Exploring thrombus composition in cerebral venous thrombosis: the first case report with initial insights and implications for treatment advancements

BACKGROUND

Endovascular thrombectomy (EVT) is a treatment option in patients with a cerebral venous thrombosis (CVT) who deteriorate despite anticoagulant treatment. Assessment of thrombus composition in CVT may provide insights into the pathophysiology of the disease and suggest new therapeutic strategies.

CASE REPORT

A 47-year-old woman (smoking habit and estradiol/progesterone-releasing intra-uterine device) diagnosed with massive CVT underwent EVT (complete recanalization via aspiration catheter and stentriever) due to acute-onset left-sided weakness and dysarthria despite 72 h of full-dose subcutaneous low-molecular heparin. Two main reddish clots (maximum diameter 15 mm) were retrieved. Microscopic assessment showed an erythrocyte-rich thrombus (83.9% of entire thrombus surface) with layers of platelets/fibrin (lines of Zahn: 13.9% fibrin and 38.5% platelet [CD61+]). The immunological profile was dominated by neutrophils (30% MPO+), with neutrophil extracellular traps (NETs) in 1.9% of thrombus surface. T- (CD3+), B-lymphocytes (CD20+), and monocytes/macrophages (CD68+) were rather rare (2.2%, 0.7%, and 2.0% respectively). We found no evidence (0.0%) of hemosiderin and endothelial cells (CD34+). Full clinical recovery occurred prior to discharge.

CONCLUSION

This is the first case report of a CVT with histologic assessment of the thrombus retrieved via EVT. Evaluating thrombi in CVT can provide key insights into disease pathophysiology and guide treatment advancements.

New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline

Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.

Characteristics and outcomes of cerebral venous thrombosis associated with COVID-19

INTRODUCTION

Previous reports and meta-analyses derived from small case series reported a mortality rate of up to 40% in patients with coronavirus disease 2019 associated cerebral venous thrombosis (COVID-CVT). We assessed the clinical characteristics and outcomes in an international cohort of patients with COVID-CVT.

PATIENTS AND METHODS

This was a registry study of consecutive COVID-CVT patients diagnosed between March 2020 and March 2023. Data collected by the International Cerebral Venous Thrombosis Consortium from patients with CVT diagnosed between 2017 and 2018 served as a comparison. Outcome analyses were adjusted for age and sex.

RESULTS

We included 70 patients with COVID-CVT from 23 hospitals in 15 countries and 206 controls from 14 hospitals in 13 countries. The proportion of women was smaller in the COVID-CVT group (50% vs 68%, p < 0.01). A higher proportion of COVID-CVT patients presented with altered mental state (44% vs 25%, p < 0.01), the median thrombus load was higher in COVID-CVT patients (3 [IQR 2-4] vs 2 [1-3], p < 0.01) and the length of hospital stay was longer compared to controls (11 days [IQR 7-20] vs 8 [4-15], p = 0.02). In-hospital mortality did not differ (5/67 [7%, 95% CI 3-16] vs 7/206 [3%, 2-7], aOR 2.6 [95% CI 0.7-9]), nor did the frequency of functional independence after 6 months (modified Rankin Scale 0-2; 45/58 [78%, 95% CI 65-86] vs 161/185 [87%, 81-91], aOR 0.5 [95% CI 0.2-1.02]).

CONCLUSION

In contrast to previous studies, the in-hospital mortality rate and functional outcomes during follow-up did not differ between COVID-CVT patients and the pre-COVID-19 controls.

Cerebral venous thrombosis

Cerebral venous thrombosis is part of the so-called thrombosis in unusual sites. It is defined as an occlusion in the cerebral venous territory. Its incidence is progressively increasing, especially in developing countries. It is more frequently observed in young women, with hormonal factors such as pregnancy or hormonal contraception being significant risk factors in the development of this condition. The clinical presentation will depend fundamentally on the topography of the thrombosis, with a confirmatory diagnosis based mainly on imaging tests. The treatment generally consists of anticoagulation, and other options may be considered depending on the severity of the case. Overall, the prognosis is better than that of other intracranial vascular disorders. This review describes the current evidence available regarding cerebral venous thrombosis.

Is a minimum duration of 5 days of unfractionated heparin infusion necessary before transition to oral anticoagulation in cerebral venous thrombosis? a retrospective chart review

In managing cerebral venous sinus thrombosis (CVT), the standard approach has been administering parenteral anticoagulation for at least five days, despite limited supporting evidence. This study aimed to determine the optimal duration of parenteral anticoagulation for CVT patients and its potential impact on their functional outcomes upon discharge. This retrospective observational cohort study was conducted across multiple healthcare centers and included adult CVT patients who received varying durations of parenteral anticoagulation: less than 5 days (n = 25) or 5 days or more (n = 16). The primary focus was on the duration of acute anticoagulation treatment, with secondary endpoints including hospital stay length and functional outcomes. The study found that a shorter duration of anticoagulation treatment (< 5 days) was linked to more favorable outcomes, as measured by the modified Rankin Scale (mRS) (68% vs. 25%, RR = 0.37, CI 0.15-0.90, p = 0.007). However, regression analysis showed non statistically significant associations for all variables except gender. Female patients were significantly more likely to receive a shorter duration of anticoagulation (Odds Ratio: 2.6, 95% CI: 2.2-3.1, P-Value: <0.001). These findings suggest a potential connection between shorter anticoagulation duration (< 5 days) and improved CVT patient outcomes, as indicated by their mRS scores at discharge. The observed relationship between female gender and shorter anticoagulation duration warrants further exploration. Nevertheless, caution is necessary when interpreting these findings due to the small sample size and specific patient characteristics. Further research in a larger and more diverse cohort is essential to validate these results and understand their implications fully.

Dural arteriovenous fistula involving superior petrosal sinus with petrosal venous drainage in association with cerebral venous thrombosis: Literature review and illustrative case

Background

Dural arteriovenous fistulas (DAVFs) involving superior petrosal sinus (SPS) and superior petrosal vein (SPV) are extremely rare. The pathogenesis of these fistulas remains unclear. We are illustrating 2 cases of DAVFs involving the superior petrosal sinus and veins associated with venous sinus thrombosis with a literature review.

Methods

We reviewed the literature using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on DAVFs involving the SPS and/or SPV. Additionally, we searched for additional articles through the reference lists of the included studies.

Results

Our review yielded 20 articles from 1997 until 2022 involving 33 patients with 34 fistulas, including our 2 patients. The mean age was 55.1 ± 12.9 years (range 25-85), 54.5% were males (n = 18). The patients presented with hemorrhage in 36.4% (n = 12), and progressive myelopathy in 30.3% (n = 10). Most fistulas often had arterial supply from MMA, MHT, and/or OA. The fistulas had infratentorial drainage in 64.71% (n = 22), supratentorial drainage in 23.53% (n = 8), and both supra and infratentorial drainage in 11.76% (n = 4). In 27.3% (n = 9), cerebral venous thrombosis was mentioned or identified. Endovascular treatment was performed in 47.1% of cases (n = 16), surgery in 29.4% (n = 10), and combination of treatments in 23.5% (n = 8). A total of 30.3% (n = 10) of cases had incomplete recovery or poor result.

Conclusion

DAVFs involving the SPS and/or SPV are associated with aggressive natural history, requiring early diagnosis and prompt treatment, leading to good prognosis. These fistulas may be acquired in origin, probably secondary to cerebral venous thrombosis.

De novo formation of remote dural arteriovenous fistula following treated cavernous sinus dural arteriovenous fistula

Background

The development of new dural arteriovenous fistulas (DAVFs) at another location following endovascular treatment of cavernous sinus DAVFs (CSDAVFs) are extremely rare. Our aim is to review cases of de Novo DAVFs that occurred after treatment of CSDAVFs at our institution and those reported in the literature.

Methods

We reviewed all cases of CSDAVFs evaluated by 2 experienced neuroradiologists. A literature search was performed using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on De Novo DAVFs following the endovascular treatment of cerebrovascular malformations. Addition articles were searched through the reference lists of the included articles.

Results

From June 2004 and September 2019., we identified 3 (2.5%) cases of De Novo DAVFs occurred after endovascular treatment or spontaneous obliteration of CSDAVFs from 119 treated CSDAVFs at our institute. Our review yielded 9 articles involving 12 patients with 15 de novo DAVFs, including our 3 patients. The mean age was 55.08 ± 12.9 years (range 43-69), 83.3% were females (n = 10). The new remote DAVFs occurred after endovascular treatment of CSDAVFs in 10 (83.3%) patients. The de novo DAVFs occurred following spontaneous complete regression in 2 (16.7%) patients. All de novo DAVFs developed after complete obliteration of treated CSDAVFs.

Conclusion

Sinus thrombosis and elevated venous pressure may play an important role in the pathogenesis of a de novo DAVF formation. In addition, thrombophilic abnormalities and the use of contraceptives may contribute to sinus thrombosis, leading to the development of the second remote DAVF after treatment of CSDAVFs.

Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study

INTRODUCTION

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications.

OBJECTIVE

The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain.

METHODS

We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 10 Spanish centres.

RESULTS

We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3 to 6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P =  .03), focal deficits (P = .001), and encephalopathy (P < .001) showing a statistically significant association with poor prognosis (mRS > 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%.

CONCLUSION

The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Ominous Causes of Headache

PURPOSE OF REVIEW

While primary headaches like migraines or cluster headaches are prevalent and often debilitating, it's the secondary headaches-those resulting from underlying pathologies-that can be particularly ominous. This article delves into the sinister causes of headaches, underscoring the importance of a meticulous clinical approach, especially when presented with red flags.

RECENT FINDINGS

Headaches, one of the most common complaints in clinical practice, span a spectrum from benign tension-type episodes to harbingers of life-threatening conditions. For the seasoned physician, differentiating between these extremes is paramount. Headache etiologies covered in this article will include subarachnoid hemorrhage (SAH), cervical artery dissection, cerebral venous thrombosis, meningitis, obstructive hydrocephalus, and brain tumor.

Dabigatran etexilate versus warfarin in cerebral venous thrombosis in Chinese patients (CHOICE-CVT): An open-label, randomized controlled trial

BACKGROUND

The efficacy and safety of dabigatran etexilate for Chinese patients with cerebral venous thrombosis (CVT) has not been well established.

METHODS

CHOICE-CVT was an exploratory, single-center, randomized, open-label study in the National Center for Neurological Disorders involving Chinese patients with CVT aged 18 to 80 years who were randomly assigned (1:1) to either dabigatran etexilate or warfarin. Oral anticoagulants were initiated after 10-15 days of LMWH. The primary efficacy and safety endpoints included the number of patients with recurrent CVT and/or deep venous thrombosis (DVT) and major clinical bleeding within 180 days. Secondary efficacy endpoints included venous recanalization and change in papilledema at day 180. Secondary safety outcomes comprised death, clinical nonmajor bleeding, and any bleeding. The study was registered with ClinicalTrials.gov under NCT03930940.

RESULTS

Between October 2017 and February 2023, a total of 89 patients were enrolled and randomly assigned to receive either dabigatran etexilate (n = 44) or warfarin (n = 45). At day 180, the dabigatran etexilate group showed a statistically nonsignificant but likely clinically significant number of patients with recurrent CVT and/or DVT (8 (18.2%; 95% CI, 6.3-30.0) vs 3 (6.7%; 95% CI, 0.0-14.2), p = 0.099, with a power (1-β) of 38.401%) compared with the warfarin group. The dabigatran etexilate group showed a comparable number of patients with clinical major bleeding (0 (0) vs 0 (0) p = 1.000), and clinical nonmajor bleeding (1 (2.3%; 95% CI, 0.0-6.9) vs 1 (2.2%; 95% CI, 0.0-6.7)) but demonstrated a lower risk of any bleeding (1 (2.3%; 95% CI, 0.0-6.9) vs 9 (20.0%; 95% CI, 7.8-32.2)) compared with the warfarin group. Most patients in both groups achieved venous recanalization according to the Modified Qureshi scale (27 (75%; 95% CI, 60.1-89.9) in the dabigatran etexilate group vs 34 (82.9%; 95% CI, 70.9-95.0) in the warfarin group) and exhibited improvement in papilledema as per the Frisén classification (35 (97.2%; 95% CI, 91.6-100.0) in the dabigatran etexilate group vs 37 (88.1%, 95% CI, 77.9-98.3) in the warfarin group).

CONCLUSIONS

These findings regarding efficacy and safety support the consideration of dabigatran etexilate therapy as a viable treatment option for Chinese patients with CVT.

SIRT1-Mediated HMGB1 Deacetylation Suppresses Neutrophil Extracellular Traps Related to Blood-Brain Barrier Impairment After Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is a neurovascular disease with recently increasing incidence. Aseptic inflammatory responses play an important role in the pathology of CVT. Recent studies report that neutrophil extracellular traps (NETs) are major triggers of thrombosis and inflammation in stroke, but their effect on brain injury in CVT requires further validation. In this study, two CVT animal models were used to simulate superior sagittal sinus thrombosis and cortical vein thrombosis. The effects of brain tissue infiltration of NETs and the molecular mechanisms associated with NET formation were deeply explored in combination with proteomics, histology, and serology. The results showed that the cortical vein thrombosis model could be combined with more severe blood-brain barrier (BBB) disruption and showed more severe cerebral hemorrhage. Decreased Sirtuin 1 (SIRT1) expression promotes high mobility group box 1 (HMGB1) acetylation, causing increased cytosolic translocation and extracellular release, and HMGB1 can promote NET formation and recruitment. In addition, corticocerebral accumulation of NETs contributes to BBB damage. This establishes a vicious cycle between BBB damage and NET accumulation. SIRT1 mediated-HMGB1 deacetylation may play a critical role in attenuating BBB damage following CVT. This study employed a combined validation using models of venous sinus thrombosis and cortical vein thrombosis to investigate the deacetylation role of SIRT1, aiming to offer new insights into the pathological mechanisms of brain injury following CVT.

Ultrasonic optic nerve sheath diameter can be used as a diagnostic measure after accidental dural puncture during cesarean section: a case report

BACKGROUND

Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache.

CASE PRESENTATION

The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient's symptoms were relieved and she was discharged from the hospital 49 days later.

CONCLUSIONS

Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.

Prognosis after cerebral venous thrombosis: Mortality during initial admission and at 30 days and one year after discharge in a large Canadian population-based cohort

BACKGROUND

Prognosis following cerebral venous thrombosis (CVT) is more favorable than other stroke types, but longer-term literature is limited, and trends over time are under-explored.

OBJECTIVE

Using administrative data, we examined factors associated with mortality in the inpatient setting, at 30 days and at one year following hospital discharge among a large consecutive cohort of Canadian patients with CVT.

DESIGN/METHODS

CVT patients from British Columbia (BC), Canada from 2000 to 2017 were identified using ICD diagnosis codes from the BC subset of the Canadian Institute for Health Information's Discharge Abstract Database. Logistic regression was used to investigate factors associated with inpatient mortality and survival analysis with Cox regression was used to explore factors associated with mortality at 30 days and one year.

RESULTS

Of 554 incident CVT patients identified, 508 (92 %) survived their index admission. Older age (OR 1.04, 95 % CI 1.03-1.06, p < 0.01) and the presence of seizures (OR 2.31, 95 % CI 1.08-4.94, p = 0.03) or intracranial bleeding (OR 2.28, 95 % CI 1.08-4.85, p = 0.03) were associated with increased odds of inpatient mortality. Mortality after hospital discharge was 3.0 % at 30 days and 9.4 % at one year. Older age (HR 1.05, 95 % CI 1.02-1.08, p < 0.01 at 30 days; HR 1.05, 95 % CI 1.04-1.07, p < 0.01 at 1 year) and having recent or active malignancy (HR 4.17, 95 % CI 1.51-11.52, p < 0.01 at 30 days; HR 4.60, 95 % CI 2.60-8.11, p < 0.01 at 1 year) were significantly associated with higher risks of mortality at 30 days and one year after discharge. There were decreases in inpatient mortality over the study period, but this was offset by higher mortality within 30 days after discharge in the later study epochs.

CONCLUSIONS

Among patients discharged with a diagnosis of CVT, one-year mortality was high at 9.4 %. Older age and a history of cancer were associated with higher mortality after discharge.

Clinicoradiological Features and Long-term Cognitive and Functional Outcome in Patients with Deep Cerebral Venous Thrombosis

Background

Deep cerebral venous thrombosis (DCVT) can have long-term functional and cognitive sequelae. Although literature exists on cognitive impairment after arterial stroke, cognitive sequelae after cerebral venous thrombosis (CVT) are much less studied.

Methods

Clinical records of 29 patients diagnosed with DCVT were reviewed. The Modified Telephonic Interview for Cognitive Status (TICS-M) was adapted and validated in the regional language (Kannada) and applied to 18 patients with DCVT, at a mean follow-up duration of 5.32 years. Screening for depression was done via telephonic Patient Health Questionnaire-9 (PHQ-9)-Kannada version, and functional status was screened by applying the modified Rankin Scale (mRS).

Results

DCVT had a mortality rate of 10.34% due to acute complications. mRS scores of 0-1 were achieved at follow-up in all patients who survived. Receiver operating characteristic (ROC) analysis revealed a cutoff of ≤44.5 (maximum score of 49) for the diagnosis of cognitive impairment via TICS-M (Kannada version) in DCVT patients. Evidence of cognitive dysfunction was seen in eight patients (42.10%), and three patients (16.66%) had evidence of depression.

Conclusions

Survivors of acute DCVT can potentially have long-term cognitive sequelae. Screening for cognitive dysfunction, depression, and functional status can be effectively done using telephonically applied scales that are adapted to the local language. Neuropsychological evaluation and early cognitive rehabilitation can be initiated for patients in whom deficits are identified on cognitive screening.

Factors associated with the initial intracranial hemorrhage occurrence in patients with cerebral venous thrombosis

OBJECTIVES

Studies focusing on intracranial hemorrhage (ICH) in patients with cerebral venous thrombosis (CVT) are limited; thus, we aimed to identify factors associated with the occurrence of ICH in Thai patients with CVT.

METHODS

This retrospective cohort study recruited patients with CVT admitted to a tertiary university-based hospital between 2002 and 2022. The baseline characteristics, clinical presentations, radiographic findings, and etiologies were compared between the ICH and non-ICH groups. The factors with p < 0.2 in the univariate analysis were further analyzed using multivariable logistic regression analysis to identify independent factors associated with ICH in patients with CVT.

RESULTS

Of 228 screenings, 202 patients were eligible. The incidence rate of ICH was 36.63%. The ICH group showed a higher prevalence of focal neurological deficits (63.51% vs. 26.56%, p < 0.001), seizures (68.92% vs. 21.88%, p < 0.001), dependency status at admission (60.81% vs. 39.84%, p = 0.004), superior sagittal sinus thrombosis (71.62% vs. 39.07%, p < 0.001), superficial cortical vein thrombosis (36.49% vs. 10.16%, p < 0.001), and hormonal use (17.57% vs. 7.03%, p = 0.021) than the non-ICH group. In contrast, the ICH group showed a lower prevalence of isolated increased intracranial pressure (10.81% vs. 21.88%, p = 0.048) than the non-ICH group. Seizures (adjusted odds ratio [aOR], 4.537; 95% confidence interval [CI], 2.085-9.874; p < 0.001), focal neurological deficits (aOR, 2.431; 95% CI, 1.057-5.593; p = 0.037), and superior sagittal sinus thrombosis (aOR, 1.922; 95% CI, 1.913-4.045; p = 0.045) were independently associated with ICH in the multivariable logistic regression analysis.

CONCLUSIONS

Seizures, focal neurological deficits, and superior sagittal sinus thrombosis are associated with ICH in patients with CVT.

[Multifocal cerebral venous thrombosis]

Cerebral venous thrombosis is a rare condition and represents a neurological emergency. It is a particular subtype of stroke, characterized by a huge diversity of neurological symptoms. Due to the diversity of its potential clinical presentations, medical imaging plays an important role in its early detection, even on non-dedicated examinations often performed in search of another acute neurological pathology. The aim of this case report is to illustrate the different radiological signs of cerebral venous thrombosis and to discuss the difficulties in diagnosing it by imaging at the acute stage.

Comparison of edoxaban and enoxaparin in a rat model of AlCl3-induced thrombosis of the superior sagittal sinus

Cerebral sinus venous thrombosis (CSVT) is an uncommon disease that is usually treated with anticoagulation (heparin, low-molecular heparin, or vitamin K-antagonists). We compared treatment with edoxaban, an oral factor Xa-antagonist, that has not been approved in patients with CSVT, with enoxaparin, a well-established therapy, in a rat model of CSVT. Fifty male Wistar rats were randomized into 5 groups (10 animals each) and subjected to aluminum chloride (AlCl3)-induced thrombosis of the superior sagittal sinus (SSS) or sham procedure. Animals with thrombosis of the SSS were treated with edoxaban, enoxaparin, or placebo. Diagnostic workup included neurological examination, MRI imaging, MR-flow measurements of the SSS, and immunohistochemical staining. Neurological examination revealed no differences between treatment groups. Seven days after initial thrombosis, flow in the SSS was lower in the active treatment group as compared to sham-operated animals (p < 0.05). Flow in the SSS in the active treatment groups (edoxaban 1 h prior to thrombosis: 0.16 cm/s ± 0.06 cm/s; edoxaban 6 h after thrombosis: 0.13 cm/s ± 0.05 cm/s; enoxaparin: 0.13 cm/s ± 0.04 cm/s; placebo: 0.07 cm/s ± 0.02 cm/s) was higher as compared to placebo (p < 0.05), but there were no differences between the active treatment groups (p > 0.05). Immunohistochemical staining showed no differences in the actively treated animals. Edoxaban proved to be similar to enoxaparin in a model of experimental AlCl3-induced CSVT.

Can mechanical thrombectomy be effective in deep cerebral venous thrombosis worsening on anticoagulant? Insight from two cases

OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare condition whose clinical presentation can range from simple headaches to severe impairment of alertness. Some clinical forms, such as involvement of the deep venous system, are associated with a poorer clinical prognosis despite well-managed anticoagulation. The role and timing of rescue mechanical thrombectomy for these patients is not well established.

METHOD

Clinical and imaging follow-up are discussed according to our treatment decision.

RESULTS

We describe two cases with deep venous system thrombosis that were treated unsuccessfully with optimal anticoagulation, with a spectacular clinical and radiological response after mechanical thrombectomy (MT).

CONCLUSION

These cases demonstrate that, despite the negative results of the TO-ACT trial, MT could be considered as a rescue treatment in some clinical forms of deteriorating CVT despite optimal anticoagulation.

Assessment of fibrinogen albumin ratio in patients with pregnancy-related cerebral venous thrombosis

INTRODUCTION AND OBJECTIVE

Cerebral venous thrombosis (CVT) is a cerebrovascular disease observed more commonly in women of childbearing age. There is currently no biomarker used to predict the risk of CVT during the follow-up of pregnant/postpartum patients. In this context, the objective of this study is to investigate the importance of fibrinogen and albumin levels and fibrinogen-to-albumin ratio (FAR) values, which predispose to thromboembolism, in pregnant/postpartum patients.

MATERIAL AND METHOD

The study sample consisted of 19 pregnant/postpartum patients with a diagnosis of CVT, 20 pregnant/postpartum patients without CVT. Albumin and fibrinogen levels and FAR values were compared between these two groups.

RESULTS

Fibrinogen level was significantly higher in pregnant/postpartum CVT patients compared to pregnant/postpartum patients without CVT (p = 0.010). On the other hand, albumin level was significantly lower in pregnant/postpartum CVT patients compared to the other group (p = 0.010). Lastly, FAR level was significantly higher in pregnant/postpartum CVT patients compared to the other group (p = 0.011). There was no correlation between FAR values and modified Rankin score.

CONCLUSION

The study findings indicated that high fibrinogen and low albumin levels and high FAR values are associated with an increased risk of CVT in pregnant/postpartum patients.

Mastoid fluid signal in acute cerebral venous thrombosis is is associated with increased clot burden

PURPOSE

Mastoid air cell abnormalities in the form of hyperintense T2 fluid signal have been reported in cases of acute Cerebral Venous Thrombosis (CVT) without otologic infection and have been hypothesized to be a result of venous congestion rather than infectious mastoiditis. The aim of this study was to investigate a link between the spectrum of mastoid abnormalities and clot burden in patients with acute CVT.

METHODS

A retrospective study of adult patients admitted to the National Institute of Mental Health and Neurosciences between 2016 and 2023 who were diagnosed with acute CVT and had no clinical evidence of active or recent ear infections was conducted. Pre- and post-contrast MR Images were analyzed to identify the dural sinuses and/or cerebral veins involved and the presence of fluid signal in the mastoid. Fluid signal in the mastoid was graded from 0 to 3 as described by Shah et al- no fluid signal (grade 0), thin curvilinear hyperintensities (grade 1), thick crescenteric hyperintensities (grade 2), and complete hyperintensity (grade 3). Clot Burden Score (CBS) was calculated by assigning one point for each sinus involved, one point for extension of thrombus into the intracranial Internal Jugular Vein (IJV), one point for thrombosis of cortical veins and one point for thrombosis of deep cerebral veins.

RESULTS

A total of 89 patients with acute CVT were included in the final analysis. Median time from presentation to MRI was 2 days (range 0-13). 51 patients (57.3%) had fluid signal in the mastoid air cells on T2-weighted images, of whom 33 showed mucosal contrast enhancement. Higher grade of fluid signal in the mastoid was present ipsilateral to the side of venous thrombosis in 59 out of 60 patients with posterior fossa CVT. CBS was significantly different between patients with different grades of fluid signal (p = 0.002). Grade 2-3 fluid signal was associated with higher clot burden (CBS > 3) in both the entire study population (n = 89) - OR = 8.281, 95 %CI: 2.758-24.866 (p < 0.001) and among patients with posterior fossa CVT - OR = 4.375, 95 %CI: 1.320-14.504 (p = 0.016). Among patients with posterior fossa CVT, grade 2-3 fluid signal was associated with left sided transverse and/or sigmoid sinus thrombosis - OR = 5.600, 95 %CI: 1.413-22.188 (p = 0.014), and extension of thrombosis into the IJV - OR = 4.606, 95 %CI: 1.162-18.262 (p = 0.030).

CONCLUSION

T2 fluid signal in the mastoid is associated with venous congestion in adults with acute CVT without evidence of otologic infection. Moderate-to-severe T2 fluid signal in the mastoid air cells is associated with increased clot burden.

ChAdOx1 nCoV-19 Vaccine and Thrombosis with Thrombocytopenia Syndrome among Adults: A Systematic Review

Several vaccine-induced thrombotic thrombocytopenia syndrome (VITTS) cases have been reported after the ChAdOx1 nCov-19 vaccination. The current study systematically reviewed the reported post-ChAdOx1 nCoV-19 vaccination thrombotic thrombocytopenia cases. Their laboratory and clinical features, as well as the diagnostic and therapeutic measures, were investigated. Online databases were searched until 25 August 2021. Studies reporting post-ChAdOx1 nCov-19 vaccination thrombotic thrombocytopenia syndrome (TTS) were included. Overall, 167 cases (21-77 years old) from 53 publications were included showing a female dominance of 1.75 times. About 85% of the cases exhibited the primary symptoms within the first two weeks post-vaccination. Headache was the most common initial symptom (>44.2%), and hemorrhage/thrombotic problems (22.46%), as well as discoordination/weakness/numbness/ hemiparesis/cyanotic toes (19.6%), were the most prevalent uncommon initial symptoms. Prothrombin time (PT), D-dimers, and C-reactive protein were the most remarkable increased laboratory parameters in 50.6%, 99.1%, and 55.6% of cases, respectively. In comparison, platelet and fibrinogen were the most remarkable decreased laboratory parameters in 92.7% and 50.5% of cases, respectively. Most VITT cases presented with cerebral venous thrombosis/cerebral venous sinus thrombosis, supraventricular tachycardia, transverse sinus/cerebral thrombosis, pulmonary embolism, and cerebral hemorrhage. Anti-PF4 antibody measurement through immunoassays and functional assays were positive in 86.2% and 73% of cases, respectively. About 31% of the cases died. Early diagnosis and proper therapeutic measures are important in ChAdOx1 nCov-19 vaccine-induced VITTS patients. Therefore, experts are recommended to know the corresponding clinical and laboratory features, as well as diagnostic methods. Elucidation of the pathophysiologic mechanism of ChAdOx1 nCov-19 vaccine-induced TTS deserves further investigation.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy

INTRODUCTION

Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC.

MATERIALS AND METHODS

Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed.

RESULTS

Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization.

CONCLUSION

In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Seizures in cerebral venous thrombosis - A retrospective analysis of a tertiary centre cohort

BACKGROUND

Seizures are common in cerebral venous thrombosis (CVT). The occurrence of acute symptomatic seizures (ASS) has implications for patients' management, with some patients developing unprovoked late seizures (ULS). We aimed to determine risk factors for the development of ASS, ULS, and seizure recurrence (SR) in patients with CVT.

METHODS

We performed an observational retrospective analysis of 141 patients with CVT. We recorded the occurrence of seizures, their time relation to the first-symptom onset, and their relation with demographic, clinical, CVT risk factors, and radiological findings. Seizure recurrence (total recurrency, recurrent ASS, and recurrent LS), potential risk factors, and the use of antiepileptic drugs (AED) were also analysed.

RESULTS

Thirty-two (22.7%) patients developed seizures: 23 (16.3%) were ASS and 9 (6.3%) ULS. After multivariable logistic regression, seizure patients had more focal deficits (p = 0.033), parenchymal lesion (p < 0.001), sagittal sinus thrombosis (p = 0.007). In ASS, more frequent focal deficits (p = 0.001), encephalopathy (p = 0.001), mutation in V Leiden factor (p = 0.029), and parenchymal brain lesions (p < 0.001) were observed. ULS patients were younger (p = 0.049) and took more hormonal contraceptives (p = 0.047). Thirteen (9.2%) patients suffered SR (2 recurrent ASS only, 2 recurrent LS only, 2 both acute and recurrent LS), which was more frequent in patients with focal deficits (p = 0.013), infarct with haemorrhagic transformation (p = 0.002), or previous ASS (p = 0.001).

CONCLUSION

The occurrence of seizures in patients with CVT is related to focal deficits, structural parenchymal lesions, and superior sagittal sinus thrombosis. SR is frequent, even in patients under AED. This shows the important impact that seizures have on CVT and its long-term management.

Clinical, radiological profile and prognostic role of transcranial color-coded duplex in cerebral venous thrombosis: a case-control study

BACKGROUND

Cerebral venous thrombosis is a rare type of stroke, occurring more among young individuals. The presentation is highly variable, and this can delay diagnosis and management, thereby affecting outcome. The aim is to study the clinical, radiological profile, risk factors for cerebral venous thrombosis (CVT) and the role of transcranial color-coded duplex (TCCD) in CVT prognosis among Egyptian patients.

METHODS

Eighty CVT patients and 80 normal healthy individuals were included. Magnetic resonance imaging, magnetic resonance venography, and genetic thrombophilia tests were done for patients. Deep cerebral venous system was evaluated using B-mode transcranial color-coded duplex (TCCD) for both groups.

RESULTS

Showed female predominance with gender specific risk factors being the most common etiology. The most common hereditary thrombophilia was homozygous factor V Leiden mutation and anti-thrombin III (AT III). Headache was the most common presentation. Forty-three patients had transverse sinus thrombosis. Regarding TCCD, there was an increase in mean blood flow velocities, peak flow velocities and end diastolic flow velocities in deep middle cerebral vein and basal veins in CVT group compared to control group. There was a positive correlation not reaching statistical significance between flow velocities in the deep venous system and modified Rankin Scale.

CONCLUSION

Clinical presentation is extremely variable. In our population, homozygous factor V Leiden mutation and AT III deficiency were the most common. Increased deep cerebral venous system flow velocities using TCCD in patients with CVT reflect their venous hemodynamic state.

Association between inflammatory biomarkers and venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a common thrombotic vascular disease that has a significant impact on people's well-being and quality of life. A plethora of clinical studies explore the relationship between inflammatory biomarkers and VTE but yield conflicting results. This article proposed to pool these studies to draw a more convincing conclusion.

METHODS

We searched several databases for studies before April 2023. Available data was processed using Stata software (version 15.0 SE) and R (version 4.1.2). This meta-analysis has been registered in PROSPERO (CRD42022321815). The VTE in this review encompassed pulmonary embolism, deep vein thrombosis, and cerebral venous thrombosis.

RESULTS

A total of 25 articles were finally involved in this study. Our results revealed that higher levels of high-sensitivity C-reactive protein (hs-CRP, MD, 0.63, 95%CI, 0.21-1.05) and C-reactive protein (CRP)> 3ug/ml (OR, 1.52, 95%CI, 1.18-1.96) might be regarded as risk factors for future VTE occurrence. The elevated levels of monocyte (MD, 0.03, 95%CI, 0.00-0.05), hs-CRP (0.85, 0.61-1.08), CRP (0.66, 0.20-1.13) and IL-6 (0.47, 0.25-0.70) might represent the previous VTE; a series of markers such as white blood cell (1.43, 0.88-1.98), neutrophil (1.79, 1.02-2.56), monocyte (0.17, 0.14-0.21), hs-CRP (3.72, 1.45-5.99), IL-6 (5.99, 4.52-7.46), platelet-lymphocyte ratio (33.1, 24.45-41.78) and neutrophil-lymphocyte ratio (1.34, 0.95-1.73) increased during the acute phase of VTE.

CONCLUSIONS

In general, activated inflammatory biomarkers might not only be correlated with an increased risk of VTE, but may also give a hint of the occurrence of VTE in clinical settings.

Cortical vein involvement and its influence in a cohort of adolescents with cerebral venous thrombosis

BACKGROUND AND PURPOSE

Cortical vein thrombosis (CVT) is a rare form of cerebral venous sinus thrombosis (CVST) in adolescent patients that has received little attention. We aimed to analyze the clinical and radiological features of adolescents with CVST and investigate the effects of CVT involvement.

METHODS

Patients aged ≥ 10 to ≤ 18 years and diagnosed with CVST were identified at Xuanwu Hospital, Capital Medical University between January 2015 and August 2022 and divided into two groups according to the presence or absence of cortical vein involvement. Additionally, the patients were also categorized based on their sex. Clinical features, radiological characteristics, and 12-month follow-up outcomes were compared between the two groups.

RESULTS

Fifty-three adolescents, including 21 with CVT, were included (mean age: 15.2 ± 1.8 years; females, 54.7%). The CVT group was more likely to experience seizures (P = 0.028) and deterioration (28.6% vs. 6.2%, P = 0.047) during hospitalization than the non-CVT group. Poor short-term outcomes, based on the modified Rankin Scale (mRS) score at discharge, were more common in adolescents with CVT (P = 0.007). The proportions of patients showing edema (42.9% vs. 6.2%, P = 0.004) and mass effect (P = 0.015) were significantly higher in the CVT group. Recanalization was observed in 61.9% and 82.1% of the patients in the CVT and non-CVT groups, respectively, during the first imaging review (median, 22 days). After a 12-month follow-up, female adolescents had more frequent resident secondary headaches than male adolescents (52.9% vs. 12.5%; P = 0.014).

CONCLUSIONS

Cortical vein involvement in adolescents with CVST was associated with a higher risk of epilepsy at presentation, deterioration during hospitalization, edema, and mass effect on acute imaging. Moreover, cortical vein involvement may lead to worse short-term outcomes. Sex differences require consideration in etiological analyses and prolonged follow-ups.

Cerebral venous thrombosis (CVT) complicating tubercular meningitis

BACKGROUND

Tuberculous meningitis (TBM), complicated with cerebral venous thrombosis (CVT), has been sparsely reported and needs to be investigated further.

METHODS

Among those with tuberculous meningitis in Haihe Hospital, Tianjin University, 3 patients with venous sinus thrombosis were identified retrospectively. "Tuberculous meningitis" and "cerebral venous thrombosis" were used as keywords, and the retrieved literature was summarized and analyzed. Our data were combined with previously reported case data to describe this new condition.

RESULTS

Among 28 patients with a median onset age of 31 years for TBM, 17 were females. The manifestations were fever, headache, and seizure. Magnetic resonance imaging (MRI) venography showed that the most common site of venous sinus thrombosis involved superior sagittal sinus, left transverse sinus, left sigmoid sinus, cavernous sinus, and straight sinus. The abnormalities found on MRI include hydrocephalus, exudates, hemorrhage, meningeal enhancement, infarction, and tuberculoma. In the acute phase, all patients received standard anti-TB treatment, and 14/28 patients received anticoagulant treatment. The mortality rate of these patients was 17.9%, and 21/28 (75%) became functionally independent.

CONCLUSIONS

CVT is one of the rare complications of TMB and must be considered a differential diagnosis in patients with TBM who show poor clinical features and/or develop new neurological signs.

Trends in utilization and outcomes of mechanical thrombectomy for cerebral venous thrombosis: A National Inpatient Sample study

BACKGROUND AND PURPOSE

Cerebral venous thrombosis (CVT) is usually treated with systemic anticoagulation, but mechanical thrombectomy (MT) and local infusion of a thrombolytic agent have been proposed as an alternative therapy. In this study, we analyze National Inpatient Sample (NIS) to determine the trends of MT including discharge other than home (DOTH) and mortality.

MATERIAL AND METHODS

Healthcare Utilization Program-NIS (HCUP-NIS) was queried between 2005 and 2018 for CVT and MT. Cochran-Armitage test was conducted to assess linear trend of proportion of utilization and DOTH of MT. Multivariable logistic regression was conducted to assess odds of undergoing MT among CVT admissions, odds of in-hospital mortality, and DOTH for all admissions involving MT for CVT.

RESULTS

A total of 1331 (1.56%) admissions involved MT out of 85,370 CVT cases. Utilization of MT had an upward trend of 0.13% (p < 0.001) per year. Trend in proportion of incidence of DOTH among MT admission remained stationary (trend: 0.70%; p = 0.417). Patients with cerebral edema (odds ratio [OR]: 4.34; p < 0.001) or hematological disorders (OR: 2.28; p < 0.001) were more likely to receive MT for CVT. Additionally, patients with coma (OR: 3.17; p = 0.023) or cerebral edema (OR: 4.40; p = 0.001) had higher odds of mortality.

CONCLUSION

There was an increasing trend of utilization of MT. Proportions of DOTH among MT procedures, however, remained stable. Patients with greater risk factors, including hematological disorders and cerebral edema, were more likely to undergo MT. Among patients treated with MT, those with coma or cerebral edema were more likely to die.

Extensive cerebral venous thrombosis after resection of third ventricle colloid cyst

Background

The third ventricle colloid cyst (CC) is a benign growth usually located in the third ventricle and can cause various neurological symptoms, including sudden death. Modern surgical interventions may still result in a wide range of complications and cerebral venous thrombosis (CVT) is among them.

Case Description

A 38-year-old female with an existing diagnosis of diabetes mellitus (DM) and hypothyroidism and a 6-month history of headaches, blurred vision, and vomiting presented to our clinic 3 days after the headaches became excessively severe. Neurological examination on admission revealed bilateral papilledema without any associated focal neurological deficits. Brain computed tomography and magnetic resonance imaging confirmed the presence of a third ventricle CC and associated non-communicating hydrocephalus involving the lateral ventricles. As a result, the patient underwent emergency bilateral external ventricular drainage (EVD) insertion followed by a third ventricular CC excision under neuronavigation through a right frontal craniotomy. Twelve days postoperatively, the patient developed further headaches followed by a generalized tonic-clonic seizure that led to no postictal neurological deficits. Nonetheless, computed tomography venography of the brain revealed extensive thrombosis of the superior sagittal sinus, inferior sagittal sinus, right sigmoid sinus, and right internal jugular vein. A newly diagnosed CVT was treated with intravenous heparin. The patient was discharged with warfarin, which was discontinued after 12 months. Ten years after her illness, she remained stable and free from any neurological deficits but still suffered from chronic mild headaches.

Conclusion

A preoperative venous study should be performed in all cases to gain a better understanding of the venous anatomy. We advocate meticulous microsurgical techniques to protect the venous system surrounding the foramen of Monro and reduce the amount of retraction during surgery.

Safety and clinical outcomes in endovascular treatment for symptomatic cerebral venous thrombosis: a single-center experience with meta-analysis

The role of mechanical thrombectomy (MT) in cerebral venous sinus thrombosis (CVT) is ambiguous. This study aims to share our experience with MT in CVT, supplemented by a meta-analysis on this treatment. All patients who had MT for CVT at our institution, between 2016 and 2021, were retrospectively reviewed for treatment indications, the technique used, success and complication rates, and clinical outcomes. A meta-analysis was performed for clinical and safety outcomes from published literature with > 10 patients. A total of 15 patients were included in this study. All had a venous hemorrhage or deteriorating despite anticoagulation. MT was performed using aspiration (with wide bore catheters) in 7 patients: aspiration with stent retriever in 5 and transjugular Fogarty-balloon thrombectomy in 3 patients. Adjunctive intra-sinus thrombolysis (IST) was used in 4 cases and venoplasty in 3. Technical success (restoring antegrade venous flow on arterial injection) was 100% with no procedure-related major complication. The direct transjugular approach was cheaper and faster. At 3-month follow-up, 86% of patients had good outcomes (MRS < 2). Meta-analysis of clinical and safety outcomes from 22 and 20 studies, respectively, demonstrated a positive association between MT and good outcomes as well as no significant association with hazardous periprocedural events. EVT via mechanical means for CVT is feasible in our series and meta-analysis. From our experience, trans-jugular Fogarty balloon embolectomy seems to be a potential cost-saving option, at least in a certain part of the world.

Papilledema and venous stasis in patients with cerebral venous and sinus thrombosis

BACKGROUND

Cerebral venous and sinus thrombosis (CVST) can cause increased intracranial pressure, often leading to papilledema. In this study, we investigated the association between papilledema and venous stasis on susceptibility weighted imaging (SWI) in CVST.

METHODS

Patients with CVST between 2008 and 2020 were reviewed. Patients without fundoscopic examination or SWI were excluded in this study. Venous stasis was evaluated and scored for each cerebral hemisphere: each hemisphere was divided into 5 regions according to the venous drainage territories (superior sagittal sinus, Sylvian veins, transverse sinus and vein of Labbé, deep cerebral veins, and medullary veins) and 1 point was added if venous prominence was confirmed in one territory on SWI. The venous stasis score on SWI between cerebral hemispheres with and without papilledema was compared.

RESULTS

Eight of 19 patients with CVST were excluded because of the absence of fundoscopic examination or SWI. Eleven patients (26.5 ± 2.1 years) were included in this study. Papilledema was identified in 6 patients: bilateral papilledema in 4 patients and unilateral papilledema in 2 patients. The venous stasis score on SWI was significantly higher (P = 0.013) in the hemispheres with papilledema (median, 4.0; 95% CI, 3.038-4.562) than in the hemispheres without papilledema (median, 2.5; 95% CI, 0.695-2.805).

CONCLUSIONS

This study shows that higher score of venous stasis on SWI is associated with papilledema. Therefore, the venous stasis on SWI may be an imaging surrogate marker of increased intracranial pressure in patients with CVST.

Comparative Study of Cerebral Venous Thrombosis-Risk Factors, Clinical Course, and Outcome in Subjects with and without COVID-19 Infection

BACKGROUND/OBJECTIVE

Cerebral venous thrombosis (CVT) has been increasingly reported in patients with COVID-19. Most published literature is descriptive and focuses only on CVT in COVID-19 patients. The objective of our study was to compare CVT patients' characteristics with and without an associated COVID-19 infection.

MATERIALS AND METHODS

This is a retrospective cross-sectional study. All adult patients with a confirmed diagnosis of CVT admitted to our hospital over a period of 30 months, from January 2019 to June 2021, were included. They were further divided into two groups, with and without COVID-19 infection.

RESULTS

A total of 115 CVT patients were included, 93 in non-COVID-CVT and 22 in COVID-CVT group. COVID-CVT patients were male predominant and of older age, with longer hospital stay, and higher inpatient mortality. COVID-CVT patients presented with a higher frequency of headache (82% vs. 63%), seizures (64% vs. 37%, p = 0.03), hemiparesis (41% vs. 24%), and visual changes (36% vs. 19%) as compared to non-COVID-CVT patients. Venogram showed a higher frequency of superior sagittal sinus (64% vs. 42%) and internal jugular vein (23% vs. 12%) involvement in the COVID-CVT cohort. More than 90% of patients in both groups received therapeutic anticoagulation. Mortality rates were higher in COVID-CVT group (18% vs. 11%).

CONCLUSION

COVID-CVT patients were male predominant and of older age, with higher hospital stay, and higher inpatient mortality as compared to non-COVID-CVT patients.

Cerebral venous thrombosis with hyperhomocysteinemia due to loss of heterozygosity at methylenetetrahydrofolate reductase (MTHFR) locus: a case report

BACKGROUND

Loss of heterozygosity (LOH) at methylenetetrahydrofolate reductase (MTHFR) locus has been reported in tumor tissue. But the mutation was never reported in cerebral venous thrombosis (CVT) with hyperhomocysteinemia (HHcy) before.

CASE PRESENTATION

A 14-year-old girl was admitted with an intermittent headache and nausea for 2 months. The plasma homocysteine level was 77.2 µmol/L. Lumbar puncture revealed an intracranial pressure > 330 mmH2O. Cerebral MRI and MRV revealed superior sagittal sinus thrombosis. Whole-exome sequencing revealed LOH at Chr1:11836597-11,867,232 affects exons 10-21 of C1orf167, the entire MTHFR, and exons 1-2 of the CLCN6 gene. The normal allele was the c.665 C > T/677 C > T variant in MTHFR. The patient was treated with nadroparin for 2 weeks, followed by oral rivaroxaban. Supplemental folate and vitamins B12 and B6 were prescribed. One month later, she had no headache and the intracranial pressure had decreased to 215 mmH2O. MRI showed shrinkage of the thrombosis in the superior sagittal sinus, the degree of stenosis had significantly decreased.

CONCLUSIONS

Rare LOH at the MTHFR locus should be analyzed in CVT with HHcy. With anticoagulation treatment, the prognosis was good.

Clinical application of three-dimensional T1-weighted BrainVIEW in magnetic resonance imaging of cerebral venous thrombosis: a case report and literature review

To date, there is no clinical scoring system or laboratory indicator that can rule out cerebral venous thrombosis (CVT) or provide diagnostic proof for evaluating post-treatment thrombosis recanalization during follow-up. We therefore explored an imaging method for quantitative assessment of CVT and assessed thrombotic changes during follow-up. A patient presented with severe posterior occipital distension extending to the top of the forehead and an elevated plasma D-dimer (DD2) level. Computed tomography and pre-contrast-enhanced magnetic resonance imaging revealed only a small amount of cerebral hemorrhage. Three-dimensional (3D) T1-weighted (T1W) BrainVIEW pre-contrast-enhanced magnetic resonance scanning showed subacute thrombosis in the venous sinus, and the post-contrast-enhanced scan combined with volume rendering reconstruction showed cerebral thrombosis of the venous sinus and allowed for measurement of the thrombus volume. On days 30 and 60 of post-treatment follow-up, post-contrast-enhanced scans showed progressive reduction of the thrombus volume as well as recanalization and fibrotic flow voids in the chronic thrombosis. 3D T1W BrainVIEW was helpful to observe the size of the thrombi and the situation of venous sinus recanalization during the follow-up after clinical treatment of CVT. This technique can reflect the imaging manifestations of CVT throughout the whole process to guide clinical treatment decisions.

Risk factors for the development of secondary intracranial hypertension in acute cerebral venous thrombosis

PURPOSE

Intracranial hypertension (IH) can complicate cerebral venous thrombosis (CVT), potentially causing permanent visual loss. Current knowledge on risk factors for the development of IH following CVT is scarce. We applied a compound classifier (CSF opening pressure > 25 cmH₂O, papilledema, or optic disc protrusion on MRI) as a surrogate for IH and studied the predictive value of thrombus location, the number of thrombosed segments, and thrombus volume.

METHODS

We prospectively included 26 patients with acute CVT and complete MRI data. IH was defined by CSF opening pressure > 25 cmH₂O, papilledema, or optic disc protrusion on MRI. Using high-resolution contrast-enhanced venography, we determined the thrombus location, number of thrombosed segments, and thrombus volume. We analyzed their association with IH by logistic regression, their predictive power by the area under the receiver operating characteristic curve, and their association with CSF opening pressure by linear regression.

RESULTS

IH occurred in 46% of CVT patients and was associated with higher thrombus volume (AUC 0.759, p = 0.025) and superior sagittal sinus thrombosis both alone (OR 2.086, p = 0.049) and combined with transverse sinus thrombosis (OR 2.014, p = 0.028). Effects in patients presenting CSF opening pressure > 25 cm H₂O and the compound classifier were consistent. Thrombus volume > 4 ml was the single most important predictor of higher CSF opening pressure (ß = 0.566, p = 0.035), increasing IH risk.

CONCLUSION

Larger thrombus volume, dominant transverse sinus occlusion, and extensive superior sagittal combined with transverse sinus thrombosis were associated with IH. Thrombus volumetry might identify patients at risk for IH and direct further clinical evaluation.

Age of onset of cerebral venous thrombosis: the BEAST study

Background

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke in young adults. We aimed to determine the impact of age, gender and risk factors (including sex-specific) on CVT onset.

Methods

We used data from the BEAST (Biorepository to Establish the Aetiology of Sinovenous Thrombosis), a multicentre multinational prospective observational study on CVT. Composite factors analysis (CFA) was performed to determine the impact on the age of CVT onset in males and females.

Results

A total of 1309 CVT patients (75.3% females) aged ⩾18 years were recruited. The overall median (IQR-interquartile range) age for males and females was 46 (35-58) years and 37 (28-47) years (p < 0.001), respectively. However, the presence of antibiotic-requiring sepsis (p = 0.03, 95% CI 27-47 years) among males and gender-specific risk factors like pregnancy (p < 0.001, 95% CI 29-34 years), puerperium (p < 0.001, 95% CI 26-34 years) and oral contraceptive use (p < 0.001, 95% CI 33-36 years) were significantly associated with earlier onset of CVT among females. CFA demonstrated a significantly earlier onset of CVT in females, ~12 years younger, in those with multiple (⩾1) compared to '0' risk factors (p < 0.001, 95% CI 32-35 years).

Conclusions

Women suffer CVT 9 years earlier in comparison to men. Female patients with multiple (⩾1) risk factors suffer CVT ~12 years earlier compared to those with no identifiable risk factors.

Spectrum of Serious Neurological and Psychiatric Adverse Events in Indian COVID-19 Vaccine Recipients: A Systematic Review of Case Reports and Case Series

Indian data regarding serious neurological and psychiatric adverse events, following coronavirus disease 2019 (COVID-19) vaccination, are lacking. We, therefore, systematically evaluated cases of post-vaccinal serious neurological and psychiatric adverse reactions published from India. A systematic review of cases published from India, which were archived in PubMed, Scopus, and Google Scholar databases, was performed; pre-print databases along with ahead-of-print contents were searched in addition. Retrieved articles, as on June 27, 2022, were evaluated following PRISMA guidelines. EndNote 20 web tool was used to make a PRISMA flow chart. Individual patients' data were compiled in a tabular form. The protocol of the systematic review was registered with PROSPERO (CRD42022324183). A total of 64 records describing 136 instances of serious neurological and psychiatric adverse events were identified. More than 50% (36/64) reports were from the following four states, namely, Kerala, Uttar Pradesh, New Delhi, and West Bengal. The mean age of persons developing these complications was 44.89 ± 15.77 years. In the majority, adverse events occurred within 2 weeks of administration of the first dose of COVISHIELD vaccine. Immune-mediated central nervous system (CNS) disorders were identified in 54 instances. Guillain-Barre syndrome and other immune-mediated peripheral neuropathies were reported in 21 cases. Post-vaccinal herpes zoster was recorded in 31 vaccine recipients. Psychiatric adverse events were recorded in six patients. In Indian recipients of COVID-19 vaccine, a variety of serious neurological complications were reported. The overall risk appears minuscule. Immune-mediated central and peripheral neuronal demyelinations were the most frequently reported post-vaccinal adverse events. A large number of cases of herpes zoster have also been reported. Immune-mediated disorders responded well to immunotherapy.

Clinical characteristics of cerebral venous sinus thrombosis patients with new-onset of headache

OBJECTIVE

This study aimed to assess the clinical characteristics of cerebral venous sinus thrombosis (CVT) patients with new-onset headache and to identify the risk factors for headache in this population.

METHODS

We retrospectively reviewed the demographic and clinical data of 69 CVT patients recruited between September 2017 and September 2019. Patients were classified into two groups, the headache group and the non-headache group, according to the presence or absence of new-onset headache symptoms at admission. The following characteristics and parameters were measured and analyzed, including gender, age, amount of thromboembolic cerebral venous sinus(ATCVS), and other relevant indicators.

RESULTS

The incidence of headache was 75% in this cohort. The proportion of female patients in the headache group was higher than that in the non-headache group. Patients in the headache group were younger than those without headache. CVT patients of headache group showed higher lymphocyte ratio (LR), blood urea nitrogen (BUN), and intracranial pressure (ICP) compared to the non-headache group, whereas mean corpuscular volume (MCV) and levels of protein (cerebrospinal fluid, CSF) and lactic dehydrogenase (LDH) in CSF were lower in headache patients. The data also revealed younger age and the increased level of chloride ion CI-(CSF) were the risk factors for the occurrence of headache in CVT patients.

CONCLUSION

Age, LR, MCV, BUN levels, ICP, protein (CSF), and LDH (CSF) in patients with headache were significantly different from those in the non-headache group at admission. Younger age and a level of CI- (CSF) were risk factors for headache in CVT patients. These findings may provide guidance for clinical diagnosis and treatment of CVT.

Detection of cerebral cortical vein thrombosis with high-resolution susceptibility weighted imaging - A comparison with MR venography and standard MR sequences

PURPOSE

Comparison of the performance of high-resolution susceptibility weighted imaging with standard MR sequences and MR venography to identify cortical vein clots.

METHODS

A retrospective review of 51 consecutive cases of cerebral venous thrombosis and 27 controls was performed with independent analysis of all MR sequences. Reference standard was obtained with consensus in a separate session by reviewing all MR sequences together.

RESULTS

Cortical vein clots were observed in 30 cases including 9 males and 21 females in the age range of 1 month to 70 years (Mean 34.9 ± 20.2 years). Sensitivity, specificity, negative predictive value, positive predictive value and accuracy of susceptibility weighted imaging for the identification of cortical vein clots were 0.93, 1.0, 1.0, 0.96 and 0.97 respectively. For all other sequences, sensitivity ranged from 0.06 to 0.39 and accuracy from 0.60 to 0.73. Combination of all sequences yielded a value of 1.0 for sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the detection of cortical vein clots. Significant result for area under the receiver operating curve was observed only for SWI with a value of 0.91 (p - .000).

CONCLUSION

Susceptibility weighted imaging demonstrates the best sensitivity and accuracy among standard MR sequences including MR venography for the detection of early stage cortical vein clots. However, it needs to be interpreted in combination with other MR sequences for the most accurate evaluation of cortical vein clots.

Cerebral venous thrombosis secondary to ulcerative colitis: A case report with a literature review

Ulcerative colitis is an idiopathic inflammatory bowel condition that may be worsened by thromboembolic events such deep vein thrombosis, cerebral venous thrombosis, and pulmonary embolism. Cerebral venous thrombosis is a rare but critical consequence of ulcerative colitis characterized by high mortality and morbidity rate. It is thought to be caused by the hypercoagulable state that occurs during ulcerative colitis relapse. Cerebral venous thrombosis is a reversible condition with good outcomes when detected early and treated properly. In this study, we describe the case of a young woman who presented with cerebral venous thrombosis secondary to ulcerative colitis complicated by venous infarction with petechial cerebral hemorrhage.

Cerebral venous thrombosis following an immunoglobulin-E mediated anaphylactic reaction

BACKGROUND

Prothrombotic and pro-inflammatory states are known cerebral venous thrombosis risk factors. To date, two cases of venous thrombotic events after immunoglobulin-E mediated anaphylaxis have been reported. Herein, we describe the first case of cerebral venous thrombosis in close temporal relation with an immunoglobulin-E mediated anaphylactic event.

CASE DESCRIPTION

A 51-year-old female presented with headache, language, and mental disturbance lasting for two days. Two days before the onset, she had undergone a provocative test with deflazacort to study an allergy history; after the test she developed a severe anaphylactic reaction. There were no other comorbidities, and in addition to contraceptive pill, she did not take other medications. On admission the patient was drowsy, with anomic aphasia, inattention and memory impairment. Magnetic Resonance Imaging depicted a left caudate and lenticulo-capsulo-thalamic venous infarct and thrombosis in the deep venous system. The patient was treated with anticoagulation and showed progressive improvement. Neoplastic and pro-thrombotic diseases were excluded.

CONCLUSION

The close temporal association between the anaphylactic reaction and cerebral venous thrombosis suggests that anaphylactic reaction could have been a cerebral venous thrombosis precipitating factor. Immunoglobulin-E have been suggested to have prothrombotic activity by stimulating the release of platelet activation factor, thromboxane A2 and serotonin. This case adds on to the available information on possible cerebral venous thrombosis associated conditions.

Clinical characteristics and risk factors for in-hospital death due to cerebral venous sinus thrombosis in three medical centers over a 10-year period

OBJECTIVES

We retrospectively described and analyzed clinical risk factors for in-hospital death due to cerebral venous thrombosis (CVT).

METHODS

A total of 172 CVT patients were seen over a 10-year period at three medical centers in China. Demographic and clinical characteristics, neuroimaging, treatment, and outcome data were collected and analyzed.

RESULTS

The 28-day in-hospital mortality rate was 4.1%. All seven deceased patients died of transtentorial herniation and were more likely to exhibit coma (42.86% vs. 3.64%, P = 0.003), intracranial hemorrhage (ICH; 85.71% vs. 36.36%, P = 0.013), straight sinus thrombosis (71.43% vs. 26.06%, P = 0.019), and thrombosis of the deep cerebral venous system (DVS; 28.57% vs. 3.64%, P = 0.036) than surviving patients. Multivariate analysis identified coma (odds ratio [OR], 11.17; 95% confidence interval [CI], 1.85-67.46, P = 0.009), ICH (OR, 20.47; 95% CI, 1.11-376.95, P = 0.042), and DVS thrombosis (OR, 36.16; 95% CI, 2.66-491.95, P = 0.007) as independent acute-phase mortality predictors. Thirty-six patients received endovascular treatment. The Glasgow Coma Scale score increased postoperatively compared with preoperatively (P = 0.017).

CONCLUSIONS

The main cause of 28-day in-hospital CVT-associated death was a transtentorial hernia, and patients with risk factors such as ICH, coma, and DVS thrombosis were more likely to die. Endovascular treatment may be a safe and effective treatment for severe CVT when conventional management is inadequate.

Predictors of Mortality and Functional Outcome in Pregnancy and Puerperium-Related Cerebral Venous Thrombosis

INTRODUCTION

Cerebral venous thrombosis (CVT) associated with pregnancy and puerperium has long been recognized, with poor information in terms of functional outcomes. Our objective was to analyze risk factors, clinical, imaging, and laboratory variables to predict functional outcome and death in this population.

METHODS

CVT registries from three referral centers from Pakistan, Turkey, and Mexico, recruiting prospective cases, were combined for CVT associated with pregnancy or puerperium. Datasets and variables were standardized. Demographic characteristics, presentation, risk factors, and functional outcomes in pregnancy/puerperium-related CVT were analyzed. Binary logistic regression was used to assess predictors of outcome. The main outcome was modified Rankin score >2 at 30 days and mortality at 30 days.

RESULTS

Five hundred fifty-three cases (median age 28 years [IQR 23-34]) of CVT associated with pregnancy and puerperium were included; 439 cases (79.4%) happened in the puerperium and 20.6% during pregnancy (53.5% occurred during the first trimester). Anemia (36.7%) and dehydration (22.9%) were the commonest obstetric risk factors identified. Predictors of poor outcome (mRS >2) were encephalopathy (OR 12.8, p < 0.001), cases from Mexican origin (OR 3.1, p = 0.004), fever/puerperal infection (OR 2.7, p = 0.02), and anemia (OR 2.2, p = 0.01). Cases from Mexican origin (OR 12.0, p = 0.003) and Encephalopathy (OR 7.7, p < 0.001), presented with the highest mortality association in the final adjusted model.

DISCUSSION/CONCLUSION

In CVT associated with pregnancy and puerperium, encephalopathy, fever/puerperal infection, and anemia are associated with bad functional outcomes, meanwhile encephalopathy and cases from Mexican origin with higher mortality in the acute (30-days) of CVT onset. Anemia and infection are potential reversible predictors of poor outcome that clinicians should be aware of in order to prevent poor outcomes in these patients.

Cerebral venous thrombosis in adolescence: Looking beyond the obvious

Behçet's disease (BD) is a rare systemic vasculitis with multisystemic involvement. Neurological involvement, called neuro-Behçet's disease (NBD), mostly involves the central nervous system and cerebral venous thrombosis (CVT) is the predominant neurological manifestation in the pediatric age. A 12-year-old female with a past medical history of a CVT, without an identifiable etiology, was admitted with a five-day right fronto-orbital headache. Neuroimage showed a subacute thrombosis of a right superficial sylvian vein, with indirect signs of intracranial hypertension and no imaging signs of vasculitis. Prothrombotic screening and immunologic study were normal. She was started on acetazolamide and hypocoagulation with progressively improving. She had a history of frequent oral aphthae and an episode of a genital ulcer three months before admission. Pathergy test was negative. HLA-B51 was positive. She was diagnosed with NBD and started therapy with colchicine and infliximab. After discharge, the patient remains without symptoms, hypocoagulated, and on infliximab regimen, without complications to report. This case, only diagnosed in the second episode of CVT, is paradigmatic of the difficulty in establishing the diagnosis of BD.

Predictors of Seizures and Associated Functional Outcome in a Cerebral Venous Thrombosis Cohort: An Ambispective Cohort Study

Background and Purpose

We aimed to explore the characteristics, clinical features, predictors of seizure, and associated clinical outcomes in patients with cerebral venous thrombosis (CVT).

Methods

We enrolled patients with CVT from January 2014 to July 2020. Prospectively patients were recruited from December 2018. We analyzed predictors of seizures and associated good functional outcomes (modified Rankin Scale, mRS: 0-2) using multivariable logistic regression.

Results

We enrolled 153 patients with CVT in which 77 (50%) had presented with a seizure. The median age was 31 years (IQR 16-46), and the majority were men (73.2%). Focal to bilateral tonic-clonic was the most common seizure type (27%), followed by generalized seizures (22%). None of the patients had status epilepticus. Antiseizure medications (ASM) were used in 71% of patients at diagnosis, 42% having received them prophylactically. Supratentorial parenchymal involvement was seen in 72% of seizure patients compared to 38% in those without, and superior sagittal sinus was most commonly involved. Percentage of patients who achieved good clinical outcome (mRS 0-2) at 3 months did not vary significantly between both groups. The only predictor for seizures with CVT was the presence of a parenchymal lesion (OR-3.75, 95% CI 1.79-7.85), whereas seizure occurrence (OR- 12.55, 95% CI- 1.53-102.59) was associated with statistically significant risk for recurrent seizures, by multiple logistic regression analysis. Seizure occurrence was not associated with adverse functional outcomes.

Conclusion

Seizures at presentation occurred in 50% of patients with CVT which was associated with a parenchymal lesion in the brain. There was no association between seizure at presentation and clinical outcome.

Cerebral Venous Thrombosis as The Sole Presenting Manifestation of Human Immunodeficiency Virus and Hepatitis B Virus Co-Infection

BACKGROUND

Cerebral venous thrombosis (CVT) following either human immunodeficiency virus (HIV) infection or hepatitis B virus (HBV) infection is a very rare condition. Moreover, it has never been reported as the presenting manifestation of HIV and HBV co-infection, even more so when the patient had a normal CD4 count and no demonstrable opportunistic infections. We aimed to report the first case of an adult Indian male, an intravenous drug abuser who developed CVT as the presenting manifestation of HIV-HBV co-infection.

METHODS

Patient data were obtained from medical records from the Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India.

RESULTS

A 25-year-old male with a history of intravenous drug abuse and a normal CD4 count developed CVT as the presenting manifestation of HIV-HBV co-infection. His CD4 count was normal, and he had no demonstrable opportunistic infections. He had an uneventful recovery of the condition (CVT) following the institution of conventional anticoagulation therapy alongside anti-retroviral therapy.

CONCLUSION

Whether illicit drug abuse or HIV/HBV infection itself or all in combination led to this thrombotic event cannot be precisely established. Notwithstanding, we recommend serologic testing for HIV and HBV in patients suffering from CVT with high-risk behavior.