Venous sinus thrombosis in a child with nephrotic syndrome: a case report and literature review

Cerebral Venous Thrombosis in Pediatric Age: Risk Factors and Prognosis

INTRODUCTION

 Cerebral venous thrombosis (CVT) is a rare but potentially fatal disease in pediatric age with an important morbimortality. In adults several factors have been associated with worse outcomes, however there are still few studies in children. This study aims to identify risk factors associated with clinical manifestations and long-term sequelae in pediatric CVT.

METHODS

 Retrospective analysis of pediatric inpatients admitted to a tertiary-care hospital due to CVT between 2008 and 2020.

RESULTS

 Fifty-four children were included, 56% male, median age of 6.5 years (9 months-17.3 years). Permanent risk factors were identified in 13 patients (malignancy, 8; hematologic condition, 5) and transient risk factors in 47, including head and neck infections (57%) and head trauma (15%). Multiple venous sinuses involvement was present in 65% and the deep venous system was affected in four patients. Seventeen percent had intracranial hemorrhage and 9% cerebral infarction. Sixty-four percent of patients with multiple venous sinuses involvement presented with severe clinical manifestations: impaired consciousness, intracranial hypertension, acute symptomatic seizures or focal deficits. Regarding long-term prognosis, six patients had major sequelae: epilepsy (n = 3), sensory motor deficits (n = 2), and cognitive impairment (n = 3). Permanent risk factors were associated with severe clinical manifestations (p = 0.043). Cerebral infarction and intracranial hemorrhage were associated with major sequelae (p = 0.006 and p = 0.03, respectively, adjusted for age and sex).

CONCLUSION

 Permanent risk factors, involvement of multiple venous sinuses, intracranial hemorrhage, and cerebral infarction, were related to worse prognosis. Detection and early management of risk factors may limit CVT extension and reduce its morbimortality.

Urokinase prophylactic anticoagulation in children with nephrotic syndrome: a multicenter retrospective cohort study

OBJECTIVE

To analyze the clinical effect of urokinase on the prevention of thrombosis in children with primary nephrotic syndrome.

METHODS

A total of 370 children diagnosed with primary nephrotic syndrome (PNS) in the Children's Hospital of Soochow University and Zibo Maternal and Child Health Hospital from January 2018 to December 2022 were selected as the research objects. The patients were divided into a urokinase adjuvant therapy group and non-urokinase adjuvant therapy group according to the application of drugs. The clinical data of the children were collected, including sex, age, drug application, bleeding during treatment, and telephone follow-up, to record whether thromboembolism occurred in the acute stage and remission stage. The clinical pattern of PNS, renal biopsy, histopathological type, and related laboratory indexes before and after treatment were recorded.

RESULTS

A total of 313 patients were treated with urokinase and 57 patients were not. More thrombotic events was observed in non-urokinase group compared to the urokinase group(2 versus 0 episodes, p = 0.02). The thrombotic events observed included one patient had pulmonary embolism combined with right ventricular thrombosis, and another had intracranial venous thrombosis. More minor bleeding events occurred in urokinase group compared to the non-urokinase group(7 versus 1 episodes, p = 1.0). No major bleeding events occurred in either group.

CONCLUSION

The rational prophylactic use of urokinase anticoagulation in children with PNS can prevent the formation of thromboembolism and has good safety.

Analysis of 6 pediatric nephrotic syndrome cases with complications of cerebral sinovenous thrombosis and literature review

Background

Cerebral venous sinus thrombosis (CVST) is a rare but serious complication of nephrotic syndrome (NS) in children. To investigate the clinical characteristics of CVST in children with NS in order to timely diagnose this complication and reduce poor outcome.

Methods

Collect and analyze clinical data and magnetic resonance venography (MRV) results of children with NS complicated with CVST.

Results

Data of 6 patients with NS complicated with CVST were collected. 4 of the patients were steroid-sensitive nephrotic syndrome (SSNS) and 2 were steroid-resistant nephrotic syndrome (SRNS). The occurrence of CVST was observed within a time frame ranging from 12 days to 3 years following the diagnosis of NS. One patient had two episodes of thrombosis in three years, while the other five patients had only one episode of thrombosis. All patients had proteinuria at the time of episode of thrombosis. All patients presented with headache, and three of them had strabismus, seizures, and transient blindness, respectively. Neurological examination was negative. All patients were diagnosed with CVST by MRV within 3-16 days of the onset of headache. Two patients had TRPC6 gene mutation. All patients had resolution of neurological symptoms after anticoagulation treatment.

Conclusion

CVST may occur in the early stages of NS. There is currently a lack of specific diagnostic indicators to reliably identify the presence of CVST in patients with NS. Children with NS who have neurological symptoms should be promptly evaluated with imaging studies. Whether TRPC6 gene mutation is also a risk factor for CVST remains to be further studied.

Cerebral sinovenous thrombosis in children with nephrotic syndrome: systematic review and one new case

Aim

The aim of this review is to provide clinicians with characteristics of children with nephrotic syndrome and cerebral sinovenous thrombosis (CSVT).

Methods

We have reviewed 37 articles of pediatric cases and provided 1 new case. PRISMA guidelines were followed.

Results

Sixty-two patients were included in the review. CSVT was more common in males, usually occurred within 6 months of nephrotic syndrome onset and was found more often in outpatients. The superior sagittal sinus was the most common sinus affected. Non-contrast computed tomography was the most frequent radiologic study performed, with 30% of results negative for CSVT. Headache and vomiting were the most common symptoms while neurologic symptoms were less frequent. Anticoagulation treatment was strongly inconsistent throughout the literature. Thrombosis outcomes were favorable. The most common possible risk factors were corticosteroid treatment, proteinuria and hypoalbuminemia. Four children had a genetic predisposition diagnosed after thrombosis. No markers for anticoagulation prophylaxis seemed to be relevant for the majority of thrombosis occurring in outpatients.

Conclusion

Prophylactic anticoagulation does not seem reasonable to prevent CSVT. Knowledge of nonspecific symptoms and of nephrotic syndrome being a state of hypercoagulation and early use of appropriate radiologic study seem to be of major importance.

Sixth cranial nerve palsy and dense cerebral venous sinus thrombosis in a child with nephrotic syndrome

Nephrotic syndrome (NS) is a common glomerular disease characterised by massive proteinuria, hypoalbuminaemia, oedema and hyperlipidaemia. Cerebral venous sinus thrombosis (CVST) is a rare complication in children with NS. Here, we report a case of relapsing NS on steroid therapy, in a male in early childhood who presented with symptoms of headache, vomiting and double vision. On prism cover test there was 25 PD esotropia with abduction restriction in the left eye. Fundus examination showed bilateral papilloedema. He was diagnosed as sixth cranial nerve palsy of left eye. Neuroimaging reported dense CVST. He was managed with subcutaneous low molecular weight heparin and steroids. After 2 months of treatment, there was a complete resolution of esotropia and optic disc oedema. This case highlights the importance of early diagnosis of acute onset esotropia and sagittal sinus thrombosis in a case of NS.

Case report: cerebral venous sinus thrombosis and pulmonary embolism as the initial presentation in a child with asymptomatic primary nephrotic syndrome

Background

Cerebral venous sinus thrombosis (CVST) is rare, but potentially life-threatening. The clinical course definitely become more unpredictable and fatal in patients complicated by pulmonary embolism (PE). Nephrotic syndrome (NS) is an uncommon etiology of CVST. Concurrence of CVST and PE at the initial onset of NS is extremely unusual and rarely reported. Considering that edema might be absent in NS individuals, thromboembolic events probably become unrecognized, thereby causing a missed or delayed diagnosis and poor outcome. Herein, we described an extraordinary case of an adolescent boy presenting with both CVST and PE initially just within 5 days of disease onset, who was ultimately diagnosed with asymptomatic NS, aiming to emphasize a high index of suspicion of these diseases in patients with conditions of hypercoagulability.

Case presentation

A 13-year-old male child presented acutely with dizziness, fever and dyspnea, with signs of shock but undetected edema. Initial laboratory investigations revealed hypoalbuminemia, typical images of pneumonia, and normal radiographic findings on non-enhanced computed tomography of head. Despite evidence of hypoalbuminemia and neurological symptoms, the child was still misdiagnosed as pneumonia. His dyspnea and period of headache deteriorated even if hemodynamic stability and undetected fever after initial therapy. The delayed urinalysis and 24-h urine examination both showed massive proteinuria. A computed tomography angiography of chest along with cranial magnetic resonance imaging/magnetic resonance venography were subsequently performed, consistent with the imaging features of PE and CVST, respectively. The diagnosis of asymptomatic primary NS complicated by PE and CVST was ultimately confirmed. The patient received corticosteroids and antithrombotic therapy with satisfactory results.

Conclusion

A persistent clinical suspicion of CVST should be borne in mind in patients with a sudden, new or worsening headache, specifically among those with prothrombotic conditions. NS should always be considered in the differential diagnosis of risk factors for CVST, even in absence of edema. Since CVST and PE can be present simultaneously at extraordinary early-onset of NS, early radiological diagnosis is clinically substantial to proper management and satisfactory long-term outcomes.

Incidence of thromboembolism in children with primary nephrotic syndrome: a systematic review and metaanalysis

OBJECTIVE

To estimate the incidence of thromboembolism in children with primary nephrotic syndrome with Meta-analysis.

METHODS

Relevant studies published from January 1, 1980 to December 31, 2021 were retrieved from Pubmed, Web of science, Cochrane library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database(VIP) and Wangfang Database. Quality evaluation of the literatures included was conducted according to Agency for Healthcare Research and Quality(AHRQ) assessment tool, followed by data extraction and Meta-analysis with software RevMan 5.3.

RESULTS

A total of seven studies involving 3675 subjects were included. The overall prevalence was 4.9% with 95% CI of 2.83 to 7.05.However, a significant heterogeneity (P < 0.001) was observed with I² = 89%. The prevalence of venous thromboembolism was 3.3% with 95% CI of 1.7 to 4.9. The prevalence of arterial thromboembolism was 0.5% with 95% CI of 0.2 to 1.4.

CONCLUSION

Children with nephrotic syndrome are prone to thromboembolism, and it may lead to disability or death, therefore prevention measures is critical to decreasing the prevalence of thromboembolism.

Cerebral Venous Sinus Thrombosis in a Child With Idiopathic Nephrotic Syndrome: A Case Report and Review of the Literature

Cerebral venous sinus thrombosis is a rare and serious complication of nephrotic syndrome. A case of a five-year-old boy with nephrotic syndrome is described here. On the fourth day of admission, the child developed an occasional cough. A percutaneous renal biopsy was conducted to characterize the frequent-relapse nephrotic syndrome that was developed. After suspension of oral anticoagulants, the patient developed mild dizziness, headache, and vomiting. The child was diagnosed with intracranial venous sinus thrombosis based on data obtained using head computed tomography and magnetic resonance imaging. He recovered after receiving heparin and warfarin anticoagulants. We summarized the case and reviewed the literature here, showing that early diagnosis and treatment have a significant impact on the prognosis of this complication.

Cerebral Venous Sinus Thrombosis in a Child with Idiopathic Nephrotic Syndrome: a case report

Complications are rare in pediatric cases of idiopathic nephrotic syndrome (NS). Thromboembolism ranks among the most uncommon and difficult complications to diagnose, particularly in the first episode of NS, since clinical signs might be unspecific. This report describes the case of a 5-year-old girl with NS for the first time presenting with severe hypoalbuminemia (< 2g/dL). The patient responded poorly to therapy with corticosteroids. On day 8 of hospitalization she started having headaches and vomiting; she did not present hemodynamic alterations, fever or exanthems, and her neurological parameters were normal. The patient was suspected for intracranial hypertension, and computed tomography scans revealed she had cerebral venous sinus thrombosis (CVST). She was started on anticoagulants and showed clinical signs of improvement. The patient had no evident prothrombotic risk factors. She had three other episodes since she was diagnosed, one in which her plasma antithrombin level was low. Although antithrombin levels were normal in her first episode, she was tested after the resolution of proteinuria. The low levels of antithrombin seen in the first recurrence might have mirrored the initial drop in plasma antithrombin levels, an idea supported by the severe hypoalbuminemia she had when diagnosed. This severe manifestation of acquired thrombophilia might be in the origin of CVST. This report presents a rare case of thromboembolic complication in a pediatric patient with NS. The patient progressed well since she was started on anticoagulants. Although she did not present any evident risk factors at first, the development of her case indicated that severe acquired thrombophilia might have worked as the pathophysiological mechanism leading to CVST.

Thromboembolic complications at the onset of nephrotic syndrome

Nephrotic syndrome is associated with hypercoagulable states and a subsequent high risk of venous and rarely arterial thromboembolism. Although venous thromboembolism has been a recognised risk, prevalence of pulmonary embolism in patients with nephrotic syndrome is based on data from different case series. Here we report a 5 year old child with nephrotic syndrome who developed life threatening cerebral dural venous sinus thrombosis and pulmonary embolism within a month of disease onset.

Nephrotic Syndrome May Be One of the Important Etiologies of Cerebral Venous Sinus Thrombosis

OBJECTIVE

Thrombosis is a common complication of nephrotic syndrome (NS). However, cerebral venous sinus thrombosis (CVST) secondary to NS is rarely reported. Here we report a case series study of 5 cases of CVST with NS, so as to make a better understanding and management of this disorder.

METHODS

A retrospective study was performed in 5 consecutive patients with CVST in combination with NS between 2009 and 2015. The clinical manifestations, laboratory and radiological findings, treatment, and clinical outcomes were analyzed.

RESULTS

This cohort of case series consists of 1 woman and 4 men, aged 16-49 years. All patients complained initially of an acute or subacute headache. CVST attacked during NS occurrence in 3 patients, and during NS recurrence in 2 patients. The median duration of signs and symptoms prior to clinical diagnosis and treatment was 12.80 ± 7.53 days. In all patients, it was magnetic resonance venography that detected the thrombosis in the cerebral venous sinus, with the most common site of CVST to be the superior sagittal sinus (5 of 5 patients). Two or more segments of sinus were involved simultaneously in 4 patients. The treatment of CVST in NS involved therapy of CVST in the general population. All the 5 patients had full recovery, and no one relapsed with a follow-up of 26.60 ± 29.75 months.

CONCLUSIONS

NS may be one of the important etiologies of CVST. When patients with NS had progressing headache, seizure, or other unexplained neurological symptoms, CVST should be considered.