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.

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.

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

RATIONALE: Immune thrombocytopenia (ITP) is an autoimmune disease with an increased risk of bleeding. However, in recent years, it has been reported that patients with this hemorrhagic disease have the risk of thrombosis and embolism. PATIENT CONCERNS AND DIAGNOSIS: The patient, in this case, was a young female who was diagnosed with ITP. When the platelet count was low, she had skin, mucosa, internal organs, and intracranial hemorrhage. In the process of ITP and hemostatic treatment, superior sagittal sinus thrombosis occurred when she was still bleeding. INTERVENTIONS: She was given treatments for reducing intracranial pressure and controlling epilepsy. OUTCOMES: And then the embolectomy operation failed. It was suggested in this case that ITP patients with severe thrombocytopenia and bleeding tendency also have a risk of having thrombotic disease. We reviewed literatures regarding the mechanism of the simultaneous occurrence of 2 antinomy diseases and cerebral venous thrombosis. LESSONS: There are many factors for ITP patients to have thrombosis involving ITP itself, its treatment and the patients' constitution, medical history, and former medication. ITP is not only a hemorrhagic disease but also a thrombotic disease. Clinicians should be alert to the risk of thrombotic diseases in ITP treatment. Therefore thrombus monitoring and screening should be carried out, and early prevention or appropriate anticoagulant treatment should be selected, especially for patients with high risk.

Bilateral Abducens Nerve Palsy Due to Extensive Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is a relatively rare condition. We present a case of an acute aseptic thrombosis of the sagittal, transverse and sigmoid sinus in a puerperium patient with protein S deficiency. The specifics of the case include high intracranial pressure (ICP) caused by sinus thrombosis with typical symptomatology and bilateral papilloedema, which also manifested in transient bilateral abducens nerve palsy and, consequently, bilateral horizontal diplopia. The recovery of the cranial nerve function occurred 3 to 4 weeks after it was initially reported. Prompt and adequate anticoagulant therapy contributed to the almost complete recanalization of the dural venous sinus thrombosis and a positive outcome of the disease.

Multimodal Regional Brain Monitoring of Tissue Ischemia in Severe Cerebral Venous Sinus Thrombosis.

BACKGROUND: Comatose critically ill patients with severe diffuse cerebral venous thrombosis (CVT) are at high risk of secondary hypoxic/ischemic insults, which may considerably worsen neurological recovery. Multimodal brain monitoring (MBM) may therefore improve patient care in this setting, yet no data are available in the literature. METHODS: We report two patients with coma following severe diffuse CVT who underwent emergent invasive MBM with intracranial pressure (ICP), brain tissue oximetry (PbtO2), and cerebral microdialysis (CMD). Therapy of CVT consisted of intravenous unfractionated heparin (UFH), followed by endovascular mechanical thrombectomy (EMT). EMT efficacy was assessed continuously at the bedside using MBM. RESULTS: Despite effective therapeutic UFH (aPTT two times baseline levels in the two subjects), average CMD levels of lactate and glucose in the 6 h prior to EMT displayed evidence of regional brain ischemia. The EMT procedure was associated with a rapid (within 6 h) improvement in both CMD lactate (6.42 ± 0.61 4.89 ± 0.55 mmol/L, p = 0.02) and glucose (0.49 ± 0.17 vs. 0.96 ± 0.32 mmol/L, p = 0.0005). EMT was also associated with a significant increase in PbtO2 (22.9 ± 7.5 vs. 30.1 ± 3.6 mmHg, p = 0.0003) and a decrease in CMD glutamate (12.69 ± 1.06 vs. 5.73 ± 1.76 µmol/L, p = 0.017) and intracranial pressure (ICP) (13 ± 4 vs. 11 ± 4 mmHg (p = 004). Patients did not require surgical decompression, regained consciousness, and were discharged from the hospital with a good neurological outcome (modified Rankin score 3 and 4). CONCLUSIONS: This study illustrates the potential utility of continuous bedside MBM in patients with coma after severe brain injury, irrespective of the primary acute cerebral condition. Despite adequate ICP and PbtO2 control, the presence of CMD signs of regional brain cell ischemia triggered emergent EMT to treat CVT, which was associated with a significant and clinically relevant improvement of intracerebral physiology.

Surgical Thrombectomy Combined with Bilateral Decompressive Craniectomy in a Life-Threatening Case of Coma from Cerebral Venous Sinus Thrombosis: Case Report and Literature Review.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke. Medical and neurointerventional strategies, such as in situ thrombolysis, are standard therapies. These techniques are insufficient when clinical deterioration arises from mass-associated effects and transtentorial herniation; in such cases, decompressive hemicraniectomy may be indicated. To the best of our knowledge, the association of open surgical thrombectomy with bilateral decompressive craniectomy has not been reported to date. CASE DESCRIPTION: A 45-year-old woman presented with extensive cerebral venous sinus thrombosis that was resistant to anticoagulation and endovascular therapies. Her clinical condition deteriorated until she became comatose, and bilateral hemicraniectomy combined with open surgical thrombectomy through the superior sagittal sinus was indicated. Computed tomography angiography confirmed postoperative maintenance of sinus permeability. The patient's clinical status improved dramatically, and she had a favorable outcome, including recovery of her functional independence to perform all activities of daily living (modified Rankin Scale score = 0). The follow-up period was 5 years. CONCLUSIONS: Open surgical thrombectomy combined with decompressive craniectomy is a lifesaving procedure that can lead to favorable outcome and should be considered for treatment of refractory malignant cerebral venous sinus thrombosis.

Venous sinus thrombosis secondary to tuberculous meningitis: a novel cause of trigeminal neuralgia.

A 33-year-old Vietnamese man with a history of superior sagittal sinus thrombosis secondary to tuberculous meningitis presented with severe recurrent trigeminal neuralgia. A complex compensatory cerebral venous drainage system developed, and a varix, in direct contact with the root entry zone of the trigeminal nerve, was the trigger for his pain. The patient's symptoms are presently controlled with a combination of medications for neuropathic pain, however he continues to experience frequent severe exacerbations and may very well require more invasive means to manage his condition in future.

Acquired pial and dural arteriovenous fistulae following superior sagittal sinus thrombosis in patients with protein S deficiency: a report of two cases.

Two patients with protein S deficiency with acquired multiple pial and dural arteriovenous fistulae (AVFs) following superior sagittal sinus (SSS) thrombosis are reported. Case 1 is a 38-year-old male with protein S deficiency who developed generalized seizure due to SSS thrombosis. Local fibrinolysis was achieved in the acute stage. His 10-month follow-up angiogram revealed an asymptomatic acquired dural AVF arising from the middle meningeal artery and the anterior cerebral artery with drainage to the thrombosed cortical vein in the right frontal lobe. Furthermore, his 2-year follow-up angiogram revealed a de novo pial AVF from the middle cerebral artery in the Sylvian fissure with drainage to the cortical vein initially thrombosed. However, this asymptomatic pial AVF caused bleeding in the ipsilateral cerebral hemisphere 12 years after onset, whereas the dural AVF spontaneously disappeared. Surgical disconnection was successfully performed to eliminate the source of hemorrhage. Case 2 is a 50-year-old male with a past history of SSS thrombosis with protein S deficiency who developed pulsatile tinnitus and generalized seizure. His angiogram showed a cortical dural AVF in the left parietal lobe and a sporadic dural AVF involving the right sigmoid sinus. The parietal lesion was eliminated by transarterial embolization followed by craniotomy. However, a de novo pial AVF emerged from the middle cerebral artery adjacent to the previously treated lesion. Of four cortical AVFs in two patients, thrombosis of cortical veins caused by protein S deficiency might play an important role in their formation. Long-term follow-up is required because this peculiar disorder has an unusual clinical course.

Right atrial thrombosis associated with sagittal sinus thrombosis caused by protein C-S deficiency.

Right atrial thrombi may develop within the right atrium or may have peripheral venous origins that, on their way to the final destination site lodge in, right atrium. Right atrial thrombosis is classified as two type: A (mobile, thin) and B (non mobile and attached to atrial wall) that they are probably of cardiac origin due to local pathology, indwelling catheter, atrial fibrillation, stasis, rheumatological or hematological disease like protein C or S deficiency. Protein C deficiency has been reported to be a risk factor for thrombosis in multiple organs as a result of inactivation of factor of Va. We describe a case of a huge right atrial thrombus with cerebral sagittal sinus thrombosis, in a protein C-S deficient patient, in which right atrial clot was successfully removed surgically and sagittal vein treated conservatively with full recovery of his central neurologic symptom. Magnetic Resonance Imaging demonstrated thrombosis in those regions.

Transient ischaemic attack: an exceptional presenting syndrome of a superior sagittal sinus thrombosis.

We report a case of a transient ischaemic attack (TIA) as an exceptionally rare form of cerebral vein thrombosis. A 41-year-old man presented with a headache and five episodes of a transient left hemiparesis lasting approximately 10-15 min over the course of 2 weeks. Arterial origins of the disease were ruled out by detailed investigations. However, MR venography revealed a superior sagittal sinus thrombosis with numerous prominent collateral venous channels. No parenchymal lesion was seen. After medical therapy, no further transient neurological deficit occurred. Follow-up MR venography showed sinus recanalisation.

Headache in a young male: the clot thickens.

Cerebral venous sinus thrombosis  is a rare but serious cause of headache. In this report, we present a young man with poorly controlled Crohn's disease who presented with a 2-week history of headache and fluctuating left-sided sensory and motor symptoms. CT demonstrated changes consistent with either a subarachnoid haemorrhage or venous sinus thrombosis. The ensuing magnetic resonance venogram confirmed superior sagittal venous sinus thrombosis and an infarct of his right superior frontal lobe. The patient was started on low-molecular weight heparin and steroids. He required multi-disciplinary input from the stroke physicians, neurologists, gastroenterologists, dieticians and physiotherapists. He made a full neurological recovery and is now on long-term azathioprine. The purpose of this report is to highlight the consideration of venous sinus thrombosis in the diagnosis of headache and as a rare extraintestinal complication of Crohn's disease.

Macrocephaly-capillary malformation syndrome in a newborn with tetralogy of fallot and sagittal sinus thrombosis.

Macrocephaly-capillary malformation syndrome is characterized by cutaneous vascular malformations with associated anomalies as macrocephaly, macrosomia, hemihypertrophy, hypotonia, developmental delay, lax joints, loose skin, polysyndactyly, and neuroimaging abnormalities. We present a newborn with a prenatal diagnosis of macrosomia and tetralogy of Fallot. He also had macrocephaly; a high forehead; capillary hemangioma on the forehead, upper lip, and philtrum; generalized loose skin; postaxial polydactyly of both hands and feet, with neuroimaging findings of polymicrogyria and thrombosis in sagittal sinus and sinus rectus. His condition was diagnosed as macrocephaly-capillary malformation syndrome in the neonatal period and he died suddenly during sleep at 6 months of age. The clinical course in this syndrome is not as benign as was previously thought. Careful follow-up of these patients with particular emphasis on neuroradiologic and cardiologic evaluation might help decrease the risk of sudden death and to improve long-term outcome.

Bilateral optic disc swelling as a presenting sign of superior sagittal sinus thrombosis.

The case of a 59-year-old Caucasian man who presented with a 6-week history of intermittent blurring of vision and diplopia is reported. Fundoscopy revealed asymmetrical, bilateral optic disc swelling with peripapillary haemorrhages. An initial CT scan and D-dimer level were reported as normal. A subsequent MRI revealed a recanalising superior sagittal sinus thrombosis. Cerebral venous sinus thrombosis is a rare and potentially fatal condition. The author suggests that it should be part of the differential diagnosis of bilateral optic disc swelling and that a normal unenhanced CT scan and D-dimer would not rule out this potentially devastating condition.

An unusual case of transient cortical blindness with sagittal sinus thrombosis in a case of Henoch-Schonlein purpura.

INTRODUCTION: Henoch-Schonlein purpura (HSP) is one of the most common causes of small vessel vasculitis in children, but sometimes may have an atypical presentation. OBJECTIVE: To report an unusual case of transient cortical blindness in a patient with Henoch-Schonlein purpura. CASE: A 3-year-old female child was brought with the complaint of diffuse abdominal pain and hematochezia, which was preceded by high grade fever and cough. Three days later she developed hematuria, hematemesis, melena and hemoptysis along with palpable purpura. Four days later she became irritable and developed a few episodes of generalized tonic clonic seizure, followed by cortical blindness. The CT scan of the brain showed bilateral non-enhancing occipital hypodensity. The magnetic resonance venography showed thrombosis in transverse and sigmoid sinus. She was treated with corticosteroids and her mental status and vision improved. CONCLUSION: The HSP can cause transient cortical blindness, and recovery is good if therapy is initiated at the appropriate time.

Simultaneous appearance of cerebral venous thrombosis and subdural hematomas as rare cause of headache in puerperium following epidural analgesia: a case report.

The aim of this study is to report the first case of simultaneous appearance of cerebral venous thrombosis (CVT) and bilateral subdural hematomas (SDHs) following epidural analgesia for labor and delivery and to point out the difficulty of establishing such a diagnosis in the presence of postpartum headache. A 26-year old primigravida with a history of epilepsy received epidural analgesia for delivery. Three days after the uneventful spontaneous vaginal delivery she complained about the headache. Patient responded very well to the pain medication and oral hydration, and the headache was relieved. Ten days after the delivery, the headache reoccurred, and an epidural blood patch was performed that successfully relieved her symptom. Stronger progressive headache with nausea reappeared two days later and the parturient was readmitted to hospital. Urgent neuroimaging examinations detected CVT of right the transverse sinus, ipsilateral cortical veins, and partially occluded superior sagittal sinus, as well as bilateral subacute/chronic SDHs. The treatment of the patient with low molecular weight heparin and antiaggregation therapy was effective. In this case, the diagnosis was delayed because of atypical clinical presentation and potentially confounding events (epidural analgesia and assumption that it was a case of PDPH). It is important to carefully observe patients in such conditions and promptly conduct suitable diagnostic tests. Otherwise, unrecognized intracranial complications and delay of appropriate therapy could be life-threatening.

Subarachnoid haemorrhage as the initial manifestation of cortical venous thrombosis.

Aneurysmal rupture is the commonest cause of non-traumatic subarachnoid haemorrhage (SAH). SAH can rarely be the manifestation of cortical venous thrombosis (CVT). CVT is potentially lethal but treatable disorder with positive outcome if timely treatment is instituted. The site of bleeding is mainly on convexities and sulcus with sparing of basal cisterns in SAH related to CVT. Anticoagulation is the mainstay of treatment, in spite of SAH complicated by CVT. In this submission, the author highlighted a case of SAH presented as initial manifestation of CVT in an elderly woman. Early therapy with anticoagulation led to complete clinical and radiological recovery in a short duration of 2 weeks. Thus, diagnosis of CVT should be kept in mind in unusual presentation of SAH.

Sinus thrombosis in a patient with intracranial hypotension: a suggested hypothesis of venous stasis. a case report.

We describe the case of a 26-year-old man with orthostatic headache. Cerebral angiography revealed thrombosis in the sagittal sinus. Spine MRI showed cerebrospinal fluid collection at the C1-2 level. We performed blood patch and the symptoms disappeared. We report a rare case of intracranial hypotension caused by CSF leak and describe our hypothesis that SIH can change the velocity of cerebral blood flow and cause thrombosis.