Clinical Aspects of Cerebral Venous Thrombosis: Experiences in Two Institutions

Acute Sigmoid Sinus Compromise Following Skull Base Procedures: Is a "Laissez-Faire" Approach Best?

Objective  Venous sinus compromise (VSC) of the sigmoid sinus can manifest as either venous sinus thrombosis, stenosis, or a combination of the two. It may occur following retro and presigmoid craniotomy, even in the absence of overt intraoperative sinus injury. Currently, the optimal management of VSC in the perioperative period is not well established. We report our incidence and management of VSC following skull base surgery around the sigmoid sinus. Patients and Methods  A retrospective chart review of all patients undergoing presigmoid, retrosigmoid, or combined approach by the senior author from 2014 to 2019 was performed. Main Outcome Measures  Charts were reviewed for patient demographics, surgical details, details of venous sinus compromise, and patient outcomes. Statistical analyses were performed using R 3.6.0 (R Project). Results  A 115 surgeries were found with a total of 13 cases of VSC (overall incidence of 11.3%). Nine cases exhibited thrombosis and four stenosis. There were no statistically significant differences between the groups with (group 1) or without (group 2) VSC. Operation on the side of the dominant sinus did not predispose to postoperative VSC. Five patients received antiplatelet medication in the perioperative period. There was no difference in outcomes in the group that did not receive antiplatelet medication versus those who did. Conclusion  Acute iatrogenic sigmoid sinus compromise can be managed expectantly. We believe that the treatment for each instance of VSC must be individualized, considering the symptoms of the patient, rather than applying a universal algorithm.

Clinical presentations, radiological characteristics, and biological risk factors of cerebral venous thrombosis at a University Hospital in Saudi Arabia

OBJECTIVES

To describe the clinical features and possible etiologies of cerebral vein thrombosis (CVT) in a Saudi Arabian cohort.

METHODS

A retrospective, observational design was implemented. Data pertaining to 36 patients (19 female and 17 male) with confirmed CVT diagnosis admitted to a hospital in Saudi Arabia between 2008 and 2019 were obtained and analyzed.

RESULTS

The age of patients ranged between 19 to 82 years, and the mean/median age was 33/29 years. Most commonly reported symptoms were headache ( 72%), unilateral lower limb weakness (39%), and seizures (17%). Papilledema was found in 8% of patients. Thrombotic disorders were identified in 14% and infections were identified in 8% of the patients. Two patients had ulcerative colitis, 2 were diagnosed with Behcet's disease, and 2 women were using oral contraceptive pills. Single sinus thrombosis was detected in only 22% of patients. One patient with diabetic ketoacidosis died. Thrombotic disorder was the most common risk factor, followed by that iron deficiency anemia.

CONCLUSION

The transverse sinus was the most frequently thrombosed sinus. Iron deficiency anemia emerged as a predisposing preventable condition for CVT, while genetic factors were found to be less important in this cohort.

Etiologic and Clinical Features of Cerebral Venous Sinus Thrombosis in Saudi Arabia

Objective:

Our study aims to evaluate the etiologic and clinical features of cerebral venous sinus thrombosis (CVST) in Saudi Arabia, and secondarily whether gender plays a role in CVST.

Materials and Methods:

Data were collected retrospectively from the stroke registry during the period from January 2008 to April 2018, and the patients with the diagnosis of CVST were identified, and data were analyzed for any gender-specific differences in clinical presentation and etiology of cerebral venous thrombosis.

Results:

There were 15 females while 11 males with a female:male ratio of 1.4:1. The mean age was 29.4± standard deviation 8.9 with the age range of 15–49. Headache was the most common and usually the first presenting symptoms present in 65% followed by hemiparesis and cranial nerve palsies. The first neurological examination was normal in 9/26 (34.6%) of the patients, while the common abnormality was cranial nerve palsies. Infections and trauma played an important part in risk factor analysis of our patient after the pregnancy- and hormone-related conditions. Some significant differences between the clinical presentation and risk factors among males and females were noted as age at presentation was higher in females while trauma and infections were common in male patients, although the involvement of the sinuses and response to treatment did not prove to be statistically significant.

Conclusion:

The results of this study were similar to the available literature with few differences. The relatively higher proportion of males in our study can be explained partly with more cases of traumatic CVST. Some important differences were noted between the risk factors and clinical presentation among genders. Large-scale prospective studies are needed to further clarify these differences.

Seizure in cerebral venous and sinus thrombosis

Many conflicting issues exist about seizure in the setting of cerebral venous and sinus thrombosis (CVST). In this article we aimed to address the existing data regarding incidence, characteristics, predictors, treatment, and prognosis of acute and late seizures in patients with CVST and to prepare more practical information for clinicians. PubMed, Embase, Web of science and Cochrane databases were searched within 1966–2016 using relevant keywords. A total of 63 papers met the inclusion criteria. Seizures are classified as acute symptomatic seizures (ASS; first 14 days) and post‐CVST epilepsy (PCE; after 14 days). The incidence had been reported in a wide range of 6.9–76% for ASS and 4–16% for PCE. Focal and generalized seizures were observed with different predominance. ASS commonly occurred in patients with loss of consciousness, focal neurological deficits, supratentorial lesions and thrombosis in superior sagittal sinus, straight sinus, and cortical veins. PCE had been predisposed by occurrence of ASS, motor deficit, and supratentorial lesions, particularly hemorrhage. Most experts believe that primary prophylaxis with antiepileptic drugs in the acute phase is not indicated. However, the initiation of prophylaxis after the first seizure in patients with supratentorial lesions or focal neurological deficit should be recommended. The quality of current evidence is low and most conclusions are based on expert opinions. More accurate reports of seizure semiology, detailed antiepileptic treatment plans, and outcomes are necessary to answer the existing questions.

A rabbit model of cerebral venous sinus thrombosis established by ferric chloride and thrombin injection

OBJECTIVE

Cerebral venous sinus thrombosis (CVST) is a life-threatening disease with high misdiagnosis and mortality rates due to its complex etiology and unknown pathophysiology. The present study aimed to establish an animal model suitable for assessing the pathophysiology of CVST and develop treatment methods.

METHODS

40% ferric chloride (FeCl3) was administered for 5min followed by thrombin injection to induce superior sagittal sinus thrombosis (SSST). Digital subtraction angiography (DSA) was performed to ensure thrombosis and evaluate the recanalization rate 7days post-CVST. Neurological evaluation, Evans blue injection, 2,3,5-Triphenyltetrazolium chloride (TTC), and hematoxylin-eosin (H&E) staining were used to assess thrombosis and the accompanying brain parenchyma.

RESULTS

SSST was detected in all model rabbits, with a thrombus recanalization rate of 10%. Brain infarction, hemorrhage, cell edema, and disruption of the blood-brain barrier (BBB) were also observed.

CONCLUSION

The method of inducing cerebral venous sinus thrombosis by applying 40% FeCl3 and injecting thrombin is feasible and efficient. This experimental model mimics the pathogenesis and pathophysiology of actual CVST.