Cerebral venous sinus thrombosis and SCN1A, a novel association?

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke. Acquired and inherited prothrombotic conditions are the most common risk factors for CVST. Sometimes, an etiology is not found. Wide utilization of next generation sequencing technologies in clinical practice may lead to identification of risk factors other than those classically associated with CVST. METHOD AND RESULTS: This retrospective clinical-laboratory observational study has a reference patient who presented with CVST as an adolescent. Work up for prothrombotic conditions showed high homocysteine level secondary to homozygosity for a common polymorphism, c.677 C > T in the methylenetetrahydrofolate reductase (MTHFR) gene. His older unaffected brother has a similar MTHFR genotype and high homocysteine. The whole exome sequencing revealed a likely pathogenic variant in the sodium voltage gated channel, alpha subunit 1(SCN1A) gene. CONCLUSION: CVST is a multifactorial disease. Prothrombotic conditions are the most common risk factors for CVST. High homocysteine due to the common MTHFR polymorphisms was previously attributed to various thrombotic conditions including CVST. Although high homocysteine due to MTHFR polymorphism may be a contributing factor, additional risk factors such as blood flow abnormalities during SCN1A related seizures may be needed for thrombosis.

Clinical and laboratory characteristics and outcome predictors of cerebral venous sinus thrombosis in a referral neurology hospital in Bangladesh.

OBJECTIVE: We aimed to describe clinical and laboratory characteristics and determine the predictors of outcome in patients with cerebral venous sinus thrombosis. METHODS: This prospective study was conducted over 2 years among hospitalized patients with cerebral venous sinus thrombosis. Patient outcome was assessed using the Modified Rankin Scale (mRS) score at 3 months. Outcome predictors were identified using logistic regression analysis. RESULTS: Eighty-one patients were included in this study. The median mRS outcome at 3 months was 1 (interquartile range 1-3). Poor outcomes were observed in 27.2% of patients, and the mortality rate was 9.8%. Factors associated with poor outcomes were age >60 years (relative risk [RR] 5.1), hemiparesis (RR 5.4), altered level of consciousness (RR 7.1), and transverse sinus involvement (RR 1.1). In general, mRS scores were not associated with D-dimer levels (RR 2.4). However, older patients with elevated D-dimer levels showed a significant association with poor outcomes (1.6) according to mRS scores. CONCLUSION: Older age, hemiparesis, and altered consciousness levels were independent predictors of poor outcomes in patients with cerebral venous sinus thrombosis. High D-dimer level showed no association with functional disability, except in older patients.

[Clinical analysis of cases of otogenic sigmoid sinus thrombosis in children].

Objective:To analyze the clinical characteristics of middle ear mastoiditis combined with sigmoid sinus thrombophlebitis in children. Methods:Author retrospectively analyzed the clinical data of 6 children with middle ear mastoiditis combined with sigmoid sinus thrombophlebitis who were hospitalized in the Department of Infectious Diseases and Department of Neurology with first diagnosis of fever/headache, and subsequently underwent middle ear mastoidectomy in our department. All patients underwent comprehensive otoscopic, audiologic, imaging, and pathogenetic examinations. Clinical manifestations, pathogenetic features, treatment methods and prognosis were summarized, and the follow-up period was 3-6 months. Results:All 6 cases were first diagnosed with intracranial complications such as fever and headache in the internal medicine department. Within one month, all patients developed ear symptoms including pain, discharge, and hearing loss. Audiologic examination revealed conductive hearing loss in five cases and total deafness in one case. MRI, MRV and MRA examinations suggested that there were 6 cases of middle ear infection combined with thrombophlebitis of the ethmoid sinus, of which 3 cases had thrombus in the ethmoid sinus. 6 cases received surgical treatments: 2 cases of radical mastoidectomy+grommet Insertion, and 4 cases of radical mastoidectomy. Pathogenetic examination identified Streptococcus pneumoniae in three cases, Pseudomonas aeruginosa in one case, Enterobacter cloacae complex in one case, and no pathogens were detected in one case. Postoperative pathology was inflammatory granulation in all 6 cases. Follow-up was 3-6 months with no recurrence of intracranial and middle ear lesions on regular review. Conclusion:Children with recurrent fever, headache, and a recent history of acute and chronic otitis media should be evaluated for the possibility of sigmoid sinus thrombophlebitis, and imaging tests should be performed in a timely manner to clarify the diagnosis. Once diagnosed, surgery to remove the lesions around the ethmoid sinus, smooth drainage combined with antibiotic therapy is the most direct and effective treatment, and anticoagulation therapy is given when necessary. Timely diagnosis, multidisciplinary collaboration, and accurate timing of the management of primary foci and comorbidities are crucial to the treatment of the disease.

Cerebral Venous Sinus Thrombosis Secondary to Vitamin B12 Deficiency - A Case Series with Emphasis on Food Fortification.

The etiology of cerebral venous sinus thrombosis (CVST) is multifactorial. Although many acquired and genetic factors have been recognized as risk factors, hyperhomocysteinemia (hHcy) is independently associated with CVST. We describe three cases of CVST in this case series. All of them presented with headache. Two patients had papilledema and visual disturbances. On evaluation, there was CVST, and prothrombotic workup showed hHcy. In addition, two of them reported very low Vitamin B12 levels. All of them were treated with low-molecular-weight heparin followed by oral anticoagulation and Vitamin B6, B9, and B12 supplements. All of them responded to treatment, and follow-up imaging studies in two of them showed resolution of thrombosis. hHcy should be considered in the evaluation of CVST, especially in the setting of a pure vegetarian diet. Fortification of the diet with Vitamin B12 may be considered the majority of Indians consume predominantly vegetarian food.

RésuméL'étiologie de la thrombose veineuse cérébrale (CVST) est multifactorielle. Bien que de nombreux facteurs acquis et génétiques aient été reconnus comme facteurs de risque, l'hyperhomocystéinémie (hHcy) est indépendamment associée à la CVST. Nous décrivons trois cas de CVST dans cette série de cas. Tous présentaient des maux de tête. Deux patients avaient un oedème papillaire et des troubles visuels. Lors de l'évaluation, il y avait une CVST et le bilan prothrombotique montrait une hHcy. De plus, deux d'entre eux ont rapporté des niveaux très bas de vitamine B12. Tous ont été traités avec de l'héparine de bas poids moléculaire suivie d'une anticoagulation orale et de suppléments de vitamines B6, B9 et B12. Tous ont répondu au traitement, et des études d'imagerie de suivi chez deux d'entre eux ont montré une résolution de la thrombose. L'hHcy doit être envisagée dans l'évaluation de la (CVST), en particulier dans le contexte d'un régime purement végétarien. La fortification de l'alimentation avec de la vitamine B12 peut être envisagée car la majorité des Indiens consomment principalement des aliments végétariens.

Cerebral Venous Sinus Thrombosis After Lumbar Epidural Steroid Injection: A Case Report.

Cerebral venous sinus thrombosis (CVST) is an exceedingly rare complication of epidural anesthesia, with only a handful of known cases after epidural steroid injection (ESI). We report a case of CVST in a 33-year-old male patient that presented with headache after lumbar ESI. His clinical status initially improved on anticoagulation in the intensive care unit. However, he had a sudden worsening of cerebral edema that required an emergent hemicraniectomy. Ultimately, the patient was pronounced dead by neurologic criteria. This case highlights the importance of keeping this rare but potentially fatal diagnosis in the differential even in lower-risk patient populations.

The effect of SARS-CoV-2 on the incidence of post-operative venous sinus thrombosis following skull base procedures.

PURPOSE: Sinus thrombosis is a common post-operative finding after posterior fossa surgery performed in the vicinity of the dural venous sinuses. The SARS-CoV-2 virus has been shown to confer an increased risk of venous thromboembolic events owing to eliciting a hyper-inflammatory and pro-thrombotic state. In this study, we examine the incidence of post-operative venous sinus thrombosis in patients undergoing peri-sigmoid posterior fossa surgery in the pre- and post-COVID era and investigate whether COVID infection confers an increased risk of sinus thrombosis. METHODS: A retrospective review of a single institution case series of patients underwent peri-sigmoid surgery (retrosigmoid, translabyrinthine, or far lateral) approach. Relevant clinical variables were investigated that may confer an increased risk of sinus thrombosis. RESULTS: A total of 311 patients (178 in the pre-COVID era, and 133 operated on after the pandemic began in March 2020) are included in the study. The composite incidence of sinus thrombosis seen on post-operative imaging was 7.8%. The incidence of sinus thrombosis in the pre-COVID cohort was N = 12 patients (6.7%) versus N = 12 (9%) in the post-COVID cohort (p = 0.46). A history of COVID infection was not shown to confer an increased risk of post-operative sinus thrombosis (OR: 0.61; 95% CI: 0.08-4.79, p = 0.64). Only a small number of patients (N = 7, 2.3%) required either medical or surgical intervention for post-operative sinus thrombosis. CONCLUSION: The overall incidence of post-operative sinus thrombosis is similar in the pre- and post-COVID era. The findings of this study suggest that COVID infection is not associated with a higher risk of venous sinus thrombosis.

Recurrent haemorrhagic venous infarct in a patient with sickle cell disease.

Cerebrovascular accidents are uncommon but devastating complications of sickle cell disease (SCD). Notably, cerebral sinovenous thrombosis is rarely reported in SCD and poses a therapeutic dilemma regarding anticoagulation. Herein, we describe a challenging case of a patient with sickle thalassaemia admitted to the hospital with recurrent haemorrhagic infarct secondary to cerebral sinus thrombosis. The patient was successfully treated with anticoagulation without neurological deficit. No embolic or other thrombotic aetiology was found, and the stroke was presumed due to sickle cell disease, leading to a hypercoagulable state. Our case report highlights the value of early recognition of this rare but potentially life-threatening condition in SCD, considers other options of anticoagulation therapy and emphasises the importance of close multidisciplinary follow-up particularly post hospital discharge.

A Study of Cerebral Venous Sinus Thrombosis with Special Reference to Newer Risk Predictors.

BACKGROUND: Cerebral venous thrombosis (CVT) is an uncommon and frequently unrecognized type of stroke that affects approximately five people per million annually, accounts for 0.5 to 1% of all strokes, and is more commonly seen in young individuals. The exact incidence of CVT in India remains unknown. The risk factors for venous thrombosis in general are linked classically to the Virchow's triad of stasis of the blood, changes in the vessel wall, and changes in the composition of the blood. There have been numerous studies evaluating long-term as well as short-term outcomes in the presence of these inflammatory mediators. They have been reported to be beneficial in predicting outcome and, hence, potentially in guiding management. AIMS: Evaluation of prevailing risk factors associated with cerebral venous sinus thrombosis (CVST). Description of the distribution of newer inflammatory markers among the study population and their association with functional and neurologic outcome at 30 days following the occurrence of cerebral VST. MATERIALS AND METHODS: Approval from the Institutional Review Board was obtained. Written informed consent was given by willing patients, explained in vernacular. Relevant details were obtained via a clinical history and laboratory values and imaging data obtained from the hospital's electronic health information system, which were then recorded in the proforma. No personal identifying data was collected. The sample size for this study was lower than originally planned, owing to the coronavirus disease 2019 (COVID-19) pandemic. The patients were called for follow-up after 1 month of the detection of VST, and their neurologic status was recorded on the Glasgow Coma Scale (GCS) and functional status on the modified Rankin Scale (mRS). Descriptive analysis of baseline characteristics was done. Mann-Whitney U and Kruskal-Wallis H tests of significant difference between means for nonparametric data were used. Linear regression was carried out on the variables found to differ significantly among subpopulations having good and poor neurologic outcomes. Receiver operating characteristic (ROC) curves were then derived for both outcome categories. RESULTS: The study enrolled 30 patients, with ages from 18 to 70 years, of which 19 (63.3%) were male and 11 (36.67%) were female. No risk factor was identified in 23.3% of cases. The most common risk factor was the presence of substance abuse. Among presenting features, headaches were the most common, followed by seizures and focal neurologic deficits (83.3, 30, and 23.3, respectively). Coexisting intraparenchymal hemorrhage was seen in 46.67% of patients, with the transverse sinuses most commonly involved (28.77%). The median neutrophil-to-lymphocyte ratio (NLR) was 3.415 [interquartile range (IQR) 2.634-5.637], with median platelet-to-lymphocyte ratio (PLR) 160.728 (IQR 107.728-227.776) and median systemic immune-inflammation index (SII) 1067.883 (IQR 509.694-1522.837). The NLR, PLR, and SII values were found to differ significantly among subgroups having good and poor neurologic outcome on the mRS. PLR and SII significantly differed among subgroups with venous involvement and among subgroups with good and poor neurologic status on GCS, on admission as well as 30-day follow-up. NLR, PLR, and SII values on admission showed a positive association with poor neurologic outcomes. CONCLUSION: Here, a significant correlation is seen between the values of complete blood count (CBC)-derived inflammatory markers on admission. Higher-powered studies are needed to assess the potential benefits of incorporating these markers in existing risk stratification models to improve their predictive accuracy.

Cerebral venous sinus thrombosis associated with cancer: analysis of the ACTION-CVT study.

Nearly one fifth of patients with venous thromboembolism (VTE) have cancer. When both of these conditions occur, especially in cases of cerebral vein thrombosis (CVT), patient management is often challenging. The aim of this study was to compare the characteristics and event courses in patients affected by CVT with and without cancer. Consecutive patients with CVT from the ACTION-CVT cohort study were included if cancer status was reported. Risk factors as well as the clinical and radiological characteristics of patients were compared. Univariable and multivariable analyses were performed to assess variables associated with cancer. Kaplan-Meier method and log-rank test, logistic regression analysis, and propensity score matching were used to investigate any association between cancer-related CVT and study outcomes (primary outcome at 3-months: recurrent VTE or major hemorrhage; recurrent VTE; major hemorrhage; recanalization status; all-cause-death). Overall, 1,023 patients with CVT were included, of which 6.5% had cancer. Older age (adjusted odds ratio [aOR] 1.28 per decade increase; 95% confidence interval [CI] 1.08-1.52) and absence of headache (aOR 0.47; 95% CI 0.27-0.84) were independently associated with cancer. Patients with cancer had a higher risk of recurrent VTE or major hemorrhage (aOR 3.87; 95% CI 2.09-7.16), all-cause-death (aOR 7.56 95% CI 3.24-17.64), and major hemorrhage (aOR 3.70 95% CI 1.76-7.80). Recanalization rates, partial or complete, was not significantly different. CVT patients with cancer were more likely to be older, have no referred headache, and have worse outcomes compared to CVT patients without cancer.

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

BACKGROUND: The incidence of dural venous sinus thrombosis (DVST) following vestibular schwannoma (VS) surgery remains understudied. The diverse clinical presentation complicates forming anticoagulation treatment guidelines. This meta-analysis aimed to investigate the incidence of DVST post-VS surgery and to evaluate the role of anticoagulation. METHODS: A systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, was conducted. Studies reporting DVST incidence after VS surgery were included. DVST incidence stratified by detection method was the primary outcome. Adverse events per treatment strategy (anticoagulation or no anticoagulation) were the secondary outcome. Pooled incidence with respective 95% confidence intervals were calculated using the random-effects model via the DerSimonian and Laird method. RESULTS: The overall DVST incidence post-VS resection was 15.5% (95% confidence interval: 10.3%, 22.5%; 10 studies). Stratification by detection method revealed 29.4% (19.2%, 42.3%) for magnetic resonance imaging, 8.2% (3.2%, 19.5%) for computed tomography, and 0.7% (0.2%, 2.8%) upon clinical suspicion. The pooled incidence of adverse events was 16.1% (6.4%, 35.0%) for the anticoagulation treatment and 4.4% (1.4%, 12.9%) for no anticoagulation treatment, with one mortality case being among the adverse events in this latter group. CONCLUSIONS: DVST after VS surgery is more common than initially perceived, predominantly presenting asymptomatically. Variability in anticoagulation protocols hinders the establishment of definitive therapeutic stances; nevertheless, there is no supporting evidence to promote anticoagulation administration for DVST. This begs the need for further institutional comparative studies with a proper adjustment for confounding and well-defined anticoagulation regimens.

CR Appropriateness Criteria® Cerebrovascular diseases-stroke and stroke-related conditions

Cerebrovascular disease encompasses a vast array of conditions. The imaging recommendations for stroke-related conditions involving noninflammatory steno-occlusive arterial and venous cerebrovascular disease including carotid stenosis, carotid dissection, intracranial large vessel occlusion, and cerebral venous sinus thrombosis are encompassed by this document. Additional imaging recommendations regarding complications of these conditions including intraparenchymal hemorrhage and completed ischemic strokes are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Traumatic Cerebral Venous Sinus Thrombosis: Management and Outcomes.

BACKGROUND: Traumatic brain injury (TBI) with skull fractures parallel to or crossing venous sinuses is a recognized risk factor for traumatic cerebral venous sinus thrombosis (tCVST). Despite the recognition of this traumatic pathology in the literature, no consensus regarding management has been achieved. This study aimed to evaluate the impact of tCVST on TBI outcomes and related complications. METHODS: Patients within a prospective registry at a level I trauma center from 2014 to 2023 were reviewed to identify tCVST cases. The impact of tCVST presence on Glasgow Outcome Scale scores at 6 months, 30-day mortality, and hospital length of stay were evaluated in multivariable-adjusted analyses. RESULTS: Among 607 patients with TBI, 61 patients were identified with skull fractures extending to the vicinity of venous sinuses with dedicated venography. Twenty-eight of these 61 patients (44.3%) had tCVST. The majority (96.4%) of tCVST were located in a unilateral transverse or sigmoid sinus. Complete recanalization was observed in 28% of patients on follow-up imaging (7/25 with follow-up imaging). None of the 28 patients suffered attributable venous infarcts or thrombus propagation. In the adjusted analysis, there was no difference in the 30-day mortality or Glasgow Outcome Scale at 6 months between patients with and without tCVST. CONCLUSIONS: Unilateral tCVST follows a benign clinical course without associated increased mortality or morbidity. The management of tCVST should be distinct as compared to spontaneous CVST, likely without the need for anticoagulation.

Inflammatory biomarkers are correlated with thrombus burden in cerebral venous sinus thrombosis.

BACKGROUND: Increasing evidence suggests that inflammatory biomarkers play a significant role in cerebral venous sinus thrombosis (CVST). The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) are related to thrombotic conditions and indicators of systemic inflammation. OBJECTIVE: To analyze the correlation between inflammatory biomarkers and the extent of thrombus, determined by the CVST-Score. METHODS: A total of 40 patients with CVST (24 female subjects; 60%) and 40 age- and sex-matched healthy controls were retrospectively evaluated. Inflammatory biomarkers, including C-reactive protein (CRP), PLR, NLR, MLR, and the CVST-Score, were recorded to assess the relationship between biomarkers and thrombus burden. The patients were grouped according to symptom duration (group 1: 0-3 days; group 2: 4-7 days; and group 3: 8-30 days) to compare biomarker levels. RESULTS: The CRP, NLR, and PLR were significantly higher in the CVST group (p < 0.001; p = 0.003; p = 0.014 respectively). The NLR and PLR presented a significant positive correlation with the CVST-Score (p = 0.003, r = 0.464; p = 0.040, r = 0.326 respectively). The NLR was significantly higher in group 1 compared with groups 2 and 3 (p = 0.016 and p = 0.014 respectively). In group 1, there was a stronger positive correlation between the CVST-Score and the NLR (p = 0.026, r = 0.591) and the PLR (p = 0.012, r = 0.648). The multiple linear regression analysis revealed that the NLR is a key factor in predicting the CVST-Score (p = 0.019). CONCLUSION: The NLR and PLR are associated with thrombus burden in CVST, especially in patients admitted to the hospital in the early stages. The NLR is an independent factor to predict the thrombus burden in CVST.

ANTECEDENTES: Há evidências crescentes de que biomarcadores inflamatórios desempenham um papel importante na trombose venosa cerebral (TVC). A razão neutrófilo-linfócito (NLR), a razão plaqueta-linfócito (PLR) e a razão monócito-linfócito (MLR) estão relacionadas a condições trombóticas e são indicadores de inflamação sistêmica. OBJETIVO: Analisar a correlação entre NLR, PLR, MLR e a extensão do trombo, determinada pelo escore de TVC. MéTODOS: Avaliamos retrospectivamente 40 pacientes com TVC (24 mulheres; 60%) e 40 controles pareados por idade e sexo. Biomarcadores inflamatórios, incluindo proteína C reativa (PCR), PLR, NLR, MLR e escore de TVC, foram registrados para avaliar a relação entre biomarcadores e carga trombótica. Os pacientes foram agrupados de acordo com a duração dos sintomas (grupo 1: 0­3 dias; grupo 2: 4­7 dias; e grupo 3: 8­30 dias) para a comparação dos níveis de biomarcadores. RESULTADOS: A PCR, a NLR e a PLR foram significativamente maiores no grupo com TVC (p < 0,001; p = 0,003; e p = 0,014, respectivamente). A NLR e a PLR apresentaram correlação positiva significativa com o escore de TVC (p = 0,003, r = 0,464; e p = 0,040, r = 0,326, respectivamente). A NLR foi significativamente maior no grupo 1 em comparação aos grupos 2 e 3 (p = 0,016 e p = 0,014, respectivamente). No grupo 1, houve correlação mais forte entre o escore de TVC e a NLR (p = 0,026, r = 0,591) e a PLR (p = 0,012, r = 0,648). A análise de regressão linear múltipla identificou a NLR como fator-chave na predição do escore de TVC (p = 0,019). CONCLUSãO: A NLR e a PLR estão associadas à carga trombótica na TVC, especialmente em pacientes admitidos precocemente, e a RNL é um fator independente na previsão da carga trombótica.

Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke indicated by the formation of blood clots within the dural venous sinuses. These are large venous conduits that are situated between the 2 layers of the dura mater which are responsible for draining blood from the brain and returning it to the systemic circulation. Cortical venous thrombosis refers to the blockage of veins on the brain's cortical surface. Cerebral venous thrombosis encompasses both dural and cortical vein occlusions.

Dehydration in cerebral venous sinus thrombosis.

AIMS: This study aimed to unravel the dehydration status of patients with cerebral venous sinus thrombosis (CVST) to facilitate the understanding of dehydration in CVST. METHODS: This was a multicenter retrospective study and three populations were recruited, namely, patients with CVST, CVST mimics, and healthy subjects. Blood samples were obtained 1-2 days after admission to assess dehydration status. Stata 15.1 was performed for statistical analysis. RESULTS: A total of 208 patients were diagnosed with CVST, 237 with CVST mimics, and 200 healthy individuals were enrolled. The urine specific gravity (USG, 1.020 [1.014, 1.029] vs. 1.017 [1.011, 1.021]) was higher in patients with CVST than in those with mimics (all p < 0.001). The percentage of USG >1.03 was also higher in CVST (22.6%) than in its mimics (6.3%, p < 0.001). With the development of CVST, USG (acute vs. sub-acute vs. chronic, 1.022 [1.015, 1.033] vs. 1.021 [1.015, 1.031] vs. 1.019 [1.014, 1.025]) decreased. All dehydration-related markers could not differentiate CVST from its mimics and healthy populations, and they were not associated with CVST severity and prognosis (p > 0.05). CONCLUSION: High levels of USG, especially USG >1.013, were more common in patients with CVST. Dehydration-related indices could not characterize CVST and were not associated with CVST severity and prognosis.

The Clinical Value of Cranial CT Venography for Predicting Fusobacterium necrophorum as the Causative Agent in Children with Complicated Acute Mastoiditis.

BACKGROUND AND PURPOSE: Fusobacterium necrophorum (F necrophorum) is an anaerobic bacteria that causes invasive head and neck infections in children. Several studies have demonstrated an increasing prevalence of F necrophorum as the causative agent in acute mastoiditis in children, with associated high rates of intracranial complications such as epidural abscess and sinus venous thrombosis, to name a few. F necrophorum requires a treatment protocol that differs from the empiric treatment that is tailored to more common pathogens (eg, group A streptococci, Streptococcus pneumonia), and hence expediting the diagnosis is important. For evaluating complicated acute mastoiditis in children, cranial CT venography remains the imaging study of choice in most medical centers due to its availability in emergency situations. Based on our clinical experience, our hypothesis is that children with F necrophorum-associated complicated acute mastoiditis can be differentiated from those with other etiologies using CT venography. MATERIALS AND METHODS: CT venography studies of 76 children hospitalized and treated for complicated acute mastoiditis were retrospectively reviewed. Retrieved imaging data included intracranial complications (epidural abscess, sinus venous thrombosis), cranial bone-related complications, and extracranial complications (subperiosteal abscess, temporomandibular joint abscess, and soft-tissue inflammation). The cohort was divided into children with F necrophorum-related disease (study group) and those with non-F necrophorum-related disease (control group). RESULTS: Thirty-seven children (49%) comprised the study group, and 39 children in whom the causative agents were other bacteria comprised the control group. There were significantly higher rates of complications in the study group: sinus venous thrombosis (P < .001), perisigmoid epidural abscess (P = .036), and extramastoid osteomyelitis (P < .001). Thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with an otogenic variant of Lemierre syndrome) and emphysematous osteomyelitis were found only among children in the F necrophorum-related study group (32% and 22% accordingly). CONCLUSIONS: In children with complicated acute mastoiditis, CT venography findings of emphysematous osteomyelitis and/or thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with the otogenic variant of Lemierre syndrome) should lead the radiologist to suggest F necrophorum-related mastoiditis.

Sex-based difference in selected stroke etiologies: cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, dissection, migraine, pregnancy/puerperium/OC use.

Females are at higher risk than males for a multitude of cerebrovascular conditions, both common and rare; partially resulting from a complex interplay between differing process involving genetics, hormonal influences, common cerebrovascular risk factors among others. Specific topics including cervical artery dissection, cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, migraine, along with these disorders in the setting of pregnancy, puerperium and oral contraceptive utilization. Epidemiology, pathophysiology, presentation, basics of management and outcomes are presented, with sex differences throughout.

Cerebral Venous Sinus Thrombosis as an Initial Presentation of Nephrotic Syndrome: A Case Report.

Cerebral sinovenous thrombosis (CSVT) encompasses a spectrum of disorders involving thrombosis of the cerebral venous system. As shown by previous epidemiological studies, the prevalence of cerebral sinovenous thrombosis is 4-7 cases per million people. Nephrotic syndrome was very rarely associated with thrombosis cerebral veins or sinuses. Hypercoagulability and thrombotic complications in nephrotic syndrome are most commonly seen in deep veins of the lower extremities and renal veins. Our case highlights a unique scenario in which cerebral sinovenous thrombosis was the initial presentation of nephrotic syndrome in a patient that was not an important past medical or surgical problem. The patient was brought to the emergency department with severe headache, vomiting, altered mental status, and generalized body swelling. Laboratory results showed proteinuria, hypoalbuminemia and hyperlipidemia. Non-contrast brain CT demonstrated hemorrhagic venous infarct associated with vasogenic edema. A subsequent brain MR venogram demonstrated occlusion of superior sagittal and right transverse sinuses. She was managed with low molecular weight heparin and intervenous corticosteroids then shifted to rivaroxaban and oral steroids, respectively, which resulted in massive clinical improvement and resolution of thrombus.