Aluminium Chloride instead of Ferric chloride for inducing superior sagittal sinus thrombosis to reduce ferromagnetic artifacts on MRI-imaging in experimental models.

Using ferric chloride (FeCl3) to induce experimental superior sagittal sinus (SSS) thrombosis might interfere with magnetic resonance imaging (MRI)-assisted visualization and evaluation of the thrombus, the brain parenchyma, and the quality of the occlusion. The aim of this study was to investigate whether aluminum chloride (AlCl3)-induced thrombosis of the SSS has comparable properties to those of FeCl3 without causing artifacts in MRI. SSS thrombosis was induced in 14 male Wistar rats by exposure of the SSS and subsequent topical application of a filter paper strip soaked in AlCl3 (n = 7) or FeCl3 (n = 7) over a period of 15 min. The animals with AlCl3-induced SSS thrombosis showed a constant and complete occlusion with in histological analysis large thrombi. Blood flow measurements indicated a significant reduction on the first and seventh postoperative day compared to preoperative measurements. MRI enabled visualization and subsequent evaluation of the thrombus and the surrounding parenchyma. In comparison, FeCl3-induced SSS thrombosis could not be evaluated by MRI due to artifacts caused by the paramagnetic properties and increased susceptibility of FeCl3. The occluded sinus and the surrounding area appeared hypointense. The quality of SSS occlusion by AlCl3 was comparable to that of FeCl3. AlCl3 therefore represents a significant alternative substance in experimental SSS thrombosis ideally suited for studies using MRI.

Sagittal sinus thrombosis with subarachnoid haemorrhage in a patient with COVID-19 infection.

A man in his late 50s was admitted with a 10-day history of right frontotemporal headache, left arm and leg weakness, and a sudden decline in visual acuity in the right eye. The patient had recent exposure to COVID-19 infection and tested positive for the same on admission. A CT scan of the head done on arrival demonstrated a subarachnoid haemorrhage in the right central sulcus with an underlying superior sagittal sinus thrombosis. No other known risk factors for central venous sinus thrombosis could be identified. The patient had a normal level of consciousness on admission clinically; however, he was in severe pain. A collective decision was made to administer anticoagulants to the patient with heparin after carefully deliberating the risk-to-benefit ratio of a superior sagittal thrombus with an associated subarachnoid haemorrhage. Our patient recovered and was discharged after 2 weeks on warfarin. We present this case to highlight the potential risks of hypercoagulable and neurotropic complications of COVID-19 infections, with special emphasis on cerebral venous thrombosis.

Vaccine-Induced Immune Thrombotic Thrombocytopenia with Disseminated Intravascular Coagulation and Death following the ChAdOx1 nCoV-19 Vaccine.

Coronavirus is a novel human pathogen causing fulminant respiratory syndrome (COVID-19). Although COVID-19 is primarily a disease of the lungs with florid respiratory manifestations, there are increasing reports of cardiovascular, musculoskeletal, gastrointestinal, and thromboembolic complications. Developing an effective and reliable vaccine was emergently pursued to control the catastrophic spread of the global pandemic. We report a fatal case of vaccine-induced immune thrombotic thrombocytopenia (VITT) after receiving the first dose of the ChAdOx1 nCoV-19 vaccine. We attribute this fatal thrombotic condition to the vaccine due to the remarkable temporal relationship. The proposed mechanism of VITT is production of rogue antibodies against platelet factor-4 resulting in massive platelet aggregation. Healthcare providers should be aware of the possibility of such fatal complication, and the vaccine recipients should be warned about the symptoms of VITT.

Hyperthyroidism as a Precipitant Factor for Cerebral Venous Thrombosis: A Case Report.

Cerebral venous sinus thrombosis (CVT) is an uncommon yet serious condition. While CVT has many known precipitants and etiologies, hyperthyroidism as a precipitant of CVT is not well understood. This study reported a case of a 41-year-old male with a 4-year history of hyperthyroidism presented with seizure. Consequently, a diagnosis of superior sagittal sinus thrombosis was confirmed by computed tomography and magnetic resonance (MR) venograms. Extensive investigations yielded no apparent underlying cause, but laboratory findings were consistent with uncontrolled hyperthyroidism. The patient improved rapidly following anticoagulation. Follow-up MR and MRV scans 2 months after treatment revealed full recanalization of the superior sagittal sinus. This case report highlighted hyperthyroidism, as a procoagulant condition, resulting specifically in superior sagittal sinus thrombosis.

A Case of Cerebral Venous Thrombosis and Deep Venous Thrombosis Due to Hyperthyroidism with Increased Factor VIII Activity.

A 48-year-old woman was admitted to our hospital because of headache and fever. She was diagnosed with aseptic meningitis. Five days later, she had a seizure and developed left hemiparesis. Magnetic resonance imaging showed hyperintensity in the right parietal area on fluid attenuated inversion recovery imaging. She was diagnosed as having cerebral venous thrombosis (CVT) because the suprasagittal sinus was invisible on the venographic studies. Moreover, deep venous thrombosis (DVT) was detected in her left lower extremity. Laboratory findings showed hyperthyroidism and markedly increased factor VIII activity. This is a rare case of concomitant CVT and DVT induced by high factor VIII activity due to hyperthyroidism under the presence of meningitis, an additional risk factor for thrombosis.

Dural Sinus Thrombosis with Nonsymptomatic Persistent Falcine Sinus: A Case Report.

A 24-year-old woman was admitted to our hospital after convulsive status epilepticus. A cerebral magnetic resonance venography revealed a persistent fetal falcine sinus. Additionally, the posterior third of the superior sagittal sinus was hypoplastic and the abnormal deep venous drainage was accompanied. These abnormalities had already been detected by magnetic resonance imaging several years ago. In the present scan, we discovered a sinus thrombosis in the hypoplastic superior sagittal sinus. In the cerebral angiography, we observed delayed venous return in the left parieto-occipital lobe and hypothesized that cerebral venous stasis due to the thrombus caused the convulsive status epilepticus. The patient was treated with intravenous administration of heparin along with an antiepileptic drug, and she recovered with no neurological defects. In the present case, the falcine sinus and the anomalous venous return were likely congenital while the status epilepticus was derived from thrombosis in the hypoplastic superior sagittal sinus. Although the falcine sinus functioned as an alternative pathway for the superior sagittal sinus, the hypoplastic superior sagittal sinus itself may also play an important role as a venous drainage channel.

Cerebral Venous Sinus Thrombosis Score and its Correlation with Clinical and MRI Findings.

BACKGROUND: It is plausible that extent of cerebral venous sinus thrombosis (CVST) may determine clinical severity, magnetic resonance imaging (MRI) lesion, and outcome, therefore this study was undertaken. METHODS: A total of 160 CVST patients were included and their clinical details, risk factors, Glasgow Coma Scale score, and parenchymal lesion on MRI were noted. The extent of venous sinus thrombosis on magnetic resonance venography was assessed by using CVST score which was computed giving 1 point for each thrombosed sinus and 3 points to superior sagittal sinus (SSS). Death and outcome at 6 months were assessed using modified Rankin Scale (mRS) as good (≤2) and poor (mRS 3-5). RESULTS: Their median age was 29.5 years, and 76 (47%) were females. The median CVST score was 3 (range 1-9). CVST score did not correlate with clinical severity and risk factors. Insignificantly higher proportion of patients had parenchymal lesion with a CVST score of more than 2 (76.5% versus 64.2%). Superficial venous system thrombosis, however, correlated with seizure, papilloedema, and frontal lobe lesion. Frontal, temporal lesion correlated with SSS thrombosis, frontal and temporal with transverse sinus, temporal and cerebellar involvement in sigmoid, and basal ganglia and thalamus in straight sinus thrombosis. Seventeen patients (11%) died, and at 6 months, 132 (82%) had good and 11 (7%) poor recovery. Death and 6 months outcomes were not related to CVST score. CONCLUSIONS: Extent of CVST does not determine clinical severity, MRI lesion, and outcome. The location of parenchymal lesion however is related to thrombosis of draining sinus.

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.

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.

Superior sagittal sinus thrombosis as a rare complication of spontaneous intracranial hypotension syndrome: a case report and review of the literature.

In addition to an orthostatic headache, spontaneous intracranial hypotension syndrome can lead to subdural hematoma and diffusion, subarachnoid hemorrhage, and brain sag. However, cerebral venous sinus thrombosis is rarely reported in patients with spontaneous intracranial hypotension. We present the case of a 35-year-old male who developed an orthostatic headache, nausea, vomiting, and photophobia for 5 days. An enhanced brain magnetic resonance image showed extensive linear pachymeningeal enhancement in the bilateral cerebral hemispheres. Lumbar puncture showed that cerebrospinal fluid pressure was 80 mmH2O. Subsequent magnetic resonance scans demonstrated subdural effusion of the bilateral frontoparietal lobes, hyperintense T1-weighted images, and T2WI lesions within the superior sagittal sinus in 17 days. The patient was given low molecular weight heparin and adverse events occurred. Head computed tomography showed cerebral external fluid accumulation in the bilateral frontoparietal lobes. Then, digital subtraction angiography was performed at 22 days, which confirmed superior sagittal sinus thrombosis, and the patient recovered fully after therapy. The evolution of the disease and radiological findings support the diagnosis of spontaneous intracranial hypotension with superior sagittal sinus thrombosis. To the best of our knowledge, there are very few case reports describing superior sagittal sinus thrombosis as a complication of spontaneous intracranial hypotension. When spontaneous intracranial hypotension and cerebral venous thrombosis occur together, difficult practical questions arise regarding the treatment of these two conditions.

Longitudinal Volume Quantification of Deep Medullary Veins in Patients with Cerebral Venous Sinus Thrombosis : Venous Volume Assessment in Cerebral Venous Sinus Thrombosis Using SWI.

PURPOSE: Susceptibility-weighted imaging (SWI) visualizes small cerebral veins with high sensitivity and could, thus, enable quantification of hemodynamics of deep medullary veins. We aimed to evaluate volume changes of deep medullary veins in patients with acute cerebral venous sinus thrombosis (CVST) over time in comparison to healthy controls. METHODS: All magnetic resonance imaging (MRI) experiments were executed at 3 T using a 32-channel head coil. Based on SWI and semiautomatic postprocessing (statistical parametric mapping [SPM8] and ANTs), the volume of deep medullary veins was quantified in 14 patients with acute CVST at baseline and the 6­month follow-up, as well as in 13 healthy controls undergoing repeated MRI examination with an interscan interval of at least 1 month. RESULTS: Deep medullary venous volume change over time was significantly different between healthy controls and patient groups (p < 0.001). Patients with superior sagittal sinus thrombosis (SSST) showed a significant decline from baseline to follow-up measurements (9.8 ± 4.9 ml versus 7.5 ± 4.2 ml; p = 0.02), whereas in patients with transverse sinus thrombosis (TST) and healthy controls no significant volume changes were observable. CONCLUSIONS: Venous volume quantification was feasible and reproducible both in healthy volunteers and in patients. The decrease of venous volume in patients over time represents improvement of venous drainage, reduction of congestion, and normalization of microcirculation due to treatment. Thus, quantification of venous microcirculation could be valuable for estimation of prognosis and guidance of CVST therapy in the future.

Dynamic morphological changes of thrombosed lateral sinus pericranii revealed by serial magnetic resonance images.

BACKGROUND: Sinus pericranii (SP) is a rare venous anomaly involving an abnormal connection of the intracranial dural sinuses with the extracranial veins. Magnetic resonance (MR) imaging (MRI) with MR venography can detect the typically congested intra- and extracranial venous components of SP. CLINICAL PRESENTATION: We report a rare case of lateral SP associated with the superior sagittal sinus, which might had already developed almost total thrombosis of the SP at the first MRI. As this patient had not presented with classical manifestations of SP on clinical or neuroradiological findings, the initial diagnosis of SP was difficult. Repeated MRI revealed dynamic morphological changes associated with reperfusion of the thrombosed SP via the cortical vein. CONCLUSION: MR venography combined with gadolinium enhancement was useful for diagnosis of the SP with an extremely slow flow status.

Serial Arterial Spin Labeling May Be Useful in Assessing the Therapeutic Course of Cerebral Venous Thrombosis: Case Reports.

We report two cases of cerebral venous thrombosis (CVT) which serial arterial spin labeling (ASL) was useful in evaluating the clinical course of the disease. A 48-year-old female presented with acute seizure, and was diagnosed as transverse-sigmoid sinus thrombosis. ASL imaging revealed low signal intensity in the right temporal lobe, suggesting the decreased perfusion by elevated venous pressure. Soon after the treatment, while the development of venous collateral has not fully observed by magnetic resonance (MR) angiography, low ASL signal within the right temporal lobe have shown remarkable improvement. A 65-year-old female presented with vomiting and subsequent seizure was diagnosed as superior sagittal sinus thrombosis. The low ASL signal within the right frontal lobe seen in the acute stage improved to the normal level by the course of time, before the good collateral can be seen by MR angiography. This is the first report to assess the sequential change of the cerebral perfusion of CVT by ASL, and ASL may provide additional useful information in combination with conventional modalities.