Diagnosis and management of cerebral venous thrombosis

Dural Venous Sinus Thrombosis After Vestibular Schwannoma Surgery: Should We Anticoagulate?

BACKGROUND

The incidence of dural venous sinus thrombosis (DVST) following vestibular schwannoma (VS) surgery remains understudied. The diverse clinical presentation complicates forming anticoagulation treatment guidelines. This meta-analysis aimed to investigate the incidence of DVST post-VS surgery and to evaluate the role of anticoagulation.

METHODS

A systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, was conducted. Studies reporting DVST incidence after VS surgery were included. DVST incidence stratified by detection method was the primary outcome. Adverse events per treatment strategy (anticoagulation or no anticoagulation) were the secondary outcome. Pooled incidence with respective 95% confidence intervals were calculated using the random-effects model via the DerSimonian and Laird method.

RESULTS

The overall DVST incidence post-VS resection was 15.5% (95% confidence interval: 10.3%, 22.5%; 10 studies). Stratification by detection method revealed 29.4% (19.2%, 42.3%) for magnetic resonance imaging, 8.2% (3.2%, 19.5%) for computed tomography, and 0.7% (0.2%, 2.8%) upon clinical suspicion. The pooled incidence of adverse events was 16.1% (6.4%, 35.0%) for the anticoagulation treatment and 4.4% (1.4%, 12.9%) for no anticoagulation treatment, with one mortality case being among the adverse events in this latter group.

CONCLUSIONS

DVST after VS surgery is more common than initially perceived, predominantly presenting asymptomatically. Variability in anticoagulation protocols hinders the establishment of definitive therapeutic stances; nevertheless, there is no supporting evidence to promote anticoagulation administration for DVST. This begs the need for further institutional comparative studies with a proper adjustment for confounding and well-defined anticoagulation regimens.

Endothelial receptor proteins in acute venous thrombosis and delayed thrombus resolution in cerebral sinus vein thrombosis

BACKGROUND AND PURPOSE

Cerebral sinus venous thrombosis (CSVT) is a rare but life-threatening disease and its diagnosis remains challenging. Blood biomarkers, including D-Dimer are currently not recommended in guidelines. Soluble endothelial receptor proteins (sICAM-1, sPECAM-1 and sVCAM-1) have been shown to be promising diagnostic biomarkers in deep vein thrombosis (DVT) and pulmonary embolism (PE). Therefore, we examined endothelial receptor proteins as potential biomarkers for detecting CSVT.

METHODS

In this bi-centre, prospective study, we quantified D-Dimer as well as sICAM-1, sPECAM-1 and sVCAM-1 in plasma of patients with clinically suspected CSVT managed in the neurological emergency department (ED) of a tertiary care hospital. All patients underwent cerebral magnetic resonance imaging (MRI) and were followed up after 3, 6 and 12 months to detect thrombus resolution.

RESULTS

Twenty-four out of 75 (32%) patients with clinically suspected CSVT presenting with headache to the ED were diagnosed with acute CSVT. These patients had a mean age of 45 ± 16 years and 78% were female. In patients with CSVT, mean baseline D-dimer (p < 0.001) and sPECAM-1 (p < 0.001) were significantly higher compared to patients without CSVT. The combination of D-Dimer and sPECAM-1 yielded the best ROC-AUC (0.994; < 0.001) with a negative predictive value of 95.7% and a positive predictive value of 95.5%. In addition, higher baseline sPECAM-1 levels (> 198 ng/ml) on admission were associated with delayed venous thrombus resolution at 3 months (AUC = 0.83).

CONCLUSION

sPECAM-1 in combination with D-Dimer should be used to improve the diagnostic accuracy of acute CSVT and sPECAM-1 may predict long-term outcome of CSVT. Confirmatory results are needed in other settings in order to show their value in the management concept of CSVT patients.

Contrast-enhanced 3D black-blood magnetic resonance imaging for diagnosis of cerebral venous thrombosis

PURPOSE

Cerebral venous thrombosis (CVT) is often under-recognized on routine magnetic resonance imaging (MRI) examinations without concomitant magnetic resonance venography (MRV). Contrast-enhanced black-blood MRI (BBMRI) based on a three-dimensional T1-weighted variable-flip-angle turbo spin echo sequence, one of the sequences used routinely in our practice, has the potential for detection of thrombi in patients with CVT. The aim of this study is to evaluate the diagnostic performance and enhancement patterns of contrast-enhanced three-dimensional BBMRI for the diagnosis of CVT.

MATERIALS AND METHODS

Contrast-enhanced BBMRI and contrast-enhanced MRV sequences of 64 patients, acquired from June 2018 to January 2021, were retrospectively reviewed by neuroradiologists for detection of CVT in each venous sinus segment. Diagnostic performance values were calculated for contrast-enhanced BBMRI based on enhancement patterns.

RESULTS

Of 749 venous segments from 64 patients analyzed, CVT was demonstrated in 41 venous segments from 12 patients on contrast-enhanced MRV (CE MRV). Thick wall enhancement and total enhancement patterns were dominantly demonstrated in thrombosed segments. Compared with contrast-enhanced MRV, contrast-enhanced BBMRI had a patient-based sensitivity and specificity of 100% and 98.1%, respectively, and a segment-based sensitivity and specificity of 87.8% and 96.2%, respectively. The positive predictive value of contrast-enhanced BBMRI in detecting CVT was 92.3% (patient-based) and 57.1% (segment-based), and the negative predictive value was 100% (patient-based) and 99.3% (segment-based).

CONCLUSION

Contrast-enhanced BBMRI has high diagnostic performance in detection and diagnosis of CVT. This sequence may be useful to recognize CVT when dedicated CE MRV was not performed in patients with nonspecific neurological symptoms.

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.

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.

Mechanical Thrombectomy for Refractory Cerebral Venous Sinus Thrombosis in a Child with Nephrotic Syndrome : A Case Report

Nephrotic syndrome (NS) is associated with cerebral venous sinus thrombosis (CVST), which is a rare cerebrovascular disorder in children. Systemic anticoagulation with heparin is the standard therapy for CVST, and mechanical thrombectomy (MT) has been described as a salvage treatment for adult anticoagulant refractory CVST, However, it has never been reported in children. We describe a case of MT for refractory CVST in a child with NS. A 13-year-old boy with newly diagnosed NS presented to an emergency department with acute headache. A head computed tomography showed acute thrombus in the superior sagittal sinus, straight sinus and transverse sinus. The child was started on heparin therapy, but clinically deteriorated and became unresponsive. In view of the rapid deterioration of the condition after anticoagulation treatment, the patient received intravascular treatment. Several endovascular technologies, such as stent retriever and large bore suction catheter have been adopted. After endovascular treatment, the patient's neurological condition was improved within 24 hours, and magnetic resonance venography of the head demonstrated that the CVST was reduced. The child recovered with normal neurological function at discharge. This case highlights the importance of considering MT for refractory CVST, and we suggest that MT may be considered for refractory CVST with NS in children.

Successful hybrid endovascular treatment for refractory cerebral venous sinus thrombosis in pregnancy: A case report

Background

Cerebral venous sinus thrombosis (CVST) in pregnancy was common and endovascular treatment (EVT) could be an effective and safe treatment for patients with severe and refractory CVST. However, the efficacy and safety of hybrid EVT (craniotomy + endovascular treatment) for CVST were unknown. We represented a rare case of hybrid EVT through the incision of the superior sagittal sinus in a pregnant woman with CVST who failed to EVT through the femoral vein pathway.

Case presentation

A 26-year-old woman, in her second month of pregnancy, complained of a headache for 5 days and aggravation with coma combined with convulsions for 2 days. She was diagnosed with CVST in the local hospital by digital subtraction angiography (DSA) and treated with anticoagulation. She had no history of illness and the biochemical tests were normal. Hybrid EVT (craniotomy + EVT) was attempted after failing to conduct EVT through the femoral vein pathway due to difficulty to reach the target cerebral venous sinus. Briefly, a small hole was made in the frontotemporal head to expose the superior sagittal sinus and a 6F sheath was inserted into 2cm of superior sagittal sinus incision and fixed on the scalp, after repeated aspiration by 5F intermediate catheter and balloon dilatation of stenosis in the right transverse sinus and right sigmoid sinus, the cerebral venous system got successful recanalization. No obvious complications were found and the patient recovered very well after the surgery.

Conclusion

Anticoagulation was the standard treatment for CVST. EVT could rapidly restore venous flow and improve the prognosis for refractory and severe CVST. EVT by hybrid surgery through the superior sagittal sinus incision may be safe and effective for desperate patients with severe CVST.

Tumor Thrombus within the Superior Sagittal Sinus Detected on FDG PET Venography

Early detection of cereberal venous sinus thrombosis is important to prevent complication. Here we present an interstecting case of tumor thrombsosis of the superior sagittal venous sinus in a follow up case of adenocarcinoma esophagus, highlighting the feasibility for FDG PET venography for detection of the same.

Cerebral Venous Thrombosis in a 17-Year-Old Female Patient: A Case Report

Cerebral venous thrombosis (CVT) is a rare disorder predominantly affecting young women. Clinical presentation is not specific and varies depending on the location of the thrombus. The diagnosis requires clinical suspicion with confirmation by images. Guidelines for treatment recommend heparin during the acute phase even in patients with intraparenchymal hemorrhage. It is associated with a good prognosis when diagnosed and treated promptly. We present a case of CVT and intraparenchymal hemorrhage in a 17-year-old female with severe headache, nausea, vomiting, and altered mental status. The patient was diagnosed with CVT secondary to systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). She showed improvement after anticoagulation and corticosteroids.

Imaging Outcomes of Emergency MRI in Patients with Suspected Cerebral Venous Sinus Thrombosis: A Retrospective Cohort Study

Cerebral venous sinus thrombosis (CVST) is a rare neurological emergency condition with non-specific symptoms. Imaging options to rule out CVST are computed tomography (CT) and magnetic resonance imaging (MRI). This study aimed to determine the imaging outcomes of emergency MRI as a first-line imaging method in patients with suspected CVST. In this retrospective cohort study, we analyzed emergency brain MRI referrals from a five-year period in a tertiary hospital for suspicion of CVST. We recorded patient characteristics, risk factors mentioned in the referrals, and imaging outcomes. Altogether 327 patients underwent emergency MRI on the grounds of suspected CVST. MRI showed evidence of CVST among five patients (1.5%). Imaging showed other clinically significant pathology in 15% of the patients and incidental findings in 5% of the patients. Despite clinical suspicion, the diagnostic yield of emergency MRI for CVST is low and similar to that previously reported for CT. MRI is an alternative imaging method devoid of ionizing radiation in patients with suspected CVST.

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.

Cerebral venous thrombosis in patients with Sjögren's syndrome: A case report and literature review

Although cerebral venous thrombosis (CVT) is known to be induced by autoimmune diseases such as systemic lupus erythematosus and antiphospholipid syndrome, CVT caused by Sjögren's syndrome (SS) is scarcely reported in the medical literature. Since the first report of SS-induced CVT in 1994, only five cases have been reported, and the clinicopathological features of the disease are not well documented. We herein present a case report of a 41-year-old woman who was diagnosed with SS-induced CVT and perform a literature review of six cases of SS-induced CVT with a discussion of the pathogenesis, features of clinic symptoms, treatment, and prognosis of SS-associated CVT. We aim to improve the understanding of SS-induced CVT among clinicians and reduce the incidence of missed clinical diagnoses.

An obvious antinomy, superior sagittal sinus thrombosis in a patient with immune thrombocytopenia: Case report and a review of literatures

RATIONALE

Immune thrombocytopenia (ITP) is an autoimmune disease with an increased risk of bleeding. However, in recent years, it has been reported that patients with this hemorrhagic disease have the risk of thrombosis and embolism.

PATIENT CONCERNS AND DIAGNOSIS

The patient, in this case, was a young female who was diagnosed with ITP. When the platelet count was low, she had skin, mucosa, internal organs, and intracranial hemorrhage. In the process of ITP and hemostatic treatment, superior sagittal sinus thrombosis occurred when she was still bleeding.

INTERVENTIONS

She was given treatments for reducing intracranial pressure and controlling epilepsy.

OUTCOMES

And then the embolectomy operation failed. It was suggested in this case that ITP patients with severe thrombocytopenia and bleeding tendency also have a risk of having thrombotic disease. We reviewed literatures regarding the mechanism of the simultaneous occurrence of 2 antinomy diseases and cerebral venous thrombosis.

LESSONS

There are many factors for ITP patients to have thrombosis involving ITP itself, its treatment and the patients' constitution, medical history, and former medication. ITP is not only a hemorrhagic disease but also a thrombotic disease. Clinicians should be alert to the risk of thrombotic diseases in ITP treatment. Therefore thrombus monitoring and screening should be carried out, and early prevention or appropriate anticoagulant treatment should be selected, especially for patients with high risk.

A 44-Year-Old Male With Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare condition that can result in severe neurological complications when left untreated. Disease pathology results from thrombus development within the superficial cortical veins or the dural sinuses. Thrombosis impedes cerebral drainage leading to venous congestion and consequent increase in cerebral pressure, parenchymal damage, and blood-brain barrier disruption. Headache is the most common presenting symptom; other symptoms include focal neurological signs, seizures, papilledema, and altered sensorium. Diagnosis is typically made with visualization of obstructed flow in the cerebral venous system using one of three imaging modalities: computed tomography-venography (CTV), magnetic resonance imaging with venography (MRV), and diagnostic cerebral angiography. First-line therapy for CVST is anticoagulation, and the prognosis is generally favorable with early detection and prompt treatment. In this case report, we discuss a singular case of a patient presenting with loss of consciousness who was found to have CVST and treated with anticoagulation therapy in the setting of an intraparenchymal hemorrhage.

Cerebral Venous Thrombosis in a Patient With Smith-Magenis Syndrome

Smith-Magenis syndrome (SMS) is a complex genetic developmental disorder characterized by distinctive physical features, cognitive impairment, developmental delay, and behavioral abnormalities. It is caused by a microdeletion of chromosome band 17p11.2 encoding for multiple genes including the Retinoic-acid-induced (RAI1) gene. RAI1 gene is expressed in many tissues, acting as a transcriptional regulator. It is a dosage-sensitive gene. The variants of the RAI1 gene have been explored with some contributing to systemic manifestations. The hematological manifestations such as venous thrombosis (VT) including cerebral venous thrombosis (CVT) have not been reported to date. We report a case of a 25-year-old female with SMS who presented with lethargy and gastrointestinal symptoms and was diagnosed with CVT. Our case highlights the risk of VT in patients with SMS and therefore holding a high index of suspicion for early diagnosis and management.

Cerebral Venous Thromboses in a Patient With No Reported Risk Factors: A Case Report

Stroke is a neurologic condition caused either by brain ischemia or brain hemorrhage, where most cases are a result of ischemic brain injury. Stroke more commonly affects the arterial blood supply of the brain, but in rare cases, it is evoked by the occlusion of the venous sinuses that drain blood from the brain. This phenomenon is known as cerebral venous sinus thrombosis (CVST), also referred to as cerebral sinovenous thrombosis. The pathogenesis of CVST is not completely understood, although common risk factors associated with the condition include obesity, hypercoagulable states, oral contraceptive use, intracranial infections, trauma, and, more recently, coronavirus disease 2019 (COVID-19). Immediate medical intervention is required because CVST can result in increased intracranial pressure and diffuse cerebral edema, which can bring about fatal complications that can lead to early death. However, CVST is challenging to diagnose, as its clinical presentation is highly variable. It can range from headaches to signs of elevated intracranial pressure, including nausea, vomiting, and vision problems. In this case report, the patient is a 25-year-old previously healthy African American female who presented with a weeklong headache and acute onset of delirium an hour prior to arrival at the hospital. The patient had prior emergency department (ED) visits from different facilities where head imaging was performed and showed negative results allowing her to return home. The patient was then brought by a friend to our ED due to altered mental status and agitation. Initial computed tomography of the head did not reveal acute abnormalities; however, magnetic resonance angiography and magnetic resonance venography revealed evidence of venous sinus thrombosis and lack of flow requiring urgent attention. The patient was then referred to endovascular neurology, but despite medical intervention, the patient's medical status deteriorated, and she was declared brain dead. Although rare, this case report emphasizes the atypical presentation and the severity of CVST where a young individual with no significant past medical history presented with neurological symptoms that rapidly progressed to complications that caused her early death.

Rehabilitation of Post-Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is rare and only accounts for 0.5% of all reported stroke cases. CVT includes severe headaches with neurological deficits, but the vague presentation of symptoms necessitates efficient clinical examination and imaging for a proper diagnosis. Here, we present a case of this rare type of stroke. Our patient exhibited continuous headaches, further complicated by other neurological deficits. We documented this case to aid in the diagnosis and rehabilitation management of CVT. We aim to demonstrate to physicians the importance of early rehabilitation in such stroke cases and improve the outcome for patients.

Cerebral venous sinus thrombosis with an acute subdural hematoma treated with endovascular intervention: A case report

We report two cases of endovascular intervention for management of cerebral venous sinus thrombosis complicated by an acute intracranial hemorrhage during treatment with therapeutic anticoagulation. The first patient developed an acute subdural hematoma with progressive enlargement and was subsequently managed with venous sinus thrombectomy. The second patient developed an intraparenchymal and subdural hematoma and was treated with middle meningeal embolization. Anticoagulation is the primary treatment for cerebral venous sinus thrombosis but also contraindicated in an acute intracranial hemorrhage. In these cases, after endovascular intervention both patients resumed therapeutic anticoagulation without further hematoma expansion or additional invasive interventions. Both patients made an excellent neurological recovery and returned to their baseline functional independent status. Given the need for anticoagulation, endovascular intervention in the form of thrombectomy or middle meningeal artery embolization may be a viable adjuvant to anticoagulation in select patients.

Venous stroke–a stroke subtype that should not be ignored

Based on the etiology, stroke can be classified into ischemic or hemorrhagic subtypes, which ranks second among the leading causes of death. Stroke is caused not only by arterial thrombosis but also by cerebral venous thrombosis. Arterial stroke is currently the main subtype of stroke, and research on this type has gradually improved. Venous thrombosis, the particular type, accounts for 0.5–1% of all strokes. Due to the lack of a full understanding of venous thrombosis, as well as its diverse clinical manifestations and neuroimaging features, there are often delays in admission for it, and it is easy to misdiagnose. The purpose of this study was to review the pathophysiology mechanisms and clinical features of arterial and venous thrombosis and to provide guidance for further research on the pathophysiological mechanism, clinical diagnosis, and treatment of venous thrombosis. This review summarizes the pathophysiological mechanisms, etiology, epidemiology, symptomatology, diagnosis, and treatment heterogeneity of venous thrombosis and compares it with arterial stroke. The aim is to provide a reference for a comprehensive understanding of venous thrombosis and a scientific understanding of various pathophysiological mechanisms and clinical features related to venous thrombosis, which will contribute to understanding the pathogenesis of intravenous stroke and provide insight into diagnosis, treatment, and prevention.

The Hospitalization Rate of Cerebral Venous Sinus Thrombosis before and during COVID-19 Pandemic Era: A Single-Center Retrospective Cohort Study

OBJECTIVES

There are several reports of the association between SARS-CoV-2 infection (COVID-19) and cerebral venous sinus thrombosis (CVST). In this study, we aimed to compare the hospitalization rate of CVST before and during the COVID-19 pandemic (before vaccination program).

MATERIALS AND METHODS

In this retrospective cohort study, the hospitalization rate of adult CVST patients in Namazi hospital, a tertiary referral center in the south of Iran, was compared in two periods of time. We defined March 2018 to March 2019 as the pre-COVID-19 period and March 2020 to March 2021 as the COVID-19 period.

RESULTS

50 and 77 adult CVST patients were hospitalized in the pre-COVID-19 and COVID-19 periods, respectively. The crude CVST hospitalization rate increased from 14.33 in the pre-COVID-19 period to 21.7 per million in the COVID-19 era (P = 0.021). However, after age and sex adjustment, the incremental trend in hospitalization rate was not significant (95% CrI: -2.2, 5.14). Patients > 50-year-old were more often hospitalized in the COVID-19 period (P = 0.042). SARS-CoV-2 PCR test was done in 49.3% out of all COVID-19 period patients, which were positive in 6.5%. Modified Rankin Scale (mRS) score ≥3 at three-month follow-up was associated with age (P = 0.015) and malignancy (P = 0.014) in pre-COVID period; and was associated with age (P = 0.025), altered mental status on admission time (P<0.001), malignancy (P = 0.041) and COVID-19 infection (P = 0.008) in COVID-19 period.

CONCLUSION

Since there was a more dismal outcome in COVID-19 associated CVST, a high index of suspicion for CVST among COVID-19 positive is recommended.

Cerebral venous thrombosis during the COVID-19 Pandemic: A multi-center experience

Objective

To describe the clinical characteristics and outcomes of CVT in patients with history of recent COVID-19 infection or vaccination.

Methods

We reviewed demographic, clinical, and radiographic characteristics of non-pyrogenic, non-traumatic CVT cases at our multi-center institution between March 2020 and December 2021. Patients were grouped according to their history of recent COVID-19 infection or vaccination into group-I (+COVID-19 association) and group-II (-COVID-19 association).

Results

Fifty-one patients with CVT were included, of which 14 (27.4%) had a positive COVID-19 association: 10 with infection and 4 with mRNA-COVID-vaccine. Nine patients in group-I had COVID-19 infection or vaccine within 30 days of CVT diagnosis, including 3 patients with active infection at the time of CVT diagnosis. Half of the patients in group-I (n = 7,50.0%) and 32.4% (n = 12) of group-II were male, and mean age was 52.6 years in group-I and 51.4 years in group-II. Fever at presentation was noted in one patient who had active COVID infection (I=1 (7.1%), II= 0 (0%)). Higher rates of comorbidities were observed in group-II: hypertension (I= 2 (14.3%), II= 13 (35.1%)), deep venous thrombosis(I=1(7.1%), II= 10 (27.0%)), pulmonary emboli (I=1(7.1%), II= 8(21.6%)), or stroke(I=0(0%), II= 6(16.4%)). Three patients had thrombocytopenia at the time of CVT diagnosis (5.4%) and most patients (n = 37, 72.5%) were treated medically with anticoagulation. Complication rate during hospitalization was 17.6% (n = 6), and no mortality was noted.

Conclusion

Twenty-seven percent of CVT patients were associated with COVID-19 infection or vaccination, and the majority presented within 30 days of infection/vaccination.

Cerebral venous sinus thrombosis as the initial presentation of essential thrombocythemia - A case report and literature review

Myeloproliferative disorders (MPD) are associated with vascular thrombosis. Common sites for thrombosis are large arteries; however, less commonly, cerebral venous sinus thrombosis (CVST) has also been reported. It is rare to have CVST as an initial presentation of MPD. We discuss a male patient in whose presentation due to CVST led to the diagnosis of essential thrombocythemia (ET). Furthermore, we performed a literature review to evaluate the association of CVST with ET.

•

Myeloproliferative disorders can rarely manifest as cerebral venous sinus thrombosis with its initial presentation.

•

Literature review suggests a female preponderance for the development of CVST in MPD.

•

Patients usually have a favorable outcome with anticoagulation and cytoreductive therapy.

•

The role of novel anticoagulants is emerging in patients with CVST.

•

Until more evidence is available, it should be limited where standard anticoagulation cannot be done safely.

Cerebral venous sinus thrombosis and dural arteriovenous fistula associated with protein S deficiency: a case series study

OBJECTIVE

To describe the characteristics of patients with cerebral venous sinus thrombosis (CVST) and dural arteriovenous fistula (AVF) associated with protein S (PS) deficiency.

METHODS

We conducted a search of medical records in Hainan General Hospital from January 2000 to December 2020 for coexistence of CVST and dural AVF associated with PS deficiency and searched PubMed、Embase and Chinese biomedical databases (CBM) for all literature describing CVST and dural AVF with PS. We analyzed clinical characteristics, location, sequence of CVST and dural AVF, level of PS, therapeutic methods and prognosis.

RESULTS

We presented 1 patient in our hospital's database combined CVST and dural AVF associated with PS, plus 5 cases reported in literature. The most common symptoms were headache, generalized seizure, disturbance of consciousness. The most frequent location of CVST was at internal cerebral vein, while transverse sinus, sigmoid sinus, parietal region in dural AVF. Two patients developed dural AVF several months or years after CVST. Clinical characteristics and level of PS were summarized.

CONCLUSION

These findings alert physicians to consider PS deficiency in patients who suffer from CVST, especially those combined with dural AVF.

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.

A Comparative Analysis of COVID-19 Vaccines Based on over 580,000 Cases from the Vaccination Adverse Event Reporting System

Background: The COVID-19 pandemic is being battled via the largest vaccination campaign in history, with more than eight billion doses administered thus far. Therefore, discussions about potentially adverse reactions, and broader safety concerns, are critical. The U.S. Vaccination Adverse Event Reporting System (VAERS) has recorded vaccination side effects for over 30 years. About 580,000 events have been filed for COVID-19 thus far, primarily for the Johnson & Johnson (New Jersey, USA), Pfizer/BioNTech (Mainz, Germany), and Moderna (Cambridge, USA) vaccines. Methods: Using available databases, we evaluated these three vaccines in terms of the occurrence of four generally-noticed adverse reactions—namely, cerebral venous sinus thrombosis, Guillain−Barré syndrome (a severe paralytic neuropathy), myocarditis, and pericarditis. Our statistical analysis also included a calculation of odds ratios (ORs) based on total vaccination numbers, accounting for incidence rates in the general population. Results: ORs for a number of adverse events and patient groups were (largely) increased, most notably for the occurrence of cerebral venous sinus thrombosis after vaccination with the Johnson & Johnson vaccine. The overall population OR of 10 increases to 12.5 when limited to women, and further yet (to 14.4) among women below age 50 yrs. In addition, elevated risks were found (i) for Guillain−Barré syndrome (OR of 11.6) and (ii) for myocarditis/pericarditis (ORs of 5.3/4.1, respectively) among young men (<25 yrs) vaccinated with the Pfizer/BioNTech vaccine. Conclusions: Any conclusions from such a retrospective, real-world data analysis must be drawn cautiously, and should be confirmed by prospective double-blinded clinical trials. In addition, we emphasize that the adverse events reported here are not specific side effects of COVID vaccines, and the significant, well-established benefits of COVID-19 vaccination outweigh the potential complications surveyed here.

Cerebral venous thrombosis: imaging patterns

Cerebral venous thrombosis (CVT) is an uncommon condition that is potentially reversible if properly diagnosed and promptly treated. Although CVT can occur at any age, it most commonly affects neonates and young adults. Clinical diagnosis is difficult because the clinical manifestations of CVT are nonspecific, including headache, seizures, decreased level of consciousness, and focal neurologic deficits. Therefore, imaging is crucial for the diagnosis. Radiologists should be able to identify the findings of CVT and to recognize potential imaging pitfalls that may lead to misdiagnosis. Thus, the appropriate treatment (anticoagulation therapy) can be started early, thereby avoiding complications and unfavorable outcomes.

Acute T2*-Weighted Magnetic Resonance Imaging Detectable Cerebral Thrombosis in a Rat Model of Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) is associated with a high incidence of morbidity and mortality, particularly within the first 72 h after aneurysm rupture. We recently found ultra-early cerebral thrombosis, detectable on T2* magnetic resonance imaging (MRI), in a mouse SAH model at 4 h after onset. The current study examined whether such changes also occur in rat at 24 h after SAH, the vessels involved, whether the degree of thrombosis varied with SAH severity and brain injury, and if it differed between male and female rats. Adult Sprague Dawley rats were subjected to an endovascular perforation SAH model or sham surgery and underwent T2 and T2* MRI 24 h later. Following SAH, increased numbers of T2* hypointense vessels were detected on MRI. The number of such vessels correlated with SAH severity, as assessed by MRI-based grading of bleeding. Histologically, thrombotic vessels were found on hematoxylin and eosin staining, had a single layer of smooth muscle cells on alpha-smooth muscle actin immunostaining, and had laminin 2α/fibrinogen double labeling, suggesting venule thrombosis underlies the T2*-positive vessels on MRI. Capillary thrombosis was also detected which may follow the venous thrombosis. In both male and female rats, the number of T2*-positive thrombotic vessels correlated with T2 lesion volume and neurological function, and the number of such vessels was significantly greater in female rats. In summary, this study identified cerebral venous thrombosis 24 h following SAH in rats that could be detected with T2* MRI imaging and may contribute to SAH-induced brain injury.

Acute cerebral venous thrombosis - still an underdiagnosed pathology in emergency computed tomography of the brain

Purpose

Acute cerebral venous thrombosis (CVT) is a rare condition that can lead to a serious clinical state; thus, prompt diagnosis and treatment are mandatory. Head computed tomography (CT) plays a crucial role in the initial prompt diagnosis in the emergency setting. The aim of the study was to retrospectively analyse emergency head CT studies and the rate of incorrect diagnoses and main sources of pitfalls.

Material and methods

Retrospective analysis of 31 emergency CT studies (22 without contrast, 19F/12M, age range: 4-94 years) of patients with confirmed acute CVT.

Results

Thrombosed dural sinuses were found in 24/31 (77.4%) cases, thrombosed veins in 7/31 (22.6%) cases, no lesions within vessels in 2/31 (6.5%) cases. Haemorrhagic brain lesions were found in 9/31 (29%) cases, hypodense oedema in 6/31 (19.6%) cases, brain swelling in 1/31 (3.2%) cases, and no parenchymal lesions were revealed in 15/31 (48.4%) cases. Correct diagnosis of CVT was established in 15 cases (48.4%); however, it was incorrect in 16 cases (51.6%). Incorrect cases consist of 4 groups: 1 – with both vascular and parenchymal lesions that were overlooked (50%), 2 – with vascular lesions only, which were either overlooked, misinterpreted, or covered by artefacts (31.3%,), 3 – with parenchymal lesions only, which were misinterpreted (12.5%), and 4 – with no lesions present in the emergency head CT (6.2%).

Conclusions

The high rate of incorrect diagnoses of acute CVT based on emergency head CT requires constant training of radiologists and their close cooperation with clinicians because a delayed diagnosis may be lethal to the patient.

Cerebral venous thrombosis in the puerperium: a reflective case study

The increased risk of stroke during pregnancy and the puerperium - defined as being the first six weeks post-partum - has been well documented. The incidence, however, is still very low and has been estimated at 30 per 100,000 pregnancies. Strokes can result from several causes, including ischaemia, intracerebral bleeds, subarachnoid bleeds and venous thrombosis. Cerebral venous thrombosis (CVT) - a complete or partial occlusion of the major cerebral venous sinuses or cortical veins - accounts for 27%-57% of all pregnancy and puerperium-related strokes, which would equate to an incidence of 8-16 episodes per 100,000 deliveries. This article discusses the case of a young woman who presented to the emergency department complaining of bilateral eye pain. It considers the causes, the variability of presenting symptoms, diagnosis and treatment options for CVT. Given the variability of the condition's presentation, this article aims to assist nurses in identifying at-risk patients and promotes the benefits of collaboration with colleagues to improve patient outcomes.

A Case-Based Review of Cerebral Venous Infarcts With Perfusion Imaging and Comparison to Arterial Ischemic Stroke

Cerebral venous thrombosis (CVT) and cerebral venous infarcts (CVI) are diagnostic dilemmas secondary to their rarity, non-specific symptomatology at presentation, and variable imaging features. Despite its relatively infrequence, CVT is particularly prevalent in the younger adult population and is a potentially life-threatening disease with devastating neurological complications if not addressed in a timely manner. However, when treated promptly, CVT has the potential for a more reversible course and favorable prognosis than arterial ischemic strokes (AIS). The pathophysiology of CVI is distinct from that of AIS and is closely related to its potentially reversible nature. Familiarity with the conventional and variant venous anatomy, as well as the temporal evolution of imaging findings, is crucial in establishing diagnostic confidence. The use of MR perfusion imaging (MRP) and arterial spin-labeling (ASL) can potentially aid in the diagnosis of CVT/CVI via characterization of cerebral blood flow. The presence and extent of a cerebral perfusion deficit on either CT or MRI may play a role in clinical outcomes for patients with CVT, although future larger studies must be performed. This review presents a case-based overview focusing on the classic imaging characteristics of CVT and CVI in conjunction with bolus MRP and ASL findings in the adult population.

The Unfamiliar Case of COVID-19 Induced Cerebral Venous Sinus Thrombosis in a Pediatric Patient

The SARS-CoV-2 virus responsible for COVID-19 infection has affected the world from the end of 2019 with pulmonary and extrapulmonary manifestations. Hematologic complications are a rare but severe complication of the COVID-19 infection. There have been very few cases reported in the past showing thrombotic complications in the pediatric age group. We present a case of a 12-year-old male child showing cerebral venous sinus thrombosis (CVST) who tested positive for COVID-19 at the same time. We highlight the potential of this complication in the pediatric age group and discuss the treatment, which is an infrequent phenomenon.

Comprehensive Multi-omics Analysis Reveals Mitochondrial Stress as a Central Biological Hub for Spaceflight Impact

Spaceflight is known to impose changes on human physiology with unknown molecular etiologies. To reveal these causes, we used a multi-omics, systems biology analytical approach using biomedical profiles from fifty-nine astronauts and data from NASA's GeneLab derived from hundreds of samples flown in space to determine transcriptomic, proteomic, metabolomic, and epigenetic responses to spaceflight. Overall pathway analyses on the multi-omics datasets showed significant enrichment for mitochondrial processes, as well as innate immunity, chronic inflammation, cell cycle, circadian rhythm, and olfactory functions. Importantly, NASA's Twin Study provided a platform to confirm several of our principal findings. Evidence of altered mitochondrial function and DNA damage was also found in the urine and blood metabolic data compiled from the astronaut cohort and NASA Twin Study data, indicating mitochondrial stress as a consistent phenotype of spaceflight.

Headache in cerebral venous thrombosis

Headache has been consistently reported as the most common symptom of cerebral venous thrombosis and as the most frequent presenting feature. It is often the heralding symptom, preceding other manifestations of the disease by days or even weeks. This aspect highlights the importance of recognizing headache due to cerebral venous thrombosis, as early recognition of the disease can lead to a rapid diagnosis with appropriate imaging techniques and as early treatment with heparin can dramatically change the course of the disease and alter the prognosis. Unfortunately, although common, the headache has no specific features, and the clinical presentation of CVT is highly variable, making the correct diagnosis in the emergency setting a challenging task for clinicians, even in the case of highly specialized ones such as neurologists. In this review, we will briefly summarize the epidemiology and physiopathology of CVT, and then we will discuss in more details the causes, features, and course of headache, focusing on its relevance for differential diagnosis and on red flags that should suggest the possibility of CVT as the cause of the headache.

Cerebral Venous Thrombosis Presenting as a Subacute Headache in a Young Man With Undiagnosed Factor V Leiden Mutation

Cerebral venous sinus thrombosis (CVT) is a rare but potentially life-threatening condition that presents with non-specific symptoms. This condition is more common in women and can be associated with local infection and hypercoagulable conditions, including protein C and S deficiency, factor V Leiden mutation, anti-thrombin III deficiency, thrombophilia, vasculitis, and malignancy. We report the case of a 24-year-old man who presented with a left temporal headache and right upper and lower extremity paresthesia. He also experienced impaired vision (altered spatial sensation), dental pain, bruxism, nausea, and vomiting. Magnetic resonance imaging and magnetic resonance venography of the brain revealed widespread thrombosis of the cerebral sinuses as well as left superior cerebral cortical veins bilaterally. No evidence of venous infarct was found. Subsequent hematologic evaluation showed the presence of heterozygous factor V Leiden mutation. Testing of family members subsequently revealed the presence of this same mutation in his mother and all three siblings, although there was no family history of stroke, hypercoagulability, or atypical headaches. The patient was started on low-molecular-weight heparin and later transitioned to apixaban. Progression of his headache and visual abnormalities led to the discovery of increased intracranial pressure as demonstrated by papilledema and characteristic findings on computed tomography scan. He was treated with acetazolamide with improvement of his symptoms. CVT is uncommon and can be a diagnostic challenge due to its atypical presentation. Clinicians should consider this diagnosis in patients with a subacute onset of atypical headache, especially when accompanied by seizures, focal neurological deficits, or altered consciousness.

Bilateral thalamic lesion presenting as Broca's type subcortical aphasia in cerebral venous thrombosis: index case report

A 35-year-old man with a history of multiple substances abuse (alcohol, tobacco and cannabis) presented with acute, severe, holocranial headache associated with nausea and few episodes of vomiting followed by acute onset Broca-type aphasia with intact comprehension from next day, without any other focal neurodeficits, seizure or altered sensorium. Neurological examination was marked by Broca-type aphasia and failure in convergence reaction bilaterally, rest unremarkable. Brain imaging revealed lesions in bilateral thalamus, while magnetic resonance venography showed multiple flow voids in posterior part of superior sagittal sinus and bilateral transverse sinus. A diagnosis of cerebral venous sinus thrombosis was made. Subsequent investigations revealed decreased levels of protein C, protein S and antithrombin III. The patient was started on anticoagulation to which his headache and aphasia recovered completely after 8 and 12 days of therapy, respectively. He is being continued on anticoagulation and is following-up with us for past 4 months uneventfully.

Cerebral Vascular Thrombosis Associated With Ulcerative Colitis and Primary Sclerosing Cholangitis

ABSTRACT

We report a case of a sudden death of a 23-year-old man with a history of ulcerative colitis and primary sclerosing cholangitis due to cerebral vascular thrombosis. He was found supine in bed with no signs of trauma or drug use. Three days before being found, he had complained of fever and excessive diarrhea. At autopsy, the brain was markedly edematous with diffuse subarachnoid hemorrhage over the left cerebral hemisphere. The vessels at the base of the brain were unremarkable, and there was no significant hemorrhage over the inferior surfaces. On sectioning, clotted blood was identified in the left frontal lobe and lateral ventricles. Microscopically, the left cerebral hemisphere showed extensive intraparenchymal hemorrhage, necrosis, and numerous thrombosed leptomeningeal vessels. Sections of the transverse and descending colon showed changes consistent with the history of ulcerative colitis.Cerebral venous and sinus thrombosis represents approximately 1% of all strokes and is a known rare complication associated with inflammatory bowel disease (IBD). Symptoms of cerebral venous thrombosis are highly variable and may manifest as headache, focal neurological deficits, seizure, or encephalopathy. In addition to acquired hypercoagulability risk factors patients develop during active disease flares (eg, dehydration), studies suggest that IBD itself represents an independent risk factor for thrombosis. It is important for the forensic pathologist to consider thrombotic complications, particularly those in the cerebral venous system, as potential manifestations of known or undiagnosed IBD.

Squamous cell carcinoma of the scalp causing cortical venous thrombosis and Intraparenchymal hematoma

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We present a case of squamous cell carcinoma causing cortical venous thrombosis (CoVT)

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This is the first case of an invasive scalp lesion causing CoVT and brain hemorrhage

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Some cases of CoVT may be managed conservatively

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Recurrent, invasive squamous cell carcinoma remains therapeutically challenging

Current imaging modalities for diagnosing cerebral vein thrombosis - A critical review

Cerebral vein thrombosis (CVT) is a rare presentation of venous thromboembolism. Prompt and accurate diagnosis is essential as delayed recognition and treatment may lead to permanent disability or even death. Since no validated diagnostic algorithms exist, the diagnosis of CVT mainly relies on neuroimaging. Digital subtraction angiography (DSA) is the historical diagnostic standard for CVT, but is rarely used nowadays and replaced by computed tomography (CT) and magnetic resonance imaging (MRI). High quality studies to evaluate the diagnostic test characteristics of state of the art imaging modalities are however unavailable to date. This review provides an overview of the best available evidence regarding the diagnostic performance of CT and MRI for the diagnosis of CVT. Notably, available studies are observational, mostly small, outdated, and with a high risk of bias. Therefore, direct comparison between studies is difficult due to large diversity in study design, imaging method, reference standard, patient selection and sample size. In general, contrast-enhanced techniques are more accurate for the diagnosis of CVT then non-contrast-enhanced techniques. CT venography and MRI have been both reported to be adequate for establishing a final diagnosis of CVT, but choice of modality as used in clinical practice depends on availability, local preference and experience, as well as patient characteristics. Our review underlines the need for high-quality diagnostic studies comparing CT venography and MRI in specific settings, to improve clinical care and standardize clinical trials.

Prothrombogenic polymorphic variants of hemostatic and folate metabolism genes In patients with aseptic cerebral venous thrombosis

Cerebral venous sinus thrombosis (CVT) becomes the cause of stroke in less than 1% of patients. In 20-30% of patients, the cause of thrombosis remains unclear, and thrombosis is considered idiopathic. Inherited hypercoagulable conditions significantly increase the risk of CVT. The aim of the study was to evaluate the frequency of prothrombogenic polymorphic variants of hemostatic and methionine-homocysteine metabolism genes alleles and genotypes in patients with aseptic CVT. Fifty one patients aged 18–75 with aseptic CVT were examined. The control group included 36 healthy volunteers. Neuroimaging methods included brain MRI in standard modes (T1, T2, T2 d-f (FLAIR), DWI) and MR venosinusography. All patients were surveyed to identify carriers of prothrombogenic polymorphic variants of hemostatic and folate metabolism genes alleles and genotypes. Prothrombogenic polymorphic variants of hemostatic genes were detected in 94% of patients, and the variants of the methionine-homocysteine metabolism genes were observed in 86% of patients. The differences between distributions of alleles and genotypes 5G6754G of the PAI-1 gene, G103T of the FXIIIA1 gene, A66G of the MTRR gene, A2756G of the MTR gene in the group of patients with CVT and in the control group were significant. Allele 4G, genotypes 4G/4G and 5G/4G of 5G6754G polymorphism of the PAI-1 gene; allele T of G103Т polymorphism of the FXIIIA1 gene; allele G and genotype A/G of A66G polymorphism of the MTRR gene; allele G and genotype A/G of A2756G polymorphism of the MTR gene correlated with aseptic CVT. It was concluded that the gene polymorphisms 5G6754G (PAI-1), G103T (FXIIIA1), A66G (MTRR) and A2756G (MTR) carriage increased the risk of aseptic CVT and did not affect the thrombosis clinical manifestations.

Clinical Aspects, Diagnosis and Management of Cerebral Vein and Dural Sinus Thrombosis: A Literature Review

Cerebral vein and dural sinus thrombosis (CVST) is an uncommon cause of stroke, but its delayed diagnosis carries significant morbidity and mortality. Several studies have reported higher incidence of CVST than that previously reported. The clinical presentation of CVST varies and can be atypical. Advancement in neuroimaging modalities has made it possible to make an early diagnosis and initiate management with a wide range of therapeutic options, including direct oral anticoagulants and endovascular treatment. This narrative review summarizes the epidemiology, clinical aspects, diagnosis and management of CVST.

Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.