychiatric systemic lupus erythematosus

A 51-year-old woman undergoing steroid treatment for systemic lupus erythematosus (SLE) was admitted to our hospital after developing a fever, consciousness disturbance and seizures, leading to a diagnosis of SLE-induced meningoencephalitis. Although steroid therapy improved her symptoms, she complained of post-lumbar puncture thunderclap headaches during follow-up, and cerebral venous thrombosis (CVT) was subsequently diagnosed on magnetic resonance venography and cerebral angiography. This is a rare case of neuropsychiatric SLE complicated by CVT during treatment for aseptic meningoencephalitis. The onset of aseptic meningoencephalitis and administration of the lumbar puncture and steroid therapy may have induced the development of the patient's CVT symptoms.

Cerebral venous-sinus thrombosis: a case series analysis

BACKGROUND

Cerebral venous-sinus thrombosis is an uncommon form but important cause of stroke, especially in young-aged women.

METHODS

We performed a retrospective descriptive-analytical study in which 124 patients with cerebral venous-sinus thrombosis, who referred to Nemazee Hospital, Shiraz University of Medical Sciences from January 2000 to March 2008, were included, and their demographic, etiologic, radiological and prognostic characteristics were evaluated.

RESULTS

The patients' mean age was 34.01±10.25. Eighty seven (70.16%) were women and 37 (29.83%) were men. The most frequent clinical manifestations were headache, papilledema and seizures. Fifty seven (65.51%) women took oral contraceptive pills. Twenty of 57 women (35.08%) took the pill longer than one month to be able to fast in Ramadan or perform the Hajj ceremonies. In the mean time they developed cerebral venous-sinus thrombosis. Superior sagital sinus, with or without lateral sinuses, was the most involved area (70.96%). High mortality and morbidity rates (14.51% and 35.48%, respectively) were found in patients. Poor prognostic factors at the time of admission were stupor and coma (P=0.001) and evidence of hemorrhage in primary CT scan (P=0.005).

CONCLUSION

Taking oral contraceptive pills was a main factor associated with cerebral venous-sinus thrombosis. Clinical manifestations, prognostic factors, common involved sinuses and image findings of this study were similar to those of other studies. Health care policy makers should design a plan to warn susceptible women of the risk of cerebral venous-sinus thrombosis, and to educate them the ways to prevent it.

[Cerebral venous thrombosis and acute polyradiculoneuritis revealing systemic lupus erythematosus]

INTRODUCTION

Neurological manifestations of systemic lupus erythematosus are frequent and polymorphic. In 40% of cases, lupus can be revealed by neurological symptoms. Cerebral nervous system complications predominate and can be a negative factor for prognosis. Peripheral features are rare and various and can compromise functional prognosis, sometimes with fatal outcome.

CASE REPORT

We report the case of a 30-year-old woman who presented a cerebral venous thrombosis of the superior longitudinal sinus. Outcome was favorable with antibiotics and anticoagulants. Four months later, she developed an acute polyradiculoneuritis associated with an inflammatory syndrome and positive tests for antinuclear antibody and antinuclear anti-DNA. The diagnosis of neurolupus was retained on the basis of four criteria of the American college of Rheumatology. The patient was given steroid therapy associated with a course of intravenous immunoglobulin. She has fully recovered her deficit.

CONCLUSION

Cerebral venous thrombosis and acute polyradiculonévrites are rare events in systemic lupus erythematosus. Early diagnosis and management are crucial.

Cerebral venous sinus thrombosis risk factors

Cerebral venous sinus thrombosis is an uncommon disease marked by clotting of blood in cerebral venous, or dural sinuses, and, in rare cases, cortical veins. It is a rare but potentially fatal cause of acute neurological deterioration previously related to otomastoid, orbit, and central face cutaneous infections. After the advent of antibiotics, it is more often related to neoplasm, pregnancy, puerperium, systemic diseases, dehydration, intracranial tumors, oral contraceptives, and coagulopathies are the most common causes, but in 30% of cases no underlying etiology can be identified. It has been found in association with fibrous thyroiditis, jugular thrombosis after catheterization, or idiopathic jugular vein stenosis. Other factors include surgery, head trauma, arterio-venous malformations, infection, paraneoplastic, and autoimmune disease. This article presents a comprehensive review of cerebral venous sinus thrombosis etiologies.