Profile and Outcome of Prospective Non-Septic Lateral Sinus Thrombosis Patients from a Stroke Unit of a Developing Country.

Background: Due to effective treatment of middle ear infections there is a change in etiologies causing lateral sinus thrombosis (LST) and outcome. There is a paucity of literature describing homogenous group of patients with nonseptic LST (NS-LST). Objective: To describe the clinical profile, risk factors, outcome of patients of NS-LST seen at a single center from South India. Methods and Materials: Prospective, observational study of 100 patients of NS-LST patients, diagnosed by magnetic resonance imaging (MRI) seen at the stroke unit. Results: During 2 years, 100 patients of NS-LST (isolated: combined: 27:73) (male: female: 44:56), mean age: 31.45 ± 11.13 years, were seen. Subacute presentation (74%) with headache, seizures, focal deficits, and features of raised intracranial pressure were presenting features. Hyperhomocysteinemia (61%), anemia (57%), postpartum state (41%), OCP use (37%), and low VitB12 (32%) were commonly seen risk factors. Imaging with MRI compared withcomputerized tomography (CT) had better diagnostic sensitivity (100% vs. 67%), detection of parenchymal (81% vs. 67%)/hemorrhagic (79% vs. 74%) lesions, and cortical vein thrombosis (31% vs. 15.46%). Treatment with anticoagulation and supportive therapy resulted in good outcome (mRS (0-2)) at 3 months in 81%.There were four deaths, all during admission (one - isolated, three - combined) and 11 patients underwent decompressive surgery. Patients with low GCS level of sensoriumat admission, hemiparesis, combined LST, cerebellar involvement, and decompressive craniectomy had a poor outcome. Conclusion: This single-center large cohort study of NS-LST patients brings out the clinical features, risk factors (peculiar to developing countries), and the superiority of MRI in the diagnosis. Majority of patients have good outcome, with low mortality with 10% requiring decompressive surgery.

[Clinical analysis of 11 cases of otogenic intracranial complications treated by multidisciplinary collaboration].

Objective:To analyze the clinical diagnosis, treatment ，and surgical timing of otogenic intracranial complications. Methods:The clinical data of 11 patients with intracranial complications with ear symptoms as the first manifestation in Department of Otorhinolaryngology Head and Neck Surgery, Qilu Hospital of Shandong University（Qingdao） from December 2014 to June 2022 were collected, including 8 males and 3 females, aged from 4 to 69 years. All patients had complete otoendoscopy, audiology, imaging and etiology examination, and the diagnosis and treatment plan was jointly developed through multidisciplinary consultation according to the critical degree of clinical symptoms and imaging changes. Among the 11 patients, 5 cases were treated with intracranial lesions first in neurosurgery department and middle ear lesions later in otolaryngology, 3 cases of meningitis, were treated with middle ear surgery after intracranial infection control, 1 case was treated with middle ear lesions and intracranial infection simultaneously, and 2 cases were treated with sigmoid sinus and transverse sinus thrombosis conservatively. They were followed up for 1-6 years. Descriptive statistical methods were used for analysis. Results:All the 11 patients had ear varying symptoms, including ear pain, pus discharge and hearing loss, etc, and then fever appeared, headache, disturbance of consciousness, facial paralysis and other intracranial complication. Otoendoscopy showed perforation of the relaxation of the tympanic membrane in 5 cases, major perforation of the tension in 3 cases, neoplasia in the ear canal in 1 case, bulging of the tympanic membrane in 1 case, and turbidity of the tympanic membrane in 1 case. There were 4 cases of conductive hearing loss, 4 cases of mixed hearing loss and 3 cases of total deafness. Imaging examination showed cholesteatoma of the middle ear complicated with temporal lobe brain abscess in 4 cases, cerebellar abscess in 2 cases, cholesteatoma of the middle ear complicated with intracranial infection in 3 cases, and sigmoid sinus thrombophlebitis in 2 cases. In the etiological examination, 2 cases of Streptococcus pneumoniae were cultured in the pus of brain abscess and cerebrospinal fluid, and 1 case was cultured in streptococcus vestibularis, Bacteroides uniformis and Proteus mirabilis respectively. During the follow-up, 1 patient died of cardiovascular disease 3 years after discharge, and the remaining 10 patients survived. There was no recurrence of intracranial and middle ear lesions. Sigmoid sinus and transverse sinus thrombosis were significantly improved. Conclusion:Brain abscess, intracranial infection and thrombophlebitis are the most common otogenic intracranial complications, and cholesteatoma of middle ear is the most common primary disease. Timely diagnosis, multidisciplinary collaboration, accurate grasp of the timing in the treatment of primary focal and complications have improved the cure rate of the disease.

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.

Differentiation of transverse sinus thrombosis from congenitally atretic transverse sinus with time-resolved contrast-enhanced magnetic resonance angiography.

AIM: To establish the value of time-resolved contrast-enhanced magnetic resonance angiography (TR-MRA) in identifying transverse sinus (TS) thrombosis in patients with a unilaterally absent TS signal on phase-contrast (PC) magnetic resonance venography (MRV). MATERIALS AND METHODS: Forty-five patients who were suspected of TS thrombosis clinically with a unilaterally absent TS signal on PC MRV were evaluated using TR-MRA. The image quality was compared between PC MRV and TR-MRA via calculating signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) of the normal TS. Images obtained by PC MRV and TR-MRA were assessed independently by two neuroradiologists regarding whether the absent signal was thrombosis or hypoplastic TS. Then a consultant neurologist made the final diagnosis based on all available clinical, laboratory, and radiological results (delivered by a consultant neuroradiologist via computed tomography [CT]/CT venography, magnetic resonance imaging [MRI]/MRV or digital subtraction angiography [DSA]), which was set as the reference standard. The accuracy of the radiological diagnosis from both techniques was assessed. RESULTS: For image quality, the SNRs and CNRs of TR-MRA were 452.14 and 440.92, respectively, significantly higher than that of PC MRV (both p<0.001). The interobserver agreement of TR-MRA in identifying TS thrombosis from hypoplastic TS was excellent (κ = 0.951; 95% confidence interval [CI], 0.902-1), much higher than PC MRV (κ = 0.526; 95% CI, 0.389-0.663). Consensus of assessment based on TR-MRA was highly consistent with the reference standard (100% sensitivity, 96.67% specificity) and superior to PC MRV (60% sensitivity, 90% specificity). CONCLUSION: TR-MRA is better than PC MRV for visualising TS and distinguishing thrombosis from congenitally atretic TS.

Transvenous Embolization with Ethylene Vinyl Alcohol and Arterial Flow Control of a Dural Arteriovenous Fistula of the Isolated Transverse Sinus.

Dural arteriovenous fistulas draining into an isolated sinus often require a multimodal treatment, with transarterial and transvenous approaches.1-6 However, there is no consensus about the injection technique. Some authors suggest filling the sinus with coils in order to have a compact cast without unnecessary migration of the embolic material. We present a case of a patient with left temporal hemorrhage caused by a dural arteriovenous fistula on the isolated left transverse sinus. In this operative video we demonstrate how the arterial flow control during treatment allows us to obtain a compact cast of the embolic material inside the isolated sinus without coils (Video 1).

IgG4-related pachymeningitis and mastoiditis, associated with cerebral venous thrombosis: A case report.

IgG4-related disease (IgG4-RD) is a multisystem fibroinflammatory condition; this can be a challenging diagnosis that requires clinico-pathologic correlation. We report a young woman, presenting with cranial nerve palsy. The work-up revealed pachymeningitis, cerebral venous thrombosis (CVT), and a destructive lesion in the mastoid. We diagnosed IgG4-RD through mastoidectomy. Thus, a biopsy of asymptomatic, infrequently affected organs, like the mastoid, can meet all histopathological criteria. In neuro-meningeal presentations, CVT may be secondary to the local inflammatory environment of pachymeningitis. Since our patient had a deep vein thrombosis one year prior, we discuss a possible higher risk of thrombosis in IgG4-RD patients.

Surgical corridors for congenital aural atresia with otogenic cerebellar abscess and lateral sinus thrombosis.

The following is a case report of an adolescent with mental retardation who had congenital aural atresia with contralateral congenital facial palsy. She developed multiple intracranial complications (cerebellar abscess and lateral sinus thrombosis) due to cholesteatoma. We managed her in a multidisciplinary approach. This report discusses case management, emphasising the meticulous intraoperative steps taken in identifying the landmarks and precautions adopted to avoid postoperative facial palsy and other complications.

Clinical characteristics of otogenic lateral sinus thrombosis in patients under 18 years old compared with that in adult patients.

BACKGROUND: Otogenic lateral sinus thrombosis (OLST) is a rare complication of otitis media. We do not know whether the disease progress between the pediatric and adult OLST patients is consistent. However, pediatric surgical methods always refer to the adults'. AIMS/OBJECTIVES: This study aimed to seek evidence for suitable surgical methods in pediatric patients. MATERIALS AND METHODS: The clinical manifestation, laboratory findings, and findings in operation between children and adult groups were compared. RESULTS: Ten children and 17 adults OLST patients were included. Most pediatric patients had no history of chronic otitis media or cholesteatoma (p<.001). The ratios of otorrhea, tympanic perforation and sclerotic type mastoid in CT scan were significantly lower in the children group (p<.05). The mean air conduction hearing threshold in the children and adolescent group (31.25 ± 21.27 dB) was significantly lower than that of the adult group (77.6 ± 23.66 dB) (p<.001). The diseases in attics (66.7%) and the ossicular chain destruction (33.3%) were not as severe as those in the adult group (p<.05). The eustachian tube closure was found similar in two groups. CONCLUSIONS AND SIGNIFICANCE: Conservative surgery is recommended to pediatric OLST to obliterate the diseases and improve middle ear and mastoid drainage, preserving hearing function.

Does measurement of the jugular foramen diameter on MRI help to differentiate transverse sinus thrombosis from unilateral transverse sinus hypoplasia?

BACKGROUND AND PURPOSE: The transverse sinus (TS) is a frequent location of cerebral venous thrombosis. However, unilateral TS hypoplasia is a frequent variation and radiological imaging pitfall in the diagnosis because it may mimic unilateral TS thrombosis. The purpose of this study is to find a cutoff value for bilateral jugular foramen (JF) diameter ratios on magnetic resonance imaging (MRI) for differentiating TS thrombosis from TS hypoplasia. MATERIALS AND METHODS: We retrospectively reviewed magnetic resonance venography results for 174 patients with reduced unilateral TS caliber resulting from either unilateral thrombosis (80 patients) or unilateral hypoplasia (94 patients). We calculated the ratio by proportioning the diameter of the JF ipsilateral to the TS with caliber reduction to the diameter of the contralateral JF. The Mann-Whitney U test was used to compare the ratios between thrombosis and hypoplasia groups, and the cutoff value was calculated by receiver-operating characteristic curve analysis. RESULTS: The ratio of bilateral JF diameters was lower in patients with hypoplasia than those with thrombosis (P < .01). The cutoff value to determine the diagnosis of TS hypoplasia with maximum accuracy was 0.638, with a sensitivity of 91.3% and specificity of 64.9%. CONCLUSION: In equivocal cases, calculating the cutoff value by proportioning the diameter of JF ipsilateral to the TS with caliber reduction to the contralateral JF seems to be an efficient, quick, and straightforward method and valuable aid to differentiate TS thrombosis from TS hypoplasia.

Otogenic Lateral Sinovenous Thrombosis in Children: A Case Series from a Single Centre and Narrative Review.

AIM: We aimed to describe otogenic lateral sinovenous thrombosis (OLST), a rare, potentially life-threatening complication of otomastoiditis. METHODS: Children diagnosed with OLST in a tertiary-care Hospital from 2014 to 2019 was retrospectively selected. Clinical and radiological features, timing of diagnosis, treatment and outcome are reported. RESULTS: Seven children (5 males) were studied. Fever and neurological symptoms (headache, lethargy, diplopia, dizziness and papilledema) were always present. Otalgia and/or otorrhea were found in 6 children; none had signs of mastoiditis. Diagnosis was reached after 7 days (median) from clinical onset. Brain CT-scan was performed in 5 children being diagnostic for 3. Venography-MRI detected OLST and mastoiditis in all cases without parenchymal lesions. Treatment was based on intravenous rehydration, antibiotic and low-molecular weight heparin; acetazolamide was added in 3 children. Mastoidectomy and ventriculoperitoneal-shunting were selectively performed. Patients were discharged after 26 days (median). Follow-up neuroimaging showed sinus recanalization after a median time of 6 months. CONCLUSION: A multidisciplinary approach is needed to optimize diagnostic-therapeutic protocols of pediatric OLST.

Pediatric otitic hydrocephalus: Report of two unusual cases and literature review.

Otitic hydrocephalus (OH) comprises a form of benign intracranial hypertension, which is secondary to otogenic lateral sinus thrombosis (LST). Only a small percentage of the patients with otogenic LST go into developing OH, and this may be associated with the multiplicity of anatomic variations of the cerebral venous drainage pathways. We present two pediatric cases of OH, along with a comprehensive review of the relevant literature. Both cases discussed in this article had concomitantly a rather rare anatomical variation; a high-riding, dehiscent jugular bulb, which might have played a role in the development of their clinical syndrome. The pediatric population with this particular imaging finding should receive special attention. Clinical implications of this concurrence are fitly discussed.

Unilateral Nonvisualization of a Transverse Dural Sinus on Phase-Contrast MRV: Frequency and Differentiation from Sinus Thrombosis on Noncontrast MRI.

BACKGROUND AND PURPOSE: Unilateral decreased/nonvisualization of a transverse dural sinus on MRV poses a diagnostic dilemma when gadolinium administration is contraindicated. We determined the frequency of unilateral decreased/nonvisualization of the transverse dural sinus and the performance of pregadolinium MR imaging sequences in diagnosing transverse sinus thrombosis in the presence of unilateral decreased/nonvisualization on phase-contrast MRV. MATERIALS AND METHODS: We conducted a retrospective review of consecutive 3D phase-contrast MRV (VENC, 30 cm/s) and routine brain imaging (noncontrast sagittal T1, axial T2, FLAIR, DWI, GRE, and postgadolinium 3D-MPRAGE images) performed during a 3-year period for a total of 208 patients. Nonvisualization of a transverse dural sinus was defined as ≥50% nonvisualization of the transverse sinus caliber versus the contralateral side on MRV. Noncontrast imaging findings were considered abnormal when hyperintense signal was present on T2, FLAIR, T1, and DWI, and there were T2* blooming artifacts on GRE and DWI. Postgadolinium 3D-MPRAGE was used to confirm the diagnosis of transverse sinus thrombosis. RESULTS: Nonvisualization of a transverse dural sinus was observed in 72/208 (34.6%) patients on MRV; 56/72 (77.8%) were without transverse sinus thrombosis, and 16/72 (22.2%) patients had transverse dural sinus thrombosis. Nonvisualization of a transverse dural sinus was seen in 56/192 (29.2%) patients without transverse sinus thrombosis and 16/16 (100%) with transverse sinus thrombosis. Abnormal findings on DWI (transverse sinus hyperintense signal or T2* blooming artifact) are 93.8% sensitive and 100.0% specific for transverse sinus thrombosis. Other noncontrast MR imaging sequences ranged from 56.3%-68.8% sensitive and 91.1%-100.0% specific. CONCLUSIONS: Nonvisualization of a transverse dural sinus is a frequent phenomenon on phase-contrast MRV. DWI can be effectively used to exclude sinus thrombosis when nonvisualization of a transverse dural sinus is a diagnostic conundrum on phase-contrast MRV and contrast-enhanced studies are contraindicated.

Surgical management of raised intracranial pressure secondary to otogenic infection and venous sinus thrombosis.

PURPOSE: This study reviews paediatric patients with raised intracranial pressure as a result of venous sinus thrombosis secondary to otogenic mastoiditis, requiring admission to the paediatric neuroscience centre at the University Hospital Wales, Cardiff. The consensus regarding the management of otogenic hydrocephalus in the published literature is inconsistent, with a trend towards conservative over surgical management. We reviewed our management of this condition over a 9-year period especially with regard to ventriculo-peritoneal (VP) shunting. METHODS: Analysis of a prospectively collected database of paediatric surgical patients was analysed and patients diagnosed with otogenic hydrocephalus from November 2010 to August 2018 were identified. Our data was compared with the published literature on this condition. RESULTS: Eleven children, 7 males and 4 females, were diagnosed with otogenic hydrocephalus over the 9-year period. Five (45.5%) required VP shunt insertion to manage their intracranial pressure and protect their vision. The remaining six patients (54.5%) were managed medically. CONCLUSIONS: When children with mastoiditis and venous sinus thrombosis progress to having symptoms or signs of raised intracranial pressure, they should ideally be managed within a neuroscience centre. Of those children, almost half will need permanent cerebrospinal fluid diversion to protect their sight.

Bilateral Transverse Sinus Thrombosis following Craniotomy and Cranial Reconstruction for Sagittal Craniosynostosis.

INTRODUCTION: Craniotomy and cranial reconstruction is the most common procedure for children older than 6 months with craniosynostosis. Dural sinus thrombosis after this surgery has not been well reported in the literature. CASE PRESENTATION: This 2-year-old child underwent a bilateral craniotomy and cranial reconstruction for sagittal craniosynostosis. He had a partial thickness tear of the wall of the right transverse sinus which was uneventfully managed. Postoperative imaging showed evidence of bilateral thrombosis of the transverse sinus with a small occipital hemorrhage. He was started on low-molecular-weight heparin. Follow-up imaging showed nonprogression of the thrombosis. Four days later, he developed pulmonary hemorrhage, had an extended period of low oxygenation and hypotension with acute respiratory distress syndrome, and had to be ventilated for a prolonged period. Follow-up MRI showed evidence of extensive bilateral cortical hypointensities possibly due to hypoxemia. At the last follow-up, he continued to be grossly neurologically impaired. CONCLUSION: Thrombosis of the dural sinuses is a very rare occurrence after an extensive craniotomy and cranial reconstruction. However, it should be considered during the postoperative period and, if diagnosed, it should be treated with anticoagulants. Avoiding a direct sinus injury during reflection of the craniotomy flap and covering the exposed sinus with moist cottonoids during the surgery is advocated to prevent sinus thrombosis.

Tentorial Venous Anatomy: Cadaveric and Radiographic Study with Discussion of Origin and Surgical Significance.

BACKGROUND: Described variations of tentorial venous anatomy impact surgical sectioning of the tentorium in skull base approaches; however, described configurations do not consistently explain postoperative complications. To understand the outcomes of 2 clinical cases we studied the tentorial venous anatomy of 2 cadavers. METHODS: The venous anatomy of the tentorium isolated in 2 uninjected fresh cadaver head specimens with preserved bridging veins was observed by transillumination before and after methylene blue injection of the dural sinuses and tentorial veins. Our findings in cadavers were applied to explain the clinical and radiologic (magnetic resonance imaging and computed tomographic venography) findings in the 2 cases presented. RESULTS: A consistent transtentorial venous system, arising from transverse and straight sinuses, communicating with supra- and infratentorial bridging veins was seen in the cadaver and patient radiography (magnetic resonance imaging and computed tomographic venography). Our first patient had a cerebellar venous infarct from compromise of the venous drainage from the adjacent brain after ligation of a temporal lobe bridging vein to the tentorium. Our second patient suffered no clinical effects from bilateral transverse sinus occlusion due to drainage through the accessory venous system within the tentorium. CONCLUSIONS: Herein, we elaborate on transtentorial venous anatomy. These veins, previously reported to obliterate in completed development of the tentorium, remain patent with consistent observed configuration. The same transtentorial venous system was observed in both cases and provided insight to their outcomes. These findings emphasize the importance of the transtentorial venous system physiologically and in surgical approaches.

Stenting of symptomatic lateral sinus thrombosis refractory to mechanical thrombectomy.

OBJECTIVE: Endovascular mechanical thrombectomy for the treatment of cerebral venous sinus thrombosis is not always successful. We present our experience of using self-expanding stents to facilitate effective recanalization of persistent lateral sinus thrombosis refractory to endovascular mechanical thrombectomy. METHODS: Data from patients who underwent endovascular mechanical thrombectomy for the treatment of acute symptomatic cerebral venous sinus thrombosis between August 2015 and July 2018 were evaluated. Patient demographics, procedural techniques, devices used and follow-up outcomes were assessed. RESULTS: A total of 14 patients underwent endovascular mechanical thrombectomy during the study period. Of these, stenting of the occluded sinus was performed in five patients with extensive sinus thrombosis after conventional endovascular mechanical thrombectomy. Three of the five patients had a variable degree of venous infarction and/or hemorrhage before treatment. The target lesion was located in the right lateral sinus in all five patients. Due to the length of the involved sinus, two stents were required in one patient and three stents in two patients. The only procedure-related complication was an asymptomatic tearing of the sinus wall in one patient. Stent patency could not be maintained in two patients due to stent buckling within the jugular foramen segment and an inability to maintain antiplatelet medication. Modified Rankin Scale scores at 2-16 months were zero in two patients, one in two patients, and five in one patient. CONCLUSIONS: Stenting for the thrombotic occlusion of the lateral sinus is a feasible rescue method to overcome unsuccessful endovascular mechanical thrombectomy. However, currently available stenting systems may be unsuitable for use in the intracranial dural sinus system.