Cerebral sinus venous thrombosis

Cerebral Sinus Venous Thrombosis in Pediatric Acute Lymphoblastic Leukemia: Incidence, Clinical Characteristics, and Long-term Neurologic Outcomes

OBJECTIVE

To describe the incidence, clinical characteristics, and long-term outcomes of cerebral sinus venous thrombosis in children with acute lymphoblastic leukemia.

METHODS

This was a retrospective cohort study comprising pediatric patients with newly diagnosed or first-relapse acute lymphoblastic leukemia who developed cerebral sinus venous thrombosis at Texas Children's Hospital from 2002 to 2019.

RESULTS

Nineteen cases (1.7%) with cerebral sinus venous thrombosis were identified in all pediatric patients with acute lymphoblastic leukemia (n = 1129). Increased risk of cerebral sinus venous thrombosis was observed with age >10 years (P = .006). Twelve cases (63%) occurred during the induction, 4 (21%) during maintenance, and 3 (16%) during the consolidation phases of leukemia therapy. Seizures (10/19) and headaches (9/19) were the most common presenting symptoms. After treatment with anticoagulation therapy, we observed full resolution of thrombosis in 10 (53%) and partial resolution in 8 patients (42%). Long-term neurologic outcomes at follow-up in the 14 patients who survived included normal neurologic examinations (n = 10), epilepsy (n = 3), and focal neurologic deficits (n = 2). The death occurred in 5 individuals.

CONCLUSION

Cerebral sinus venous thrombosis is a notable complication of pediatric acute lymphoblastic leukemia therapy. Older age (>10 years) was a risk factor for developing cerebral sinus venous thrombosis. Despite variable patient presentations and treatment durations, favorable clinical outcomes were observed in most patients after the treatment with anticoagulation for a minimum of 3 months.

Knowledge and Perceptions of Cerebral Venous Thrombosis Among the Adult Population: A Nationwide Cross-Sectional Study in Saudi Arabia

Background

The current annual incidence of cerebral venous thrombosis (CVT) is 3-4 cases per one million population. CVT manifests itself with varying degrees of clinical presentation that may cause vital or morbid consequences if not treated and managed promptly. Studies have suggested varied levels of CVT public awareness.

Aim

To assess the level of knowledge and public perception of CVT across the different socio-economic strata of the Saudi Adult population.

Methods

A descriptive cross-sectional study was conducted using a mixed-method approach (an electronic questionnaire and phone interviews) for collecting the data. A validated questionnaire was distributed to consenting study participants and filled out to the best of their ability. The study setting was a nationwide survey conducted in Saudi Arabia and involved a representative portion of the study population.

Results

A total of 1912 participants were included in this study. Overall, the majority of study participants (67.2%) had a low knowledge level of CVT on assessment, and only 2.6% had a high knowledge level of CVT. Younger age, female gender, working adults, higher education level, marital status, Saudi nationals, and place of residency were significantly associated with knowledge of CTV (p < 0.001).

Conclusion

This study indicates a lower index of knowledge of CVT which offers an opportunity for much improvement in public perception and awareness of CVT in the study population. Our results can be utilized to target the demographics with the lowest knowledge via the most popular ways to gain information.

Deciphering Mechanisms, Prevention Strategies, Management Plans, Medications, and Research Techniques for Strokes in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune rheumatic condition characterized by an unpredictable course and a wide spectrum of manifestations varying in severity. Individuals with SLE are at an increased risk of cerebrovascular events, particularly strokes. These strokes manifest with a diverse range of symptoms that cannot be solely attributed to conventional risk factors, underscoring their significance among the atypical risk factors in the context of SLE. This complexity complicates the identification of optimal management plans and the selection of medication combinations for individual patients. This susceptibility is further complicated by the nuances of neuropsychiatric SLE, which reveals a diverse array of neurological symptoms, particularly those associated with ischemic and hemorrhagic strokes. Given the broad range of clinical presentations and associated risks linking strokes to SLE, ongoing research and comprehensive care strategies are essential. These efforts are critical for improving patient outcomes by optimizing management strategies and discovering new medications. This review aims to elucidate the pathological connection between SLE and strokes by examining neurological manifestations, risk factors, mechanisms, prediction and prevention strategies, management plans, and available research tools and animal models. It seeks to explore this medical correlation and discover new medication options that can be tailored to individual SLE patients at risk of stroke.

Sudden death in a newborn from cerebral venous sinus thrombosis resulting from meningitis

Septic cerebral venous sinus thrombosis is a rare but often fatal complication caused by bacterial meningitis and paranasal sinusitis.We report a particular case of the sudden and unexpected death of a six-day-old infant from unrecognised acute meningitis that caused a thrombotic occlusion of the venous sinuses (with the particular involvement of the torcular Herophili at the confluence of sinuses) resulting in subdural haemorrhage.This case report alerts paediatricians and neonatologists to the importance of promptly considering a possible diagnosis of meningitis without delay to avoid the fatal complications described here. As in all cases of sudden infant death our case study underlines the need for a thorough autopsy, accompanied by histological analysis, in order to identify the causes of the underlying pathological mechanisms causing death and to ensure an adequate differential diagnosis.

Characteristics of Cerebral Venous Sinus Thrombosis Due to Autoimmune Diseases: A Single-Center Retrospective Observational Study

OBJECTIVES

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular disease characterized by thrombosis of the cerebral venous or dural sinuses. Autoimmune diseases (AD) are important causes of CVST. This study aims to reveal the differences between CVST associated with autoimmune diseases compared with other causes (OCs) and Behcet's syndrome (BS) compared with other ADs.

METHODS

This is a single-center retrospective study in which the medical records of 187 patients we followed with a diagnosis of CVST between 2008 and 2023 were collected retrospectively. Four neurologists collected data on initial symptoms, neurological examinations, and laboratory findings. Findings on magnetic resonance imaging and magnetic resonance venography performed on all patients (thrombosis localizations, hemorrhagic or ischemic complications, and collateralization) were re-evaluated by 2 radiologists. The results were compared with AD, other ADs, and OCs groups.

RESULTS

There were 28 cases of CVST associated with AD. Of these, 18 were BS, and 10 were other AD. Subacute-chronic onset, headache, and transverse sinus involvement were more common in AD-related patients than in OCs. However, collateralization, venous infarction, hemorrhagic transformation, and bleeding were less common. BS-related patients had earlier age, more frequent transverse sinus, less frequent cortical vein thrombosis, and better collateralization than other ADs.

CONCLUSION

CVST is one of the rare complications in autoimmune diseases. It has a more subacute-chronic onset. Since headaches are more common, it is essential to make a differential diagnosis of CVST in autoimmune diseases with chronic headaches. Transverse sinus thrombosis is more common. Collateralization, venous infarction, and hemorrhagic transformation are less.

Cerebral Venous Sinus Thrombosis as an Initial Presentation of Nephrotic Syndrome: A Case Report

Cerebral sinovenous thrombosis (CSVT) encompasses a spectrum of disorders involving thrombosis of the cerebral venous system. As shown by previous epidemiological studies, the prevalence of cerebral sinovenous thrombosis is 4-7 cases per million people. Nephrotic syndrome was very rarely associated with thrombosis cerebral veins or sinuses. Hypercoagulability and thrombotic complications in nephrotic syndrome are most commonly seen in deep veins of the lower extremities and renal veins. Our case highlights a unique scenario in which cerebral sinovenous thrombosis was the initial presentation of nephrotic syndrome in a patient that was not an important past medical or surgical problem. The patient was brought to the emergency department with severe headache, vomiting, altered mental status, and generalized body swelling. Laboratory results showed proteinuria, hypoalbuminemia and hyperlipidemia. Non-contrast brain CT demonstrated hemorrhagic venous infarct associated with vasogenic edema. A subsequent brain MR venogram demonstrated occlusion of superior sagittal and right transverse sinuses. She was managed with low molecular weight heparin and intervenous corticosteroids then shifted to rivaroxaban and oral steroids, respectively, which resulted in massive clinical improvement and resolution of thrombus.

Superior Sagittal Sinus Thrombectomy in Pediatric Head Injury

INTRODUCTION

Injury and subsequent thrombosis of the cerebral venous sinuses may be caused by closed head injuries secondary to a variety of different mechanisms. Skull fractures can lacerate or otherwise disrupt adjacent dural sinuses. The sequelae of such injuries may include thrombosis and either partial or total occlusion of the sinus, ultimately resulting in significant venous congestion. Sagittal sinus injury is associated with a more serious outcome due to the obligatory flow into the sinus, especially posterior to the coronal suture. In such cases, venous infarction may be a severe and life-threatening complication of head injury.

CASE PRESENTATION

A 2-year-old female presented with a depressed skull fracture near the midline and a thrombus in the sagittal sinus. Anticoagulation, the standard treatment cerebral venous sinus thrombosis (CVST), was contraindicated due to intracranial hemorrhage, so immediate thrombectomy was performed with successful neurologic recovery at 9-month follow-up. To our knowledge, this case is the youngest patient documented to receive mechanical thrombectomy for superior sagittal sinus (SSS) thrombosis due to trauma.

CONCLUSION

Closed head injuries in pediatric patients may be associated with CVST, with resulting venous drainage compromise and profound neurologic sequelae. Unlike adult patients with spontaneous CVST in which anticoagulation are the standard of care, pediatric patients experiencing traumatic CVST may have contraindications to anticoagulants. If the patient has a contraindication to anticoagulation such as intracranial bleeding, endovascular mechanical thrombectomy may be an effective intervention when performed by an experienced neurointerventionalist.

A Review of Current Perspectives on Motoric Insufficiency Rehabilitation following Pediatric Stroke

Pediatric stroke (PS) is an injury caused by the occlusion or rupture of a blood vessel in the central nervous system (CNS) of children, before or after birth. Hemiparesis is the most common motoric deficit associated with PS in children. Therefore, it is important to emphasize that PS is a significant challenge for rehabilitation, especially since the consequences may also appear during the child's growth and development, reducing functional capacity. The plasticity of the child's CNS is an important predecessor of recovery, but disruption of the neural network, specific to an immature brain, can have harmful and potentially devastating consequences. In this review, we summarize the complexity of the consequences associated with PS and the possibilities and role of modern rehabilitation. An analysis of the current literature reveals that Constraint-Induced Movement Therapy, forced-use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation and robot-assisted therapy have demonstrated at least partial improvements in motor domains related to hemiparesis or hemiplegia caused by PS, but they are supported with different levels of evidence. Due to the lack of randomized controlled studies, the optimal rehabilitation treatment is still debatable, and therefore, most recommendations are primarily based on expert consensuses, opinions and an insufficient level of evidence.

Cerebral Venous Thrombosis in Pregnant and Postpartum Women Presenting to the Emergency Department with Headaches

Introduction

Cerebral venous thrombosis (CVT) is a thromboembolic disease of the intracranial venous systems. The disease can be difficult to diagnose as it often requires a high index of suspicion. Risk factors for the disease include pregnancy, oral contraceptive pills, congenital thrombophilia, infection, cancer, polycythemia, head trauma, and recent surgery. However, there have been no studies in the United States that have examined whether pregnancy and the postpartum stage are truly a risk factor for CVT. The aim of this study is to determine whether pregnant and postpartum women presenting to the emergency department with headaches have a higher incidence of CVT to better risk stratify which patients need to have advanced imaging pursued.

Methods

A retrospective, observational case-control study was performing by querying the electronic medical record at a large county hospital for patients presenting with a headache to the emergency department. Patients were stratified into groups based on whether they were diagnosed with CVT, pregnancy status, and comorbid conditions to determine the risk associated between pregnancy, the puerperium stage, and CVT.

Results

A total of 20,955 males and females presented to the emergency department between January 1, 2016 and April 13, 2023, with a chief complaint of headache. There were 19,474 female patients and 9581 male patients. In the case group, there were 793 pregnant women and 53 postpartum women. In the control group, there were 18,628 women who were not pregnant. Of the 22 patients diagnosed with CVT, 1 was in the puerperium stage and no patients were pregnant. Pregnant and postpartum patients were 1.05 (0.14-7.80) times more likely to develop CVT. Pregnant and postpartum patients were 1.73 (0.23-13.52) times more likely to develop CVT when controlled for comorbidities. Patients in the puerperium stage were 26.48 (3.33-210.87) times more likely to develop CVT when controlled for comorbidities.

Conclusion

Pregnant patients presenting to the emergency department with headaches do not have a significantly higher risk of CVT; however, puerperium patients have a significantly higher risk of CVT compared to the general population.

Thrombosis of the Vein of Trolard: An Atypical Presentation of Protein C Deficiency

Cerebral venous thrombosis refers to complete or partial occlusion of the cerebral sinus/es or the feeding cortical veins, resulting in secondary effects of vascular congestion and focal or generalized neurological deficits. One of the important causes of venous thromboembolism is inherited thrombophilia. Our case is of a 34-year-old male with no previous comorbidity who presented to the emergency department with complaints of sudden onset left-sided weakness, seizures, and loss of consciousness for one day. Thrombosis of the vein of Trolard was diagnosed based on magnetic resonance venography (MRV) film. His MRI with MRV revealed an attenuated caliber of the vein of Trolard along with abnormal signal intensity in the right fronto-parietal region and the right falcine location. He was managed with intravenous medication, including levetiracetam and topiramate. Once the diagnosis was established, he was commenced on subcutaneous Enoxaparin. Consequently, his GCS improved from 6/15 to 15/15 within the first 24 hours, and he could move his limbs on the day of discharge without any significant disability.

D-Dimer Level Associated with Amount of Sinus involvement Using Digital Subtraction Angiography on Cerebral Venous Thrombosis Patients

Background

Cerebral venous sinus thrombosis (CVST) is a form of the cerebrovascular disease characterized by varying degrees of obstruction of veins and cerebral sinuses caused by thrombus. Diagnosis is incredibly challenging due to the wide variety of symptoms and the distinct radiological aspects of affected vessels. In patients with venous thrombosis, the presence of D-Dimer is used as an indicator of the presence of endogenous fibrinolysis. D-Dimer is a by-product of fibrin polymer fragmentation.

Objective

To investigate the relationship between the level of D-Dimer and the number of sinuses in CVST by Digital Subtraction Angiography (DSA).

Methods

Retrospective data from September 2021 to September 2022 were used in this analytical observational with a cross-sectional study design. Chi-Square is used for data processing relationship analysis.

Results

Out of the 54 subjects with elevated levels of D-Dimer, 38 (70.4%) are females, whereas 16 (29.6%) are males. High levels of D-Dimer have been related to a greater risk of sinus thrombosis (p < 0.001). D-Dimer levels were similarly shown to rise in conjunction with the number of sinuses most severely damaged by thrombosis. The most common site for thrombosis to develop in this study were the left sigmoid and left transverse sinuses. Most risk factors were hormonal.

Conclusion

There is a statistically significant relationship between an increase in the D-Dimer level and the greater number of sinuses involved as determined by DSA in individuals diagnosed with CVST.

A Model of High-Speed Endovascular Sonothrombolysis with Vortex Ultrasound-Induced Shear Stress to Treat Cerebral Venous Sinus Thrombosis

This research aims to demonstrate a novel vortex ultrasound enabled endovascular thrombolysis method designed for treating cerebral venous sinus thrombosis (CVST). This is a topic of substantial importance since current treatment modalities for CVST still fail in as many as 20% to 40% of the cases, and the incidence of CVST has increased since the outbreak of the coronavirus disease 2019 pandemic. Compared with conventional anticoagulant or thrombolytic drugs, sonothrombolysis has the potential to remarkably shorten the required treatment time owing to the direct clot targeting with acoustic waves. However, previously reported strategies for sonothrombolysis have not demonstrated clinically meaningful outcomes (e.g., recanalization within 30 min) in treating large, completely occluded veins or arteries. Here, we demonstrated a new vortex ultrasound technique for endovascular sonothrombolysis utilizing wave-matter interaction-induced shear stress to enhance the lytic rate substantially. Our in vitro experiment showed that the lytic rate was increased by at least 64.3% compared with the nonvortex endovascular ultrasound treatment. A 3.1-g, 7.5-cm-long, completely occluded in vitro 3-dimensional model of acute CVST was fully recanalized within 8 min with a record-high lytic rate of 237.5 mg/min for acute bovine clot in vitro. Furthermore, we confirmed that the vortex ultrasound causes no vessel wall damage over ex vivo canine veins. This vortex ultrasound thrombolysis technique potentially presents a new life-saving tool for severe CVST cases that cannot be efficaciously treated using existing therapies.

Sagittal sinus thrombosis with subarachnoid haemorrhage in a patient with COVID-19 infection

A man in his late 50s was admitted with a 10-day history of right frontotemporal headache, left arm and leg weakness, and a sudden decline in visual acuity in the right eye. The patient had recent exposure to COVID-19 infection and tested positive for the same on admission. A CT scan of the head done on arrival demonstrated a subarachnoid haemorrhage in the right central sulcus with an underlying superior sagittal sinus thrombosis. No other known risk factors for central venous sinus thrombosis could be identified. The patient had a normal level of consciousness on admission clinically; however, he was in severe pain. A collective decision was made to administer anticoagulants to the patient with heparin after carefully deliberating the risk-to-benefit ratio of a superior sagittal thrombus with an associated subarachnoid haemorrhage. Our patient recovered and was discharged after 2 weeks on warfarin. We present this case to highlight the potential risks of hypercoagulable and neurotropic complications of COVID-19 infections, with special emphasis on cerebral venous thrombosis.

Predicting Factors for Seizures after Cerebral Venous Thrombosis: A Retrospective Single Center Cohort Study

Background: Seizures are a common complication of cerebral venous thrombosis. In this study, we intended to define clinical and neuroradiological factors associated with early and late seizures and predictors for seizure recurrence. Methods: The database of our high-volume tertiary stroke center was screened for patients diagnosed with cerebral venous thrombosis between April 2006 and July 2021. Demographics, clinical, imaging, and instrumental data were collected. Results: Out of a total of 80 patients, 30 had seizures, either within the first week after onset (22 patients) or after (8 patients). Speech impairment and intracerebral bleeding were statistically associated with seizures in univariate analysis, but in a logistic regression model, only brain damage with hemorrhagic infarct and/or presence of brain hematoma [OR 6.051; 95% CI 1.881−19.468] (p = 0.003) were predicting factors for seizures. Late seizures were significantly more frequent in younger age [OR 0.864; 95% CI 0.763−0.978] (p = 0.020). Early seizures resulted as protective factors for recurrence; an altered state of consciousness at baseline and late seizures resulted as predictive factors for relapses (0.0% vs. 81.0%, p = 0.005, and 100.0% vs. 19.0%, p < 0.005, respectively). Conclusions: Our study confirms brain bleeding as the strongest risk factor for seizures after cerebral venous thrombosis. Recurrence is unusual after early seizures, while the presence of late seizures seems to raise the risk of recurrence.

Cerebral Venous Sinus Thrombosis Secondary to Neurobrucellosis: A Case Report

Brucellosis is a common infection that rarely causes cerebral venous sinus thrombosis (CVST). In this case, a 23-year-old male presented to the emergency department with status epilepticus. With a past medical history of drinking unpasteurized camel milk, elevated inflammatory markers, and evidence of brucellosis in the serum, the patient was diagnosed with brucellosis. Further investigations revealed left transverse sinus thrombosis extending to the jugular vein. The patient was treated with enoxaparin and a combination of doxycycline, ceftriaxone, and trimethoprim-sulfamethoxazole. This regimen led to rapid and significant clinical improvement in the signs and symptoms of the patient. CVST is a rare complication of neurobrucellosis that might present with signs and symptoms of meningitis. This case report highlights the importance of keeping neurobrucellosis as a possible cause of CVST in patients living in an area endemic to brucellosis.

Cerebral venous sinus thrombosis following intracerebral hemorrhage after COVID-19 AstraZeneca vaccination: A case report

The patient was a 55-year-old female patient who presented with sudden onset of left hemiplegia, facial hemiparesis, and hypoesthesia. She has received her first dose of the AstraZeneca COVID-19 vaccine. This case indicates that vaccination may raise the hypercoagulable state even in a condition of post-ICH and anticoagulant prophylaxis.

Cerebral venous thrombosis associated with infective endocarditis in a young patient

Cerebral venous thrombosis (CVT) is a rare complication of infective endocarditis. It constitutes a diagnostic and therapeutic emergency. We report a case of cerebral thrombophlebitis due to infective endocarditis in order to discuss the diagnosis and management of this situation. The patient was a 19-year-old man presenting with sudden explosive headaches with meningeal syndrome, right hemiparesis and right hypoesthesia. The cerebral CT angiography showed a left parieto-occipital and intraventricular hematoma without classic aneurysm or mycotic aneurysm or arteriovenous malformation. The injected brain magnetic resonance imaging found a CVT in front of a stopped opacification of the left lateral branch of the superior sagittal sinus. The presence of fever, poor oral status and a heart murmur justified the prescription of transthoracic echodoppler. It showed vegetations on healthy aortic valves. The patient was put on antibiotics and anticoagulants with favorable evolution. The absence of usual risk factors for CVT, the negativity of thrombophilia tests, the inflammatory and prothrombotic state associated with the infection reinforce the causal link of infective endocarditis to CVT formation. The etiology of CVT is variable, can be multiple and requires a comprehensive assessment. Infective endocarditis is one of the rare etiologies of CVT. In this case, anticoagulation and antibiotic drugs are indicated, taking into account the risk of intracerebral bleeding.

A nitrous oxide abuser presenting with cerebral venous thrombosis: A case report

The present study describes the case of a 25-year-old male patient who presented to the emergency department with severe headache and vertigo lasting for 3 days. The patient did not have a recent history of trauma. He was vaccinated with a second dose of the AstraZeneca COVID-19 vaccine ~1 month prior, and he suffered from a vitamin B12 deficiency due to nitrous oxide abuse. Upon an examination of his vital signs, he was found to have a body temperature of 36.4˚C, a pulse rate of 64 beats per minute, a respiratory rate of 18 breaths per minute and a blood pressure of 119/68 mmHg. A neurological examination only revealed left homonymous upper quadrantanopia. The serum platelet count of the patient was 361x1,000/µl and he had elevated D-dimer levels (0.98 µg/ml). A provisional clinical diagnosis of acute cerebrovascular accident was made. A computed tomography scan of the head revealed an abnormal hyperattenuation in the straight sinus and bilateral transverse sinuses. A diagnosis of cerebral sinovenous thrombosis (CSVT) was made following a consultation with a neurologist. The patient was treated with enoxaparin at 6,000 IU, levetiracetam at 1,000 mg and mannitol at 100 ml via an intravenous drip. After admission, magnetic resonance venography revealed the absence of flow in the straight sinus and bilateral transverse sinuses. A thrombophilic investigation revealed a plasma homocysteine level of 59.03 µmol/l (upper normal limit, 15.39 µmol/l), a vitamin B12 level of <148 (lower normal limit, 187 pg/ml). CSVT secondary to homocystinemia was diagnosed. The treatment included anticoagulation and vitamin B12 supplementation. The patient was administered vitamin B12 at 500 mcg twice per day, pyridoxine at 50 mg per day, folic acid at 5 mg two times per day and edoxaban at 60 mg per day. After 7 days of treatment, his headache and quadrantanopia were improved, and the patient was discharged.

Cerebral venous thrombosis without thrombocytopenia after a single dose of COVID-19 (Ad26.COV2.S) vaccine injection: a case report

Background

The coronavirus pandemic became the hard challenge for the modern global health system. To date, vaccination is the best strategy against Sars-Cov-2-related illness. About 3 billions of people received at least one of the approved vaccines. The related adverse events were reported during the various experimental phases, but newer and less common side effects are emerging post-marketing. Vaccine-induced thrombocytopenia with thrombosis (VITT) is one of these insidious adverse reactions and it is considered responsible of venous thrombosis, in both the splanchnic and the cerebral circulation. Although its mechanism has been presumably established, resembling that observed in heparin-induced thrombocytopenia, some venous thromboses seem not to recognize this etiology and their pathogenesis remains unknown. Here we described a case of cerebral venous thrombosis after administration of the Ad26.COV2.S, presenting without thrombocytopenia, paving the way for possible novel causes of this vaccine-induced pathological condition.

Case presentation

A 45-year-old woman came to our observation for bilateral periorbital headache associated with retro-orbital pain started 8 days after administration of COVID vaccine Jannsen. Ophthalmologic exam showing a bilateral papilledema raised the suspicion of intracranial hypertension. Cerebral magnetic resonance imaging revealed signal alteration with T1-positive contrast enhancement in the right temporal and insular lobes suggestive of cerebral venous thrombosis. The absence of thrombocytopenia and platelet factor 4 (PF-4) antibodies led the clinicians to rule out VITT. The patient was treated successfully with warfarin.

Conclusion

Venous thrombosis occurring after COVID-19 vaccination represents an adverse event of special interest. Patients with thrombosis and thrombocytopenia appear to be affected by a general thrombophilic state, sustained by an autoimmune mechanism, and show a higher mortality. Thrombosis without thrombocytopenia’s pathogenesis has not yet been clarified, but laboratory data and good response to vitamin K antagonists help clinicians in the differential diagnosis with VITT. Future research will allow us to discover other possible mechanisms and maybe identify a subgroup of patients with a higher risk of developing this medical complication.

Transcranial Doppler Ultrasonography as a Diagnostic Tool for Cerebrovascular Disorders

Imaging techniques including transcranial Doppler (TCD), magnetic resonance imaging (MRI), computed tomography (CT), and cerebral angiography are available for cerebrovascular disease diagnosis. TCD is a less expensive, non-invasive, and practically simpler approach to diagnosing cerebrovascular disorders than the others. TCD is a commonly available and inexpensive diagnostic tool. However, owing to its large operator dependency, it has a narrow application area. Cerebrovascular disease indicates a group of disorders that alter the flow of blood in the brain. The brain’s functions can be temporarily or permanently impaired as a result of this change in blood flow. Timely diagnosis and treatment can restore the brain-impaired functions, resulting in a much-improved prognosis for the patients. This review summarizes the basic principles underlying the TCD imaging technique and its utility as a diagnostic tool for cerebrovascular disease.

A case series of cerebral venous thrombosis as the first manifestation of homocystinuria

Background

Cerebral venous thrombosis (CVT) is an important cause of stroke particularly in younger patients and potentially fatal if diagnosis is delayed. The presentation of symptoms is highly variable and consequently the diagnosis and underlying cause is often delayed or overlooked. Homocystinuria, a rare autosomal recessive disorder is an identified risk factor for CVT.

Purpose

A timely diagnosis and treatment of the underlying cause of CVT could result in improved outcome and prevent further events. This case series describes the clinical course of six adults presented with unprovoked CVT, in whom the diagnosis of underlying homocystinuria was delayed with adverse consequences. We aim to highlight the importance of recognising homocystinuria as an underlying cause of CVT and offer a practical approach to the diagnosis and management.

Methods

This is a retrospective case series of a cohort of 30 consecutive patients seen in a UK tertiary referral centre.

Result

Six out of 30 patients presented with CVT prior to homocystinuria diagnosis. The mean and range of age at the time of the first CVT episode was 22.6 (range 11–31) years. The mean ±SD age at diagnosis of homocystinuria as the underlying cause was 26 ± 4.2 years. The time between first CVT and diagnosis of homocystinuria ranged from 1.6 to 11 years resulting in a delay to introduction of effective treatment and, in some cases, a further large vessels thrombotic event.

Conclusion

Physician awareness of homocystinuria as an underlying cause for an unprovoked CVT will facilitate timely introduction of effective treatment to prevent a further event.

Reversible anomia and cerebral venous thrombosis: a case report and review of the literature

Background

Cerebral venous thrombosis is a rare form of venous stroke with diverse clinical manifestations. Word-finding difficulty (anomia) is rarely reported in patients with cerebral venous thrombosis.

Case presentation

We report a 30-year-old right-handed Ethiopian female patient, who presented with global headache associated with a new onset word-finding difficulty of 2 weeks duration. The headache was not responsive to over-the-counter medications. She reported blurring of vision and nausea. Two months previously, she gave birth to a dead fetus. On neurological assessment, the patient was fully conscious and oriented, with a Glasgow coma score of 15/15, and cranial nerves, motor, and sensory examinations were unremarkable. Examination of fundus showed grade 2 papilledema bilaterally. Language assessment showed normal fluency, compression, naming, reading, and repetition. Naming was assessed using a 60 second word generating test, which indicated anomia. Brain magnetic resonance imaging showed left temporoparietal ischemia, magnetic resonance venography showed thrombosis of the left transverse, sigmoid sinus, and corresponding cortical veins. She was started on warfarin 5 mg daily for 6 months and showed significant resolution of symptoms, including the anomia.

Conclusion

The present case describes a young female patient with reversible anomia as a complication of cerebral venous thrombosis. The case also highlights the importance of timely diagnosis and treatment of cerebral venous thrombosis for a benign prognosis.

Cisplatin induced cerebral sinus venous thrombosis in cervical cancer patients treated with concurrent chemoradiation: a case series

Cisplatin is a widely used chemotherapeutic agent. Concurrent chemotherapy with cisplatin is an important component in the management of carcinoma cervix. The common side effects of cisplatin chemotherapy include nausea, vomiting, dyselectrolytemia, nephrotoxicity, etc. These side effects are anticipated and managed during chemotherapy. Thromboembolic events are rare complications with cisplatin. We present three cases of cisplatin related cerebral sinus venous thrombosis (CSVT). These patients were receiving concurrent chemoradiation for carcinoma cervix. These patients presented with neurological symptoms and were evaluated and diagnosed with CSVT. They recovered after appropriate management. Clinicians should be aware that CSVT, though uncommon, is a life threatening complication during cisplatin chemotherapy which should be appropriately evaluated and effectively managed.

Stroke in Middle Eastern children with cancer: prevalence and risk factors

Objective

To determine the prevalence and to characterize the different types of strokes in children with cancer at the Children’s Cancer Center of Lebanon (CCCL), in addition to assess the factors and clinical findings leading to stroke in children.

Methods

We retrospectively reviewed the medical records and brain images (MRIs and CTs) of children admitted to the CCCL and diagnosed with cancer between years 2008 and 2017. Brain images were reviewed for the strokes’ onset, size, location, possible origin, its recurrence and type: intracranial hemorrhage (ICH), acute arterial ischemic stroke, and cerebral sinus venous thrombosis (CSVT) with and without venous infarct. Medical charts of the patients were reviewed for age, sex, their type of cancer, the treatment protocol they followed, and abnormal findings on their laboratory studies and neurological exams.

Results

Out of the 905 charts reviewed, twenty-seven children with variable types of cancer had strokes, with a prevalence of 2.9%. Their median age at cancer diagnosis was 9.4 (4.8-13.7) years and the median age at stroke onset was 10.6 (6.7-15.5) years. The median time between the cancer diagnosis and the stroke episode was 6 months. CSVT cases were the most common (60%) followed by acute arterial ischemic (22%) and hemorrhagic strokes (18%), with CSVT being the latest to occur. We observed that the different types of strokes were related to some types of cancer. Of the children that had acute arterial ischemic stroke in this cohort, 83% had brain tumors, of the children who had CSVT, 87.5% had leukemia, and of the children who had hemorrhagic stroke, 40% had leukemia. Neurological abnormalities were more prevalent in acute arterial ischemic stroke (80%). Patients with CSVT recovered better than those with other types of strokes. Strokes recurred in 60% of ischemic strokes. L-Asparaginase was significantly associated with CSVT.

Conclusions

The prevalence of strokes was 2.9% in children with cancer. We were able to identify factors related to the types of the stroke that occurred in children including the type and location of the cancer the type of treatment received, and stroke recurrence.

Chemotherapy-related neurotoxicity in pediatric cancer patients: magnetic resonance imaging and clinical correlation

Background

Cancer is the second most common cause of death among children aged 1–14 years in the USA. Pediatric malignancies have elevated morbidity and mortality in the absence of proper treatment. Intensive treatment regimens have resulted in a significant increase in the number of survivors but also have been associated with the risk of developing neurotoxicity. The purpose of this study is to emphasize the role of advanced MRI techniques in the early detection of different chemotherapy neurotoxicities and make radiologists aware of them providing early management to prevent permanent damage.

Results

We evaluated 63 patients (43 males and 20 females), and their ages ranged from (2 to 17 years) with suspected chemotherapy-related neurotoxicity. MR examinations were performed with 1.5-T Philips systems. Clinical data were correlated with magnetic resonance imaging (MRI), and different treatment complications were diagnosed. All of our 63 patients were receiving chemotherapy treatment, and they developed different neurological symptoms. Patients diagnosed as posterior reversible encephalopathy syndrome were 41 with 8 patients had typical and 33 had atypical criteria, 16 patients diagnosed as cerebral venous sinus thrombosis with magnetic resonance venography (MRV) are the most important sequence that successfully diagnosed them, and finally, 6 patients diagnosed as methotrexate neurotoxicity with diffusion-weighted images (DWI) are the most important sequence for early diagnosis.

Conclusion

Chemotherapy is associated with certain neurotoxicities, conventional MRI can detect them, but by the use of advanced MRI techniques including MRV and DWI early detection of these neurotoxicities can occur. Therefore, the combination of conventional MRI together with advanced techniques improves the diagnostic efficacy of MRI in the early diagnosis of neurotoxicity.

Cerebral Venous Sinus Thrombosis Complicating Middle Ear Infections: A Rare Complication in Post-Antibiotic Era

In the post-antibiotic era, intracranial and extracranial complications of middle ear infections have become rare. Similarly, cerebral venous sinus thrombosis (CVST), a frequent complication of middle ear infections, has become rare now. Here, we present a case of a 27-year-old male who presented with a short history of severe headache and associated episodes of intractable vomiting. There was also a prior history of right ear discharge one year back which responded to medical management. The patient did not improve clinically even after prompt symptomatic management. Contrast-enhanced magnetic resonance imaging (CEMRI) of the head and contrast-enhanced magnetic resonance venogram (CEMRV) were done, which showed right-sided otomastoiditis complicated with CVST and meningitis. Although the clinical signs of meningeal irritation and mastoid tenderness were not present on clinical examination. The patient was started on anticoagulant therapy and antibiotics for two weeks following which there was marked clinical improvement.

Case Report: Ulcerative Colitis with Multiple Dural Venous Thrombosis

Background Cerebral sinus vein thrombosis (CVT) is a rare but serious complication associated with ulcerative colitis (UC), an idiopathic autoimmune inflammatory disease of the gastrointestinal tract. Management approaches for CVT remain unclear but may include anticoagulation and surgical thrombectomy. Herein, we report a case of a 23-year-old male who developed CVT with a history of UC. The patient was presented to Howard University Hospital when he slipped and fell. On arrival at the hospital, he complained of a headache with an aching sensation, associated with light/sound sensitivity. The patient had a history of uncontrolled UC. He had positive bloody diarrhea, lower abdominal pain, but denied any other neurological deficit. Computed tomography of the head showed left frontoparietal lobe hypodensities. Neurological exam was nonfocal. Vital signs were within normal range, but the patient experienced some memory loss and personality changes. Subsequent diagnosis of CVT was made with magnetic resonance angiography and magnetic resonance venography. Immediate treatment with low-molecular-weight intravenous heparin (18 IU/kg) was introduced. His UC was managed with methylprednisolone (60 mg IV daily), proton pump inhibitors, mesalamine, ciprofloxacin, and metronidazole. His condition gradually improved. On discharge, he was prescribed prednisone, azathioprine for his UC, levetiracetam for seizure, and warfarin with an INR goal of 2-3. In conclusion, the sudden onset and/or acute worsening of neurological status such as headache and mental confusion in a patient with UC should alert the treating physician about the possibility of CVT so that timely intervention could be employed to prevent disabling and potentially lethal sequelae of this disease.

Diagnostic and Therapeutic Challenges of Cerebral Venous Thrombosis in SARS-CoV-2 Infection: A Case Report and Review of Literature

Headache, a common prodromal symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can also be a manifestation of cerebral venous thrombosis (CVT), secondary to COVID-19. CVT management continues to evolve, with direct oral anticoagulants (DOACs) emerging as an alternative to warfarin. A 44-year-old Asian female, with no past medical history, presented to the emergency room (ER) with complaints of nonproductive cough and left-sided headache. She denied a history of COVID-19 vaccination, and SARS-CoV-2 testing (with reverse transcriptase-polymerase chain reaction) was positive. Non-contrast computed tomography (CT) of the head revealed left transverse sinus hyperdensity, consistent with dense vein sign, and magnetic resonance venography (MRV) confirmed the presence of thrombus. The initial treatment included subcutaneous enoxaparin with headache resolution, and she was discharged on apixaban. Five weeks later, a non-contrast head CT showed resolution of the dense vein sign and recanalisation of left transverse sinus was seen on MRV. This report has highlighted the need for increased awareness of coagulopathy and thrombotic events, including cerebral venous thrombosis, in patients infected with SARS-CoV-2. Unremitting headache, in context of SARS-CoV-2 infection, should be evaluated with appropriate neurovascular imaging. Controlled studies are required to compare the safety and efficacy of DOACs with warfarin for management of cerebral venous thrombosis.

Characteristics of cerebral sinus venous thrombosis in men

OBJECTIVES

Cerebral sinus venous thrombosis (CSVT) is a rare stroke subtype that is more common in women, yet data regarding sex-specific characteristics are sparse. We aimed to study male-specific characteristics among patients with CSVT.

MATERIALS & METHODS

Data of consecutive patients with CSVT, admitted to a single medical centre between 2005 and 2020, were retrospectively studied. Demographics, clinical presentations, radiological and outcome parameters were compared between male and female patients. Male patients were further divided into older and younger than 35 years old for additional comparisons.

RESULTS

Out of 15,224 patients diagnosed with stroke, 150 patients (1%) presented with CSVT and 47 (31.3%) of them were males. Males had significantly higher rates of previous thrombotic events (22% vs. 7%, p = .009), malignancies (32% vs. 16%, p = .022) and Behcet's disease (22% vs. 2%, p < .001). Additionally, we found that malignancies were significantly more prevalent in older males (48% vs. 17%, p = .022), while Behcet's disease was more often found in younger patients (35% vs. 9%, p = .032). Additional age-related differences in disease characteristics among male patients included a higher frequencies of papilledema (42% vs. 13%, p = .028), and cortical vein thromboses (21% vs. 0% p = .021) observed in the younger men.

CONCLUSIONS

There are important differences in risk factors for thrombosis between men and women with CSVT. Behcet's disease is common in younger men, while malignancies are major causes of CSVT in older men.

An Update on COVID-19 Vaccine Induced Thrombotic Thrombocytopenia Syndrome and Some Management Recommendations

The thrombotic thrombocytopenia syndrome (TTS), a complication of COVID-19 vaccines, involves thrombosis (often cerebral venous sinus thrombosis) and thrombocytopenia with occasional pulmonary embolism and arterial ischemia. TTS appears to mostly affect females aged between 20 and 50 years old, with no predisposing risk factors conclusively identified so far. Cases are characterized by thrombocytopenia, higher levels of D-dimers than commonly observed in venous thromboembolic events, inexplicably low fibrinogen levels and worsening thrombosis. Hyper fibrinolysis associated with bleeding can also occur. Antibodies that bind platelet factor 4, similar to those associated with heparin-induced thrombocytopenia, have also been identified but in the absence of patient exposure to heparin treatment. A number of countries have now suspended the use of adenovirus-vectored vaccines for younger individuals. The prevailing opinion of most experts is that the risk of developing COVID-19 disease, including thrombosis, far exceeds the extremely low risk of TTS associated with highly efficacious vaccines. Mass vaccination should continue but with caution. Vaccines that are more likely to cause TTS (e.g., Vaxzevria manufactured by AstraZeneca) should be avoided in younger patients for whom an alternative vaccine is available.

Diagnosis and Management of Mixed Transcortical Aphasia Due to Multiple Predisposing Factors, including Postpartum and Severe Inherited Thrombophilia, Affecting Multiple Cerebral Venous and Dural Sinus Thrombosis: Case Report and Literature Review

Cerebral venous and dural sinus thrombosis (CVT) is an uncommon disease in the general population, although it is a significant stroke type throughout pregnancy and the puerperium. Studies describing this subtype of CVT are limited. Most pregnancy-associated CVT happen in late pregnancy, or more commonly in the first postpartum weeks, being associated with venous thrombosis outside the nervous system. Case presentation: The current study describes a case of multiple CVT in a 38-year-old woman with multiple risk factors (including severe inherited thrombophilia and being in the puerperium period), presenting mixed transcortical aphasia (a rare type of aphasia) associated with right moderate hemiparesis and intracranial hypertension. The clinical diagnosis of CVT was confirmed by laboratory data and neuroimaging data from head computed tomography, magnetic resonance imaging, and magnetic resonance venography. She was successfully treated with low-molecular-weight heparin (anticoagulation) and osmotic diuretics (mannitol) for increased intracranial pressure and cerebral edema. At discharge, after 15 days of evolution, she presented a partial recovery, with anomic plus aphasia and mild right hemiparesis. Clinical and imaging follow-up was performed at 6 months after discharge; our patient presented normal language and mild right central facial paresis, with chronic left thalamic, caudate nucleus, and internal capsule infarcts and a partial recanalization of the dural sinuses.

New Horizons for Diagnostic Pitfalls of Cerebral Venous Thrombosis: Clinical Utility of a Newly Developed Cerebral Venous Thrombosis Diagnostic Score: A Case Report and Literature Review

Patient: Male, 35-year-old

Final Diagnosis: Cerebral venous

Symptoms: Bloody diarrhea • throbbing persistent headache • weight loss

Medication: —

Clinical Procedure: —

Specialty: Neurology

Test Battery Approach to Assess an Individual with Cerebral Venous Sinus Thrombosis: A Speech Language Pathologist's Perspective

Cerebral venous sinus thrombosis (CVST) is an uncommon stroke that has a varied clinical profile. Quite often, speech language pathologists limit the assessment of these patients to a language assessment alone. Subsequently, it is possible that they may miss out certain relevant information which can aid them in their intervention. The aim of the current study was to highlight the relevance of adopting a test battery approach to assess a patient diagnosed with CVST. Here, we present a test battery approach to assess a 43-year-old patient who reported to us after CVST. The test battery included various formal and informal measures. Apart from the routine measures, an additional test for assessing the cognitive linguistic profile was included in the battery which yielded us significant information regarding the patient. Thus, we concluded that speech language pathologists should follow a test battery approach to get a clear idea about the clinical profile of the patient, to avoid misdiagnosis, and also to provide suitable intervention.

Plasminogen Activator Inhibitor-1 (PAI-1) Gene Polymorphisms Associated with Cardiovascular Risk Factors Involved in Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST), accounting for less than 1% of stroke cases, is characterized by various causes, heterogeneous clinical presentation and different outcome. The plasminogen activator inhibitor-1 (PAI-1) gene polymorphisms has been found to be associated with CVST. The aim of this retrospective study was to determine the potential association of PAI-1 675 4G/5G polymorphisms and homocysteine levels with cardiovascular risk factors in a group of young patients with CVST. Eighty patients with CVST and an equal number of age and sex matched controls were enrolled. The protocol included demographic and clinical baseline characteristics, neuroimagistic aspects, genetic testing (PAI-1 675 4G/5G polymorphisms), biochemical evaluation (homocysteine-tHcy, the lipid profile, blood glucose, glycohemoglobin-HbA1c, high-sensitive C-reactive protein-hsCRP) data, therapy and prognosis. The PAI-1 675 4G/5G gene polymorphisms were significantly correlated with increased homocysteine level (tHcy) (p < 0.05), higher total cholesterol (TC) (p < 0.05), low- density lipoprotein cholesterol (LDLc) (p = 0.05) and high- sensitive C- reactive protein (hsCRP) (p < 0.05) in patients with CVST when compared with controls. From the PAI-1 gene polymorphisms, the PAI-1 675 4G/5G genotype presented statistically significant values regarding the comparisons of the blood lipids values between the CVST group and control group. The homocysteine (tHcy) was increased in both groups, patients versus controls, in cases with the homozygous variant 4G/4G but the level was much higher in the group with CVST (50.56 µmol/L vs. 20.22 µmol/L; p = 0.03). The most common clinical presentation was headache (91.25%), followed by seizures (43.75%) and focal motor deficits (37.5%). The superior sagittal sinus (SSS) was the most commonly involved dural sinus (56.25%), followed by the lateral sinus (LS) (28.75%). Intima-media thickness (IMT) values were higher in the patients' group with CVST (0.95 mm vs. 0.88 mm; p < 0.05). The fatal outcome occurred 2.5% of the time. PAI-1 675 4G/5G gene polymorphisms and higher homocysteine concentrations were found to be significantly associated with CVST in young patients.

Clinical and epidemiological profile of cerebral venous thrombosis. A Multicenter retrospective study in Aseer Region Saudi Arabi

Objectives:

To assess the epidemiological pattern and correlates with the clinical outcome of Cerebral venous thrombosis (CVT) in Abha, Kingdom of Saudi Arabia.

Methods:

A retrospective record-based cohort design was conducted including all patients admitted with diagnosis of CVT in 2 main tertiary hospitals in Aseer Region between 2015 to the end of 2018. The study hospitals were Aseer Central Hospital and Armed Forces Hospitals Southern Region. The data were collected by structured data sheets, including sociodemographic data. Assessment of known risk factors for CVT, clinical presentation, treatment received, and clinical outcome after treatment were extracted.

Results:

The study included 119 patients with CVT, whose ages ranged from 15 to 97 years, with a mean age of 35.5-+14.1 years. Majority of the patients were females (81.5%). Headache was the most presenting (82.4%) symptom, followed by vomiting (30.3%) and a decreased level of consciousness. Thirty-three cases (27.7%) had complications, and recanalization was recorded among 92 cases (94.8%) based on follow up vascular imaging.

Conclusion:

The study revealed that most of the cases of CVT had favorable clinical outcome and recanalization, especially those who had a shorter duration untildiagnosis. Young females were the most affected group.

A Rare Thrombophilic Occurrence: Dural Venous Sinus Thrombosis in a Patient with Significant Family History of Protein S Deficiency

Protein S is a potent anticoagulant that downregulates thrombin formation and is a vitamin K-dependent glycoprotein which is primarily synthesized in the liver. A deficiency in this protein or decreased activity, as seen in hereditary protein S deficiency, can lead to life-threatening thrombosis. Hereditary protein S deficiency is a rare disease as listed by the National Organization for Rare Disorders (NORD). It is known to cause venous as well as arterial thromboembolic events commonly occurring in the deep leg and pelvic veins. Dural venous sinus thrombosis is a rare consequence of protein S deficiency and is associated with a risk of increased morbidity and mortality. We report a case of dural venous sinus thrombosis in a patient with a family history of protein S deficiency in nine family members. A 53-year-old female presented to the ED with a three-day history of persistent left-sided headache, left facial numbness with tingling, and photophobia. She denied any visual disturbances, slurring of speech, and/or unilateral weakness. Some 10 years prior to this episode, she was placed on warfarin therapy for deep vein thrombosis (DVT) of lower extremity, but she discontinued it after three years of treatment without consulting her treating physician. She was taking oral contraceptive pills (OCPs) for two years and discontinued one month ago. She has nine family members with protein S deficiency, but the patient was never screened for a hypercoagulable state. On admission, her vital signs were within normal limits. Pupils were round and reactive to light, neck was supple, there was a sensory deficit for pinprick on the left V2-V3 distribution, and remainder of the cranial nerves and neurologic examination was unremarkable. CT scan of the head demonstrated a hyper-density within the left transverse and sigmoid sinus suspicious for dural venous sinus thrombosis. This was confirmed by CT angiogram showing a filling defect throughout the transverse sinus and sigmoid sinus extending below the jugular bulb into the superior aspect of the jugular vein. Intravenous heparin and warfarin were initiated. As the patient had severe trypanophobia and IV heparin required frequent activated partial thromboplastin time (APTT) monitoring, this was later changed to subcutaneous low-molecular-weight heparin and warfarin. Subsequent thrombosis panel showed a reduced protein S activity of 15% and low levels of total and free protein S antigens. She was discharged home with life-long warfarin therapy. In conclusion, cerebral dural venous sinus thrombosis is a rare and potentially life-threatening condition that can be seen in hereditary protein S deficiency. A high degree of suspicion in young females with worsening headache and neurologic signs and symptoms will help with timely diagnosis and management avoiding serious consequences. In a patient with a family history of thrombophilia, as seen in our patient, screening is important in order to confirm an underlying thrombophilic state. Such testing may have helped our patient regarding education on avoiding potential risk factors for thrombophilia and importance of treatment adherence.

Statistical shape modelling for the analysis of head shape variations

The aim of this study is, firstly, to create a population-based 3D head shape model for the 0 to 2-year-old subjects to describe head shape variability within a normal population and, secondly, to test a combined normal and sagittal craniosynostosis (SAG) population model, able to provide surgical outcome assessment. 3D head shapes of patients affected by non-cranial related pathologies and of SAG patients (pre- and post-op) were extracted either from head CTs or 3D stereophotography scans, and processed. Statistical shape modelling (SSM) was used to describe shape variability using two models - a normal population model (MODEL1) and a combined normal and SAG population model (MODEL2). Head shape variability was described via principal components analysis (PCA) which calculates shape modes describing specific shape features. MODEL1 (n = 65) mode 1 showed statistical correlation (p < 0.001) with width (125.8 ± 13.6 mm), length (151.3 ± 17.4 mm) and height (112.5 ± 11.1 mm) whilst mode 2 showed correlation with cranial index (83.5 mm ± 6.3 mm, p < 0.001). The remaining 9 modes showed more subtle head shape variability. MODEL2 (n = 159) revealed that post-operative head shape still did not achieve full shape normalization with either spring cranioplasty or total calvarial remodelling. This study proves that SSM has the potential to describe detailed anatomical variations in a paediatric population.

Unilateral persistent disc oedema due to cerebral sinus venous thrombosis (CSVT): diagnostic and management challenge

A 50-year-old woman was incidentally diagnosed to have unilateral disc oedema during comprehensive ophthalmological evaluation. She had a prior history of ulcerative colitis. She had normal visual function and was initially diagnosed to have incipient non-arteritic anterior ischaemic optic neuropahty. Risk factor evaluation revealed hyperhomocysteinaemia. She was asked to come for a follow-up in 2 months. However, she was lost to follow-up and returned to the clinic for the evaluation for headaches, 23 months later. Her ocular examination was stable and she had persistent unilateral disc oedema unchanged from the prior visit. Repeat MRI brain and MR venogram brain with contrast-established diagnosis of cerebral sinus venous thrombosis (CSVT). She denied any neurological symptoms. Later on, she was diagnosed to have hyperhomocysteinaemia with methyl tetrahydrofolate reductase gene mutation. This case highlights the importance of recognising although rare, unilateral disc oedema secondary to elevated intracranial pressure from CSVT.

Depression and Quality of Life after Cerebral Venous Sinus Thrombosis

Introduction:

Cerebral venous sinus thrombosis (CVST) is an important cause of stroke in young and has a favorable outcome. Long-term sequelae of CVST include motor disability, cognitive impairment, depression, anxiety, fatigue, impaired employment and poor quality of life.

Objective:

To evaluate depression and quality of life after CVST.

Methods:

Patients who completed at least 1 year after discharge were recruited for this cross-sectional observational study from our CVST cohort. Quality of life was assessed using Stroke-Adapted Sickness Impact Profile (SA-SIP 30) and depression using Hamilton Depression scale (HAM-D).

Results:

A total of 100 patients (60 men and 40 women) were included in the study. Their age ranged from 14 to 60 years (34.97 ± 10.06). The interval from discharge to assessment of quality of life was 2.2 ± 1.6 years. In all, 98% of patients had good modified Rankin score at follow-up. SA-SIP 30 did not reveal any functional disability for physical functioning. Seven had impairment for psychosocial domain despite having good modified Rankin scores. Thirty patients had depression. Patients with higher mRS at discharge had increased presence of depression. Quality-of-life scores did not correlate with presence of seizure, headache, infarction and sinuses involved.

Conclusion:

This is the first Indian study demonstrating depression in patients with CVST and use of SA-SIP to assess quality of life in them. Occurrence of depression in CVST is as high as in arterial strokes.

Management and outcomes of newborns at risk for inherited antithrombin deficiency

BACKGROUND

As levels of antithrombin (AT) are low at birth, diagnosing inherited AT deficiency in newborns is challenging. In Stockholm, Sweden, pregnant women with known AT deficiency are referred to the Karolinska University Hospital, where local guidelines for management of newborns at risk of inherited AT deficiency have been established. Data on pregnancy, obstetric, and neonatal outcomes are recorded in a registry.

OBJECTIVES

We aimed to evaluate the current practice at the Karolinska University Hospital for managing delivery of newborns at risk for AT deficiency, the predictive value of AT levels at birth, and the neonatal outcomes of newborns with AT deficiency.

PATIENTS/METHODS

This was an observational, retrospective study. All children born to mothers with AT deficiency at the Karolinska University Hospital 2003-2018 were identified from the registry and included in the study. Data were collected from the medical records and the registry. AT activity was measured postnatally and after 6 months of age.

RESULTS

The total study cohort included 41 newborns. There was a significant association between low AT values postnatally and after 6 months of age (P = .001). Half (21/41) of the children were diagnosed with AT deficiency; two suffered from sinus thrombosis, which presented at 10 days of age. Both children with sinus thrombosis were delivered using vacuum extraction.

CONCLUSIONS

The current practice of testing newborns can in most cases predict inherited AT deficiency. The risk for thrombosis during the neonatal period is enhanced by the use of instrumental delivery.

Cerebral Venous Thrombosis: A Comprehensive Review

BACKGROUND

Cerebral sinus venous thrombosis (CSVT) is a relatively rare, potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. A literature search on PubMed using the keyword "Cerebral sinus venous thrombosis" was performed. We searched for the epidemiology, risk factors, pathophysiology, clinical features, diagnosis, and treatment of CSVT. All full-text articles in the last 10 years, in adults (>18 years), and the English language were included. We aim to give a comprehensive review of CSVT, with a primary focus on the management of the disease.

SUMMARY

The literature search revealed 404 articles that met our criteria. CSVT is a relatively rare condition that accounts for approximately 1% of all forms of stroke. They can be subdivided into acute, subacute, and chronic forms based on the time of onset of clinical symptoms. It is a multifactorial disease, and the major forms of clinical presentation include isolated intracranial hypertension syndrome, focal neurological deficits, and cavernous sinus syndrome. MRI with magnetic resonance venogram (MRV) is considered the gold standard for diagnosis. Anticoagulation with heparin or low-molecular-weight heparin is the mainstay of treatment. Endovascular management is indicated for those cases with severe symptoms or worsening of symptoms despite anticoagulation therapy. Favorable outcomes have been reported in patients who receive early diagnosis and treatment.

CONCLUSION

CSVT is a potentially fatal neurological condition that is often under-diagnosed due to its nonspecific presentation. Timely diagnosis and treatment can reduce morbidity and mortality, remarkably improving the outcome in affected individuals.

Clinical Profile and Outcome of Patients with Cerebral Venous Thrombosis Secondary to Bacterial Infections

Background:

Cerebral venous thrombosis (CVT) secondary to infectious aetiology has become rare in the antibiotic era, but is still encountered in clinical practice occasionally. In this study, we describe the clinical profile, diagnosis, and management of patients with CVT secondary to an infectious aetiology.

Methods:

This retrospective study included all adult patients over 15 years (1 January 2002 to 1 January 2017). Adult patients with a diagnosis of infective CVT secondary to bacterial infections were included in the study.

Results:

Totally, 22 patients were identified with CVT complicating bacterial infections. The focus of infection in 12 (54.54%) patients was pyogenic meningitis, 9 (40.9%) patients had a parameningeal focus and one patient developed CVT secondary to bacterial sepsis from a remote focus. Fever was the most common symptom seen in 77.3% followed by headache and depressed sensorium in 72.7% and 63.6%, respectively. The most common organism in the meningitis group was Streptococcus species, and in the parameningeal group was Staphylococcus aureus. At presentation MRI identified CVT in all 7 patients as compared to CT brain with contrast in 2/3 (66.6%). Transverse sinus was the most commonly involved sinus in meningitis. All patients were treated with appropriate antibiotics and anticoagulation was used in 50% of the patients. The in hospital, mortaility was 9%.

Conclusion:

Septic CVT, though rare can be a complication of bacterial meningitis and facial infections. Clinical symptoms that suggest a co-existing CVT should be identified and diagnosed at the earliest. The mainstay of treatment is antibiotics; the role of anticoagulation is controversial.

Bilateral papilledema and abducens nerve palsy following cerebral venous sinus thrombosis due to Gradenigo's syndrome in a pediatric patient

Purpose

To report a case of bilateral papilledema and abducens nerve palsy following cerebral venous sinus thrombosis in a 9-year-old female with undiagnosed Gradenigo's Syndrome.

Observations

The patient presented to our Emergency Room with a unilateral left 6th nerve palsy, left eye relative afferent pupillary defect, and bilateral papilledema. She underwent cranial magnetic resonance imaging with gadolinium contrast and magnetic resonance venography, which diagnosed a left mastoiditis, left sigmoid sinus and jugular vein thrombosis. The patient underwent urgent mastoidectomy and myringotomy with tube placement and was admitted for adequate treatment with intravenous antibiotics and anticoagulants.

Conclusions and importance

Gradenigo's syndrome is a rare complication of otitis media, and even rarer is cerebral venous thrombosis. This potentially life-threatening situation requires immediate surgical and antibiotic therapy. Ocular symptoms can be the initial signs of this illness.

Not Just Another Headache: Cerebral Venous Sinus Thrombosis in a Patient With Isolated Antithrombin III Deficiency

Cerebral venous sinus thrombosis (CVST) is a rare condition. Symptoms and signs arise from a combination of thrombosis of cerebral veins and increased intracranial pressure. The most common presenting symptom is a non-descriptive headache, but presentation varies with underlying etiology. CVST requires a high index of suspicion to diagnose, particularly in those without apparent risk factors. Evaluation and diagnosis should include a combination of a thorough history, ophthalmoscopic examination, laboratory studies, and imaging. Management is multidimensional and aims to reverse the underlying causes, and prompt treatment with anticoagulation by heparin to decrease thrombotic burden, risk of permanent neurological deficits, and death. In the present study, we report the case of a 61-year-old man referred to the emergency department by an ophthalmologist for bilateral papilledema and eventually diagnosed with CVST secondary to isolated antithrombin III deficiency. Although CVST is uncommon, this case is worthwhile to report as the presentation is unique, and it requires a high index of clinical awareness for timely diagnosis and early therapeutic intervention. 

Cerebral Venous Sinus Thrombosis as a Presentation of COVID-19

Coronavirus disease 19 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We describe the case of a 59-year-old man who presented with headache, hypertension and a single episode of fever with no other symptoms. He subsequently developed unilateral weakness. Computer tomography identified a cerebral venous sinus thrombosis (CVST). A subsequent test for COVID-19 was positive. This is the first report of CVST as a presenting symptom of COVID-19 infection.

Recurrent cerebral venous sinus thrombosis in a young man- A case report of JAK2-negative polycythemia vera

Polycythemia vera (PV) is a myeloproliferative disorder most commonly associated with JAK2V617F mutation. Cerebral venous sinus thrombosis (CVST) has a wide range of etiologies and PV is one of them. CVST associated with PV has a poor prognosis. Some patients with classical PV lack JAK2V617F mutation and the molecular basis of JAK2V617F-negative PV is not known. We hereby report a case of a young man who presented with headache, vomiting and altered sensorium and was found to have recurrent CSVT. The patient had primary polycythemia and was subsequently diagnosed to have JAK2-negative PV.