Cerebral Venous Thrombosis Presenting as Simultaneous Intracerebral Hemorrhage

A 37-year-old pregnant woman presented to the emergency department with central facial palsy, ipsilateral right hemiparesis, and seizures. Brain Computed Tomogram (CT) showed intracerebral hemorrhage (ICH) and bilateral frontal edema. Magnetic resonance imaging (MRI) revealed multifocal hemorrhages consistent with a diagnosis of multiple simultaneous ICH (MSICH) (Figure 1). We suspected cerebral venous thrombosis (CVT) and performed a MR angiogram confirming this diagnosis (Figure 2). Upon admission, the patient was treated with low-molecular-weight heparin and transitioned to direct oral anticoagulation at discharge. Non traumatic MSICH is a rare imaging finding with high mortality, usually arterial in origin (1). However, since treatment options vary, cerebral venous thrombosis should always be considered in the differential diagnosis, especially in young female patients with known risk factors, such as pregnancy and puerperium (2-4). MRI modalities (Echo-GRE) are valuable tools in identifying ICH when CT is inconclusive (5).

Trends in cerebral venous thrombosis before and during the COVID-19 pandemic: Analysis of the National Inpatient Sample

OBJECTIVES

We sought to provide updated incidence and trend data for cerebral venous thrombosis (CVT) in the United States from 2016-2020, examine the impact of the COVID-19 pandemic on CVT, and identify predictors of in-hospital mortality.

MATERIALS AND METHODS

Validated ICD-10 codes were used to identify discharges with CVT in the National Inpatient Sample (NIS). Sample weights were applied to generate nationally representative estimates, and census data were used to compute incidence rates. The first wave of the COVID-19 pandemic was defined as January-May 2020. Trend analysis was completed using Joinpoint regression.

RESULTS

From 2016 to 2020, the incidence of CVT increased from 24.34 per 1,000,000 population per year (MPY) to 33.63 per MPY (Annual Percentage Change (APC) 8.6 %; p < 0.001). All-cause in-hospital mortality was 4.9 % [95 % CI 4.5-5.4]. On multivariable analysis, use of thrombectomy, increased age, atrial fibrillation, stroke diagnosis, infection, presence of prothrombotic hematologic conditions, lowest quartile of income, intracranial hemorrhage, and male sex were associated with in-hospital mortality. CVT incidence was similar comparing the first 5 months of 2020 and 2019 (31.37 vs 32.04; p = 0.322) with no difference in median NIHSS (2 [IQR 1-10] vs. 2 [1-9]; p = 0.959) or mortality (4.2 % vs. 5.6 %; p = 0.176).

CONCLUSIONS

CVT incidence increased in the US from 2016 to 2020 while mortality did not change. Increased age, prothrombotic state, stroke diagnosis, infection, atrial fibrillation, male sex, lowest quartile of income, intracranial hemorrhage, and use of thrombectomy were associated with in-hospital mortality following CVT. During the first wave of the COVID-19 pandemic, CVT volumes and mortality were similar to the prior year.

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.

Homonymous hemianopia due to cerebral venous thrombosis: A case report

RATIONALE

Diagnosing cerebral venous thrombosis (CVT) can be difficult because of nonspecific symptoms, such as headache and homonymous hemianopia (HH). Herein, we present a case of delayed CVT diagnosis due to nonspecific neurological symptoms and nonprominent lesions in a patient with HH.

PATIENT CONCERN

A 65-year-old woman presented with a sudden onset headache accompanied by right HH that lasted for 1 day. Brain computed tomography and magnetic resonance imaging were initially performed due to suspicion of ischemic lesions or hemorrhage in the left postchiasmal visual pathway; however, no remarkable acute brain lesions were detected. Ophthalmological examinations revealed no notable findings, except for a definite field defect in the Humphrey visual field test. The headaches then waxed and waned but recurred 3 days after the initial symptom.A repeat brain magnetic resonance imaging was performed, which revealed left sectoral gyral swelling and vascular enhancement in the occipital lobe. To further evaluate venous drainage, additional 3-dimensional cerebral computed tomography angiography and 4-vessel angiography were conducted, revealing a partial filling defect in the left transverse sinus and superior venous drainage impairment. These findings suggested the presence of venous thrombosis in the left transverse sinus.

DIAGNOSIS

The patient was diagnosed with thrombosis of the left transverse sinus, which subsequently caused the right HH.

INTERVENTION

Anticoagulation therapy with parenteral heparin was started as soon as the diagnosis of CVT was confirmed. Eventually, the patient was solely managed with oral warfarin administration.

OUTCOMES

Following 3 days of treatment, her headache resolved, and a subsequent visual field testing conducted 2 weeks later revealed a definite improvement in the field defect.

LESSONS

Despite its favorable prognosis, CVT can be challenging to diagnose. CVT should be considered as a differential diagnosis when diagnosing patients who present with headaches accompanied by HH without prominent brain lesions.

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.

Diagnosis and Treatment of Cerebral Venous Thrombosis

OBJECTIVE

Cerebral venous thrombosis (CVT), thrombosis of the dural sinus, cerebral veins, or both, is a rare cerebrovascular disease. Although mortality rates after CVT have declined over time, this condition can result in devastating neurologic outcomes. This article reviews the latest literature regarding CVT epidemiology, details new factors associated with the development of CVT, and describes advances in CVT treatment. It also contains a discussion of future directions in the field, including novel diagnostic imaging modalities, and potential strategies to reduce the risks associated with CVT.

LATEST DEVELOPMENTS

The incidence of CVT may be as high as 2 per 100,000 adults per year. It remains a difficult condition to diagnose given its variable clinical manifestations and the necessity of neuroimaging for confirmation. The COVID-19 pandemic has revealed a novel CVT trigger, vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as an association between COVID-19 infection and CVT. Although VITT is a very rare event, timely diagnosis and treatment of CVT due to VITT likely improves patient outcomes. Direct oral anticoagulants are currently being used to treat CVT and emerging data suggest that these agents are as safe and effective as vitamin K antagonists. The role of endovascular therapy to treat CVT, despite a recent clinical trial, remains unproven.

ESSENTIAL POINTS

The incidence of CVT has increased, outcomes have improved, and the use of direct oral anticoagulants to treat CVT represents an important advance in the clinical care of these patients. Rates of CVT as a complication of COVID-19 vaccines using adenoviral vectors are very low (<5 per million vaccine doses administered), with the benefits of COVID-19 vaccination far outweighing the risks.

SARS-CoV-2 Possible Etiology of Cerebral Venous Thrombosis in a Teenager: Case Report and Review of Literature

Cerebral venous thrombosis in pediatric patient has a varied etiology. The authors present the case of a teenager who, since the debut of SARS-CoV-2 infection, has accused intermittent right side hemicrania, which has become persistent in association with nausea and vomiting since the 5th day of quarantine. She was hospitalized in the 9th day since the debut. Neuroimaging revealed extended venous cerebral thrombosis affecting the right sigmoid sinus, the transverse sinus bilaterally, the confluence of the transverse sinuses and the right internal jugular vein. The evolution was favorable under anticoagulant and symptomatic treatment. Laboratory tests excluded other etiological causes for the cerebral venous thrombosis, thus the authors consider that cerebral thrombosis is a possible complication of SARS-CoV-2 infection in teenagers.

Predictors of Recurrent Venous Thrombosis After Cerebral Venous Thrombosis: Analysis of the ACTION-CVT Study

BACKGROUND AND OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare cause of stroke carrying a nearly 4% risk of recurrence after 1 year. There are limited data on predictors of recurrent venous thrombosis in patients with CVT. In this study, we aim to identify those predictors.

METHODS

This is a secondary analysis of the ACTION-CVT study which is a multicenter international study of consecutive patients hospitalized with a diagnosis of CVT over a 6-year period. Patients with cancer-associated CVT, CVT during pregnancy, or CVT in the setting of known antiphospholipid antibody syndrome were excluded per the ACTION-CVT protocol. The study outcome was recurrent venous thrombosis defined as recurrent venous thromboembolism (VTE) or de novo CVT. We compared characteristics between patients with vs without recurrent venous thrombosis during follow-up and performed adjusted Cox regression analyses to determine important predictors of recurrent venous thrombosis.

RESULTS

Nine hundred forty-seven patients were included with a mean age of 45.2 years, 63.9% were women, and 83.6% had at least 3 months of follow-up. During a median follow-up of 308 (interquartile range 120-700) days, there were 5.05 recurrent venous thromboses (37 VTE and 24 de novo CVT) per 100 patient-years. Predictors of recurrent venous thrombosis were Black race (adjusted hazard ratio [aHR] 2.13, 95% CI 1.14-3.98, p = 0.018), history of VTE (aHR 3.40, 95% CI 1.80-6.42, p < 0.001), and the presence of one or more positive antiphospholipid antibodies (aHR 3.85, 95% CI 1.97-7.50, p < 0.001). Sensitivity analyses including events only occurring on oral anticoagulation yielded similar findings.

DISCUSSION

Black race, history of VTE, and the presence of one or more antiphospholipid antibodies are associated with recurrent venous thrombosis among patients with CVT. Future studies are needed to validate our findings to better understand mechanisms and treatment strategies in patients with CVT.

Clinical outcomes of first-pass effect after mechanical thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

OBJECTIVE

The first-pass effect (FPE) during a mechanical thrombectomy for ischemic stroke results in favorable clinical outcomes and low symptomatic intracranial hemorrhage (sICH) rates according to individual observational studies. We performed an integrated study-level meta-analysis to compare the clinical outcomes and safety profiles of single (FPE group) and multiple passages (non-FPE group) of devices in patients who achieved successful recanalizations.

METHODS

A literature search of the PubMed, Embase, and Cochrane databases for FPE was conducted. We included studies comparing outcomes between patients with and without FPE for 90-day favorable outcome, mortality, and sICH. The results from the pooled analysis using the random-effects model were presented as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Of the 8 selected studies comprising 2308 patients, the overall rates of the FPE were 40.3% (930/2308). The FPE was significantly associated with more 90-day favorable outcomes (OR: 1.31, 95% CI: 1.13-1.51) and lower mortality (OR: 0.53, 95% CI: 0.34-0.81), but there were no significant differences in sICH rates (OR: 0.80, 95% CI: 0.50-1.30). The results of the meta-regression analysis showed that there was no confounding effect of intravenous thrombolysis prior to thrombectomy.

CONCLUSION

Our findings indicated that patients who achieved the FPE would have more 90-day favorable outcomes and lower mortality compared with non-FPE patients. However, there was a limited association between the FPE and reduced sICH rates.

Atrial Fibrillation Treatment Adequacy and Outcome after Endovascular Thrombectomy

BACKGROUND

Atrial fibrillation (AF) often leads to large vessel occlusions (LVO) which may necessitate endovascular thrombectomy (EVT). Whether the adequacy of treatment with oral anticoagulants (OAC) prior to LVO modifies outcomes remains unknown.

PATIENTS AND METHODS

Consecutive EVT-treated LVO patients were recruited and the data was analyzed retrospectively. We combined patients with known AF that were untreated with OAC or inadequately treated with those with new-onset AF to form a group of undertreated-AF patients and compared them to adequately treated AF patients.

RESULTS

Of the 230 patients included, 109 (47%) had AF (86 known AF, 23 new-onset AF). AF patients were significantly older and more often reached favorable recanalization but less often had favorable outcomes compared to those without AF. Most patients with known AF (76%) were inadequately treated at stroke onset. Patients with undertreated-AF more often received tPA prior to EVT (26% vs. 4% p=0.009), more often had favorable collaterals (65% vs. 33% p<0.001) and more often reached favorable outcomes (28% vs. 9%, p=0.047) compared to adequately treated AF patients. On multivariate analyses adequately treated AF did not impact survival (Odds Ration [OR] 0.89 95% Confidence Interval [CI] 0.23-3.43), chances for favorable recanalization (OR 0.57 95%CI 0.15-2.13) or favorable outcome (OR 5.95 95%CI 0.62-57.39).

CONCLUSIONS

Treatment adequacy does not affect the rates of favorable functional outcome or survival in AF patients with LVO.

Anticoagulation delay does not affect the functional outcome of cerebral venous thrombosis

Available knowledge about the impact of anticoagulation delay on outcomes of patients with cerebral venous thrombosis (CVT) is limited. We therefore assessed the factors influencing anticoagulation delay and investigated the effect of this delay on outcomes of CVT patients. Anticoagulation delay was defined as the time interval between symptom onset and anticoagulation initiation. The primary outcome was a modified Rankin Scale (mRS) score > 2 at the final follow-up. A total of 164 eligible patients were included. The median anticoagulation delay was 9 days. Cerebral hemorrhage on admission neuroimaging correlated with earlier anticoagulation (p = 0.040). Anticoagulation delay was not associated with poor functional outcome (mRS > 2), but it was associated with residual headache across the entire cohort (earlier anticoagulation: 15/76 [19.7%] vs. later anticoagulation: 28/79 [35.4%]; p = 0.029) and in the subgroup with isolated intracranial hypertension (earlier anticoagulation: 4/25 [16.0%] vs. later anticoagulation: 14/27 [51.9%]; p = 0.007). Anticoagulation delay was found to be common among patients with CVT. Anticoagulation delay was not associated with poor functional outcome, but may have led to an increased risk of residual headache across our entire cohort and in the subgroup with isolated intracranial hypertension.

Behcet's Disease Presenting With Life Threatening Manifestation Of Cerebral Venous Thrombosis

Behcet's disease (BD) presents as uncommon inflammatory disorder involving multiple systems, identified by longstanding relapsing path. Its chief manifestations are oral and genital ulcers together with involvement of the eyes, skin and joints. Neurological and vascular complications are significant. We report a case of a twenty-four years old young male who presented with headache, fever, and vomiting along with decreased vision; and repeated oral and genital ulcers. Diagnosis of BD complicated with cerebral venous thrombosis (CVT) was made. He was treated with corticosteroids, immunosuppression therapy and colchicine along with anticoagulation therapy. He responded well to the given treatment. Cerebral venous thrombosis complications in with BD can lead to serious consequences. Early recognition and treatment may lessen poor outcomes.

Thrombosed Middle Meningeal Artery Aneurysms Mimicking Aneurysmal Bone Cysts in a Patient with Fibrous Dysplasia

BACKGROUND

The aneurysmal bone cyst (ABC) is a rare osteolytic lesion that is often associated with osseous disease such as fibrous dysplasia (FD).

CASE DESCRIPTION

A 66-year-old woman previously diagnosed with FD presented with suddenly reduced visual acuity. Computed tomography and magnetic resonance imaging revealed a large osteolytic lesion in the middle cranial fossa that had invaded the left orbit. Although its radiological findings were compatible with an ABC, rotational digital subtraction angiography revealed that this osteolytic lesion was a large middle meningeal artery (MMA) aneurysm. To release the compression force on the optic nerve and confirm the diagnosis, we performed endovascular embolization, followed by surgical removal of the lesion. Histologic examination revealed that the resected lesion met the requirements of a thrombosed aneurysm. No new neurologic deficits appeared after the surgery, and no symptomatic recurrence have been noted during the 6-month follow-up.

CONCLUSIONS

This is the first case report to show that ABC-like lesions in patients with FD could be thrombosed MMA aneurysms. It is thus possible that some lesions previously diagnosed as ABCs were thrombosed MMA aneurysms or included a thrombosed MMA aneurysm. It is therefore important to rule out the presence of a MMA aneurysm when we encounter what appears to be an ABC in the presence of FD.

Cerebral Venous Thrombosis due to Nontyphoidal Salmonella Bacteremia

A 19-year-old previously healthy man presented with convulsions, fever, headache, diarrhea, and vomiting. Brain magnetic resonance imaging revealed cerebral hemorrhaging in the right parietal lobe and thrombotic occlusion of the right great cerebral vein. Blood cultures were positive for nontyphoidal Salmonella. The patient was successfully treated with antibiotics and anticoagulants. Nontyphoidal Salmonella bacteremia can cause cerebral venous thrombosis and physicians therefore need to consider nontyphoidal Salmonella bacteremia as a potential cause of cerebral venous thrombosis.

Diagnosis of cerebral venous thrombosis: a single centre experience

OBJECTIVES

Cerebral venous thrombosis is a serious cerebrovascular disease. Due to the variability of clinical symptoms and the scarcity of occurrence, this diagnosis is often delayed. The aim of the study was to describe the risk factors, the initial findings and the imaging methods that lead to the diagnosis.

METHODS

We included 34 patients treated for cerebral venous thrombosis in the years 2004-2016. We retrospectively analyzed demographic data, initial clinical symptoms, baseline D-dimer levels, risk factors, time to diagnosis, and MR findings.

RESULTS

The most common initial clinical symptom was headache (28 patients, 82.4%). Focal neurological symptoms or signs of encephalopathy developed in 22 patients (64.7%). In 26 patients, we identified at least one risk factor in their history. In women of childbearing potential, 68% of patients (15/22) were taking hormonal contraceptives; in six people the diagnosis was immediately preceded by inflammation. In all patients, the diagnosis was confirmed by MR venography. Positive hereditary thrombophilic conditions were identified in 68% and acquired in 8% of 25 examined patients. In 22 cases, baseline D-dimer levels were examined and found to be increased in 86% of them. The mean time from the first onset of symptoms to diagnosis was 6.9 days.

CONCLUSION

Cerebral venous thrombosis has a variable clinical course and the diagnosis is determined a relatively long time after the onset of symptoms. Atypical headache in the patient's history and a set of risk factors are the key findings for indication of imaging methods and confirmation of the diagnosis.

[Neuro-Behçet in a Sub-Saharan Africa Country: a Series of Sixteen Patients in Fann Teaching Hospital, Dakar, Senegal]

Neuro-Behçet (NB) African studies are mainly North African, but Sub-Saharan Africa is not to be outdone. Our aim was to describe diagnostic and therapeutic features of NB in a Senegalese series collected in Dakar. This was a descriptive and retrospective study conducted at the Neurology department of Fann Teaching Hospital in Dakar, Senegal. All patients who met the NB's diagnostic criteria were included. Sixteen patients were collected, 14 males and 2 females with an average age of 40 years [18-71]. The main neurological signs were motor deficit (13 cases), headache (10 cases), and language disorders (4 cases). Extra-neurological signs were dermatological (14 cases), ocular (2 cases), and articular (2 cases) with aseptic unilateral gonarthritis. Fever was present in 9 patients. Neurological involvement was mostly isolated parenchymal (8 cases) or mixed (6 cases). The main clinical forms of NB were rhombencephalitis (8 cases) and retrobulbar optic neuritis (4 cases). Seven patients had a cerebral angio-Behçet with cerebral venous thrombosis (3 cases), ischemic stroke (2 cases), and intracerebral hematoma (2 cases). Under prednisone (16 cases) and azathioprine (3 cases), the short-term clinical outcome was mostly favorable (14 cases) with a modified Rankin scale at 2. NB is an under-diagnosed adult male disease in Sub-Saharan Africa and further studies are needed.

The ANRIL Genetic Variants and Their Interactions with Environmental Risk Factors on Atherothrombotic Stroke in a Han Chinese Population

BACKGROUND

Ischemic stroke (IS) is considered to be a heterogeneous, multifactorial disease with a strong genetic background. This study aims to determine whether variants in the antisense noncoding RNA in the INK4 locus (ANRIL) gene are associated with IS in Han Chinese, as well as whether there is evidence of a gene-environment interactions.

MATERIALS AND METHODS

A case-controlled association study was conducted in which only patients with atherothrombotic stroke (ATS) were enrolled. Multifactor dimensionality reduction model was employed to screen the best interaction combinations among gene and environmental risk factors; RESULTS: A total of 405 subjects (200 cases and 205 controls) and 16 single nucleotide polymorphisms (SNPs) in ANRIL gene were included in this study. The 4 SNPs (rs1537378, rs2184061, rs7044859, and rs7865618) were found to be significantly related to ATS in Chinese Han nationality. In overall people or subjects aged 45 years or older, the GG genotype and G allele of rs1537378, the AA genotype and A allele of rs2184061 and rs7865618, and the AA genotype of rs7044859 increased the risk of ATS. In males, the GG genotype and G allele of rs1537378, the AA genotype and A allele of rs7865618, and the A allele of rs2184061 conferred a susceptibility to ATS. Additionally, the AAAGAGCAAAAAATAG haplotype exhibited an elevated risk of ATS, and a significant interaction was found in ATS susceptibility between ANRIL gene and dyslipidemia; CONCLUSIONS: The ANRIL gene was related to ATS susceptibility in a Han Chinese. Future studies should be performed with larger samples and among different ethnic populations.

[Cerebral venous thrombosis during pregnancy]

OBJECTIVE

We present a case report of a patient with cerebral venous thrombosis during pregnancy.

DESIGN

Case report.

SETTING

Department of Gynaecology and Obstetrics at the Silesian Hospital.

METHODS

Own observation, review of literature.

CONCLUSION

In any tonic-clonic convulsions in pregnancy, we mainly think of an eclamptic attack and pregnancy must be ended. In case of persistent problems in the postpartum period after stabilization of the patients, differential etiology of convulsive states such as epileptic seizure, hypoglycemic spasms, CNS tumor, intracranial bleeding, cerebrovascular accident or cocaine overdose must be considered within the differential diagnosis.

Cancer and risk of cerebral venous thrombosis: a case-control study

Essentials The risk of cerebral venous thrombosis (CVT) in patients with cancer is not known. We performed a case-control study including 594 patients with CVT and 6278 controls. History of cancer increased the risk of CVT approximately 5-fold. The association was strongest with hematological cancer in the first year after diagnosis.

SUMMARY

Background Cancer is an established risk factor for leg vein thrombosis and pulmonary embolism. Controlled studies assessing the risk of cerebral venous thrombosis (CVT) in patients with cancer have not been performed. Objective To assess whether cancer is a risk factor for CVT. Patients/Methods This was a case-control study. We assessed consecutive adult patients with CVT from three academic hospitals from 1987 to 2015, and control subjects from the Dutch MEGA study (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis). We adjusted for age, sex and oral contraceptive use, and stratified for type of cancer and time since diagnosis of cancer. Results We included 594 cases and 6278 controls. In total, 53 cases (8.9%) and 160 controls (2.5%) had a history of cancer. Cases were younger (median 42 vs. 48 years), more often female (68% vs. 54%) and more often used oral contraceptives (55% vs. 23%) than controls. The risk of CVT was increased in patients with cancer compared with those without cancer (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 3.46-6.81). Patients with a hematological type of cancer had a higher risk of CVT (aOR, 25.14; 95% CI, 11.64-54.30) than those with a solid type of cancer (aOR, 3.07; 95% CI, 2.03-4.65). The association was strongest in the first year after diagnosis of cancer (hematological aOR, 85.57; 95% CI, 19.70-371.69; solid aOR, 10.50; 95% CI, 5.40-20.42). Conclusions Our study indicates that cancer is a strong risk factor for CVT, particularly within the first year of diagnosis and in patients with a hematological type of cancer.

Severe Cerebral Venous and Sinus Thrombosis: Clinical Course, Imaging Correlates, and Prognosis

BACKGROUND

Severe cerebral venous-sinus thrombosis (CVT) is a rare disease, and its clinical course, imaging correlates, as well as long-term prognosis have not yet been investigated systematically.

METHODS

Multicenter retrospective study. Inclusion criteria were CVT, Glasgow coma scale ≤9, and treatment in the intensive care unit. Primary outcome was death or dependency, assessed by a modified Rankin Score (mRS) >2 at last follow-up.

RESULTS

114 patients were included. At last follow-up (median 2.5 years), 38 patients (33.3 %) showed no or minor residual symptoms (mRS = 0 or 1), 12 (10.5 %) had a mild (mRS = 2), 13 (11.4 %) a moderate (mRS = 3), 12 (10.5 %) a severe disability (mRS = 4 or 5), and 39 (34.2 %) had died. In bivariate analysis, predictors of poor outcome were any signs of mass effect on imaging, clinical deterioration after admission, and age. In contrast, clinical symptoms on admission and parenchymal lesions per se, such as edema, infarction, or hemorrhage were not predictive. Multivariate predictors of poor outcome were an increase in National Institutes of Health Stroke Scale ≥3 after admission [odds ratio (OR) 6.7], bilateral motor signs in the further course (OR 9.2), and midline shift (OR 5.1).

CONCLUSION

The outcome of severe CVT is almost equally divided between severe impairment or death and survival with no or only mild handicap. Specifically, space-occupying mass effect and associated neurologic deterioration seem to determine a poor outcome. Therefore, early detection and treatment of mass effect should be the focus of critical care.

Plasminogen activator inhibitor links obesity and thrombotic cerebrovascular diseases: The roles of PAI-1 and obesity on stroke

One of the global socioeconomic phenomena occurred during the last decades is the increased prevalence of obesity, with direct consequence on the risk of developing thrombotic disorders. As the physiological inhibitor of tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA), plasminogen activator inhibitor-1 (PAI-1) is well known for its role in fibrinolysis. More and more evidences have shown that PAI-1 involves in physiopathologic mechanisms of many diseases and metabolic disorder. Increased serum level of PAI-1 has been observed in obesity and it also contributes to the development of adipose tissue and then has effects on obesity. Meantime, obesity affects also the PAI-1 levels. These evidences indicate the complicated interaction between PAI-1 and obesity. Many clinic studies have confirmed that obesity relates to the stroke outcome although there are many contradictory results. Simultaneously, correlation is found between plasma PAI-1 and thrombotic cerebrovascular diseases. This article reviews contemporary knowledge regarding the complex interplay of obesity, PAI-1 and stroke.

Ten years of cerebral venous thrombosis: male gender and myeloproliferative neoplasm is associated with thrombotic recurrence in unprovoked events

Cerebral venous thrombosis (CVT) is a rare venous thrombotic event. We review our local experience in the management of CVT in comparison to other venous thromboembolism (VTE) with specific focus on risk factors for thrombotic recurrence. Retrospective evaluation of consecutive CVT presentations from January 2005 to June 2015, at two major tertiary hospitals in Northeast Melbourne, Australia. This population was compared to a separate audit of 1003 consecutive patients with DVT and PE. Fifty-two patients (30 female, 22 male) with a median age of 40 (18-83) years, presented with 53 episodes of CVT. Twenty-nine episodes (55 %) were associated with an underlying risk factor, with hormonal risk factors in females being most common. The median duration of anticoagulation was 6 months with 11 receiving life-long anticoagulation. Eighty-one percent had residual thrombosis on repeat imaging, which was not associated with recurrence at the same or distant site. Nine (17 %) had CVT-related haemorrhagic transformation with two resultant CVT-related deaths (RR 22.5; p = 0.04). All three VTE recurrences occured in males with unprovoked events (RR 18.2; p = 0.05) who were subsequently diagnosed with myeloproliferative neoplasm (MPN). Compared to the non-cancer VTE population, non-cancer CVT patients were younger, had similar rate of provoked events and VTE recurrence, although with significantly higher rate of MPN diagnosis (RR 9.30 (2.29-37.76); p = 0.002) CVT is a rare thrombotic disorder. All recurrences in this audit occurred in male patients with unprovoked events and subsequent diagnosis of MPN, suggesting further evaluation for MPN may be warranted in patients with unprovoked CVT.

The Development of Cerebral Venous Thrombosis after Tadalafil Ingestion in a Patient with Antiphospholipid Syndrome

We report a case of cerebral venous thrombosis related to the ingestion of tadalafil. A 45-year-old man presented with posterior headache and was diagnosed with tension headache. Five days later, he was transported to our hospital via ambulance due to a tonic-clonic seizure. Head MRI showed cerebral venous thrombosis (CVT). He confessed to having recently taken a large doses of tadalafil. His anti-cardiolipin antibody and anti-caldiolipin-β2-glycoprotein-I complex antibody levels were elevated. Our case suggests the possibility that tadalafil is related to both cardiovascular complications and CVT in patients with hypercoagulability. Patients with conditions associated with hypercoagulability, including antiphospholipid syndrome may be better advised to avoid the use of tadalafil.

Lupus anticoagulant-hypoprothrombinemia syndrome presenting with co-existing cerebral venous thrombosis and subdural hemorrhage

The lupus anticoagulant-hypoprothrombinemia syndrome (LA-HPS) - the association of acquired factor II deficiency and lupus anticoagulant - is a rare disease that may cause a predisposition not only to thrombosis but also to severe bleeding. We are reporting on a 36-year-old female patient presenting with co-existing cerebral venous thrombosis and subdural hemorrhage. The coagulation screening showed a prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT), and a normal fibrinogen level and platelet count. Evaluation of the clotting factors revealed decreased levels of factors II (37%). Factors V, VIII, IX and XI were normal. Lupus anticoagulant (LA) was demonstrated by the Dilute Russell's Viper Venom Test (DRVVT). Immunological work-up was positive for IgG type anticardiolipines antibodies (aCL). Successful management consisted first of oral prednisone (60mg/d). Thus, anticoagulation was introduced once factor II had stabilized.

Novel oral anticoagulants in the treatment of cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with extremely diverse clinical features, predisposing factors, brain imaging findings, and outcome. Anticoagulation is the cornerstone of CVT management, however, it is not supported by high-quality evicence. Novel oral anticoagulants (NOACs) have been extensively studied in patients with deep vein thrombosis, pulmonary embolism and non-valvular atrial fibrillation. The aim of our work was to review the available evidence for NOACs in the treatment of CVT. Based on our literature search there is insufficient evidence to support the use of NOACs in CVT, although case series with rivaroxaban and dabigatran have showed promising results.

Do we have to anticoagulate patients with cerebral venous thrombosis?

Cerebral venous thrombosis (CVT) is a rare form of venous thromboembolism (VTE). Although anticoagulation is recommended for the initial and long term treatment with regards to thrombotic risks for patients with CVT, the role of anticogalution has not been fully elucidated. The aim of our literature based review was collect articles showing the benefit of anticoagulation in CVT and gathering the data of follow-up studies focusing on the recurrence of CVT and other thrombotic events. We have identified 15 follow-up studies studies with 2422 patients. The mean duration of follow-up was 37.9 months. Death occured in 6.5% and 76.4% of the patients had favorable outcome; 85.5% received initial anticoagulation with ultrafractionated or low molecular weight heparin and 82.1% received long-term anticoagulation. Recurent CVT occured in 3.7% and other thrombotic event occured in 5.4%. The mentioned studies have led to incoclusive results with regards to the clinical outcome and the presence or absence of anticoagulation. The role of long term anticoagulation should be clarified in randomized multicentre studies as the recurrence rate seems to be low and the outcome of a second event as good as that of the first one irrespective of underlying risk factors.

Nonbacterial thrombotic endocarditis presenting as intracerebral hemorrhage

Nonbacterial thrombotic endocarditis is a rare cause of valvular heart disease, most commonly associated with advanced malignancy. The morbidity of this kind of endocarditis lies in its tendency to embolize, while the valve function is usually preserved. The central nervous system is the most common site of embolization, leading to ischemic stroke. We report a case of nonbacterial thrombotic endocarditis complicated by intracerebral hemorrhage as the first manifestation of adenocarcinoma of the lung. The endocarditis led to severe aortic regurgitation. In view of the advanced stage of lung cancer, the patient refused further therapy. He passed away 3 weeks after first diagnosis of the adenocarcinoma.

Computational modelling of clot development in patient-specific cerebral aneurysm cases

ESSENTIALS: Clotting in cerebral aneurysms is a process that can either stabilize the aneurysm or lead to rupture. A patient-specific computational model capable of predicting cerebral aneurysm thrombosis is presented. The different clotting outcomes highlight the importance of personalization of treatment. Once validated, the model can be used to tailor treatment and to clarify clotting processes in aneurysms.

BACKGROUND

In cerebral aneurysms, clotting can either stabilize the aneurysm sac via aneurysm occlusion, or it can have a detrimental effect by giving rise to embolic occlusion.

OBJECTIVE

The work presented in this study details the development of an in silico model that combines all the salient, clinically relevant features of cerebral aneurysm clotting. A comprehensive computational model of clotting that accounts for biochemical complexity coupled with three-dimensional hemodynamics in image-derived patient aneurysms and in the presence of virtually implanted interventional devices is presented.

METHODS

The model is developed and presented in two stages. First, a two-dimensional computational model of clotting is presented for an idealized geometry. This enables verification of the methods with existing, physiological data before the pathological state is considered. This model is used to compare the results predicted by two different underlying biochemical cascades. The two-dimensional model is then extended to image-derived, three-dimensional aneurysmal topologies by incorporating level set methods, demonstrating the potential use of this model.

RESULTS AND CONCLUSION

As a proof of concept, comparisons are then made between treated and untreated aneurysms. The prediction of different clotting outcomes for different patients demonstrates that with further development, refinement and validation, this methodology could be used for patient-specific interventional planning.

URGENT DIAGNOSTICS OF CEREBRAL VENOUS TROMBOSIS

Investigations were carried out in 24 patients in order to evaluate information value of the data of clinical, laboratory, neuroradiological methods of research and develop the diagnostic algorithm in case of cerebral venous thrombosis (CVT). The main group consisted of 11 patients (7 male, 4 female, average age 49,1±4,3) with CVT. The comparison group included 13 patients (6 male, 7 female; average age 68,1±9,5) with ischemic stroke (IS) of moderate severity. There were revealed changes in blood and cerebrospinal fluid (CSF) as form of leukocytosis of blood and moderately increased cell count with elevated protein in CSF and blood in case of CTV. The authors noted an elevated protein in CSF and blood and leukocytosis with predominant lymphopenia in blood and neurophilic predominance in CSF within the reference range of CSF in patient with ischemic stroke. The epileptic attacks, meningeal syndromes, headaches were more often among clinical syndromes at CTV than in case of ischemic stroke. The algorithm of neuroimaging research methods and modes of MRI were determined and allowed an effective diagnostics of damages of venous sinuses, superficial and deep cerebral veins in case of urgent hospitalization of patients. It was possible to suggest the venous pathology in 7 (63,6%) cases due to SKT (without contrast) and in case of application of MR venography (2D TOFmode), there were revealed 100% of cases.

Cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults and children. In contrast to venous thromboembolism, women are affected three times more often than men. Baseline symptoms can vary considerably between patients, but most present with headache, seizures, or focal neurological deficits. Patients can be diagnosed with magnetic resonance imaging, computerized tomography-venography, or catheter angiography, although the latter is rarely required anymore. Approximately 30-50% of patients have an intracerebral hemorrhage, which can range from a small juxtacortical hemorrhage to large space-occupying lesions. Based on limited evidence from clinical trials, the primary therapy for CVT is anticoagulation with heparin. Uncontrolled studies have shown promising results for the use of endovascular treatment in severely affected patients, but these studies require confirmation in prospective clinical trials. In patients who develop clinical and radiological signs of impending herniation decompressive surgery can be both life saving and result in a good functional outcome.

Contribution and additional impact of imaging to the SPAN-100 score

BACKGROUND AND PURPOSE

Stroke Prognostication by Using Age and NIHSS score (SPAN-100 index) facilitates stroke outcomes. We assessed imaging markers associated with the SPAN-100 index and their additional impact on outcome determination.

MATERIALS AND METHODS

Of 273 consecutive patients with acute ischemic stroke (<4.5 hours), 55 were characterized as SPAN-100-positive (age +NIHSS score ≥ 100). A comprehensive imaging review evaluated differences, using the presence of the hyperattenuated vessel sign, ASPECTS, clot burden score, collateral score, CBV, CBF, and MTT. The primary outcome assessed was favorable outcome (mRS ≤ 2). Secondary outcomes included recanalization, lack of neurologic improvement, and hemorrhagic transformation. Uni- and multivariate analyses assessed factors associated with favorable outcome. Area under the curve evaluated predictors of favorable clinical outcome.

RESULTS

Compared with the SPAN-100-negative group, the SPAN-100-positive group (55/273; 20%) demonstrated larger CBVs (<0.001), poorer collaterals (P < .001), and increased hemorrhagic transformation rates (56.0% versus 36%, P = .02) despite earlier time to rtPA (P = .03). Favorable outcome was less common among patients with SPAN-100-positive compared with SPAN-100-negative (10.9% versus 42.2%; P < .001). Multivariate regression revealed poorer outcome for SPAN-100-positive (OR = 0.17; 95% CI, 0.06-0.38; P = .001), clot burden score (OR = 1.14; 95% CI, 1.05-1.25; P < .001), and CBV (OR = 0.58; 95% CI, 0.46-0.72; P = .001). The addition of the clot burden score and CBV improved the predictive value of SPAN-100 alone for favorable outcome from 60% to 68% and 74%, respectively.

CONCLUSIONS

SPAN-100-positivity predicts a lower likelihood of favorable outcome and increased hemorrhagic transformation. CBV and clot burden score contribute to poorer outcomes among high-risk patients and improve stroke-outcome prediction.

CEREBRAL VENOUS THROMBOSIS AND TURNER SYNDROME: A RARE REPORTED ASSOCIATION

Turner Syndrome is the only known viable chromosomal monosomy, characterised by the complete or partial absence of an X chromosome. It's the most common chromosomal abnormality in females. Apart from the well known dysmorphic features of the syndrome, it has been associated with a number of vascular pathologies; mainly involving the cardiovascular, renovascular, peripheral vascular and cerebrovascular system. It seems striking that thromboembolism is not considered as a feature of the syndrome. Most of the thromboembolism cases are related to the arterial vascular system; except for some rare reported portal venous thrombosis cases, peripheral venous thrombosis cases and to the best of our knowledge a single case of cerebral venous thrombosis with Dandy Walker malformation and polymicrogyria. We herein report a cerebral venous thrombosis case with Turner Syndrome. With no other found underlying etiology, we want to highlight that Turner Syndrome, itself, may have a relationship not only with the cerebral arterial vascular system pathologies but also with the cerebral venous thrombosis.

Cerebral Vein and Sinus Thrombosis in Isfahan-Iran: A Changing Profile

Objectives:

This study was performed to investigate the clinical presentation and predisposing factors for cerebral vein and sinus thrombosis (CVST) in Isfahan, Iran.

Methods:

Data from the records of all patients with CVSTreferred to the largest tertiary-care hospital of Isfahan during a five-year period (1997 to 2001) were extracted and reviewed.

Results:

The number of cases with CVST diagnosed annually was 6, 9, 11, 14 and 15 patients, respectively. Thirteen men and 42 women were diagnosed to have CVST with the mean age of 35.1± 3.8 and 28.7±1.3 years, respectively. Headache was the most frequent complaint (95%) and 63% of patients had focal neurological symptoms, including seizure (58%). Among possible predisposing factors, oral contraceptive pill was the most prevalent one, which was used by 38.1% of affected women for a period of as short as 1-3 months. Anticardiolipin antibodies were detected in 14% of patients.

Conclusion:

It seems that the annual incidence of CVST is increasing in Isfahan, perhaps due to more extensive intake of oral contraceptive pills and usage of more accurate modern diagnostic tools. The use of oral contraceptive pills was the most frequent predisposing factor; infections and postpartum factors were infrequently observed. Despite other reports from the Middle East, Behçet's disease is not a principal risk factor for CVST in Isfahani patients.