Cerebral Venous Sinus Thrombosis in Children: A Multicenter Cohort From the United States

This study presents a large multicenter cohort of children with cerebral venous thrombosis from 5 centers in the United States and analyzes their clinical findings and risk factors. Seventy Patients were included in the study (25 neonates, 35%). The age ranged from 6 days to 12 years. Thirty-eight (55%) were younger than 6 months of age, and 28 (40%) were male. Presenting features included seizures (59%), coma (30%), headache (18%), and motor weakness (21%). Common neurological findings included decreased level of consciousness (50%), papilledema (18%), cranial nerve palsy (33%), hemiparesis (29%), and hypotonia (22%). Predisposing factors were identified in 63 (90%) Patients. These included infection (40%), perinatal complications (25%), hypercoagulable/hematological diseases (13%), and various other conditions (10%). Hemorrhagic infarcts occurred in 40% of the Patients and hydrocephalus in 10%. Transverse sinus thrombosis was more common (73%) than sagittal sinus thrombosis (35%). Three children underwent thrombolysis, 15 Patients received anticoagulation, and 49 (70%) were treated with antibiotics and hydration. Nine (13%) Patients (6 of them neonates) died. Twenty-nine Patients (41%) were normal, whereas 32 Patients (46%) had a neurological deficit at discharge. Seizures and coma at presentation were poor prognostic indicators. In conclusion, cerebral venous thrombosis predominantly affects children younger than age 6 months. Mortality is high (25%) in neonatal cerebral venous thrombosis. Only 18 (25%) Patients were treated with anticoagulation or thrombolysis

Nonrandomized comparison of local urokinase thrombolysis versus systemic heparin anticoagulation for superior sagittal sinus thrombosis

Background and Purpose We sought to compare the safety and efficacy of direct urokinase thrombolysis with systemic heparin anticoagulation for superior sagittal sinus thrombosis (SSST). Methods At University at Buffalo (NY) and University of Texas (Dallas, Houston), we reviewed 40 consecutive patients with SSST, treated with local urokinase (thrombolysis group) or systemic heparin anticoagulation (heparin group). The thrombolysis group (n=20) received local urokinase into the SSS followed by systemic heparin anticoagulation. The heparin group (n=20) received systemic heparin anticoagulation only. Neurological dysfunction was rated as follows: 0, normal; 1, mild (but able to ambulate and communicate); 2, moderate (unable to ambulate, normal mentation); and 3, severe (unable to ambulate, altered mentation). Results Age (P=0.49), sex (P=0.20), baseline venous infarction (P=0.73), and predisposing illnesses (P=0.52) were similar between the thrombolysis and heparin groups. Pretreatment neurological function was worse in the thrombolysis group (normal, n=5; mild, n=8; moderate, n=4; severe, n=3) than in the heparin group (normal, n=8; mild, n=8; moderate, n=3; severe, n=1) (P=NS). Discharge neurological function was better in the thrombolysis group (normal, n=16; mild, n=3; moderate, n=1; severe, n=0) than in the heparin group (normal, n=9; mild, n=6; moderate, n=5; severe, n=0) (P=0.019, Mann-Whitney U test). Hemorrhagic complications were 10% (n=2) in the thrombolysis group (subdural hematoma, retroperitoneal hemorrhage) and none in the heparin group (P=0.49). Three of the heparin group patients developed complications of the underlying disease (status epilepticus, hydrocephalus, refractory papilledema). No deaths occurred. Length of hospital stay was similar between the groups (P=0.79). Conclusions Local thrombolysis with urokinase is fairly well tolerated and may be more effective than systemic heparin anticoagulation alone in treating SSST. A randomized, prospective study comparing these 2 treatments for SSST is warranted

Strokes in young people: experience in a bantu hospital

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Clinical profile of cerebral venous thrombosis in pregnancy and puerperium in South India

Background: Cerebral venous thrombosis (CVT) is any thrombosis occurring in intracranial veins and sinuses, which is a rare disorder affecting 5 persons per million per year with huge regional variation. Pregnancy and puerperium are the most prevalent prothrombotic states leading to cerebral venous thrombosis. The objective of this study was to analysis the clinical profile of CVT in pregnancy and puerperium.Methods: In this prospective study, we analysed 52 consecutive patients admitted with impairment of consciousness, seizures or focal neurological deficit at our hospital. The diagnosis of CVT was confirmed by neuroimaging. Detailed history, clinical examination and laboratory investigations were carried out in all the cases and analysed.Results: The incidence of CVT associated with pregnancy and puerperium at our Hospital was 3.9 per 1000 obstetric admissions. The age of the patients varied from 18-35 years with a maximum age incidence (77%) in the III decade (21-30 years). The maximum incidence was during the first two weeks of puerperium (61.8%). The most common presenting symptoms were focal or generalised seizures (88.4%) followed by headache (65.3%). In spite of the alarming clinical picture, recovery was rapid and remarkable. Total mortality was 15.5% (8 cases).Conclusions: CVT is more common during the puerperium than in the antenatal period. Obstetric CVT has a more acute onset with excellent recovery when promptly diagnosed and treated

Prognostic indicators in cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVT) can affect all age groups, particularly women of childbearing age. Overall prognosis for survival and functional independence is better than it was believed. Mortality usually ranges from 6-15% and transtentorial herniation is the major cause of death. Approximately 80% of patients are functionally independent in the long term. Altered mental status and cerebral haemorrhage at presentation are the strongest predictors of death and disability. Patients with CVT related to pregnancy and puerperium generally do better than patients with other causes. Septic CVT carries a worse prognosis than aseptic CVT and of the latter, patients with syndrome of isolated intracranial hypertension have a better prognosis than those with focal deficits or encephalopathy. Anticoagulation is believed to improve outcome in CVT although robust data are lacking. Epilepsy, headaches, visual loss, pyramidal deficits and cognitive impairment are some of the long term sequelae. The risk of recurrence of CVT is low, particularly after the first 12 months of the first episode

Demographic, Clinical, Investigational and Etiological Profile of Patients with Cerebral Venous Thrombosis and Analysis of short term outcome.

Cerebral venous / sinus thrombosis has been recognized since the early 19th century, but still remains a diagnostic and therapeutic challenge. Patients with cerebral venous thrombosis usually presents with headache, seizures, papilledema, altered sensorium and focal deficits due to thrombosis of intracranial veins / sinuses resulting in hemorrhagic infarction and increased intracranial tension. The above features are present in various combinations ranging from syndrome of raised intracranial pressure without localization to deep altered sensorium and dense hemiparesis. Cerebral venous thrombosis forms a distinctive subgroup of cerebrovascular disease in India and is a leading cause of mortality in women of reproductive age group. In India, most of the cases are seen in postpartum period in women, while alcoholism is a significant risk factor in males. The high incidence of postpartum cerebral venous thrombosis is due to lack of proper hygiene resulting in high incidence of puerperal sepsis, high prevalence of anemia, and restriction of water intake during labour as a cultural practice. Other predisposing and causative factors for cerebral venous thrombosis are oral contraceptive pills intake, procoagulant states, internal malignancies, infections. Cross [et al.] noted “usually recovery is rapid and complete if the patient survives the acute episode”. ¾ cases of cerebral venous thrombosis in pregnancy and puerperium reported by him survived with good recovery. However in pre imaging era, cerebral venous thrombosis has been diagnosed exclusively at autopsy and therefore thought to be always lethal. After the introduction of heparin in treatment of cerebral venous thrombosis, mortality has come down significantly and most of the recent studies reporting mortality of < 20% compared to earlier studies which reported mortality between 30 - 50%. However the outcome of cerebral venous thrombosis is highly unpredictable and it is not unusual to see dramatic recovery in deeply comatose patients and sudden worsening of conscious patient due to extension of thrombus. With the advent of CT and MRI / MRV the diagnosis of cerebral venous thrombosis has improved significantly. CT scan commonly shows hemorrhagic infarction with or without “cord” / “empty delta sign”. MRI / MRV diagnose & confirm the diagnosis of cerebral venous thrombosis even if the CT scan is normal and also diagnose the thrombosis of cortical veins and deep veins. After introduction of MRI many of the cases earlier diagnosed as idiopathic intracranial hypertension have been noted to have sinus thrombosis. Involvement of superior sagital sinus of varying extend with or without involvement of transverse sinus and sigmoid sinus with thrombosis of cortical veins has been reported. Involvement of deep venous system is less common than the superficial venous system but by means not rare. CONCLUSION: 1. Over a period of 27 months, 75 patients of cerebral venous thrombosis were studied. Almost more than one half (58.66%) of patients were post partum CVT, data consistent with most Indian studies. 2. CVT still remains a disease of young adults. In this study, 61.33% of patients were below 30 years of age. 3. Mean age was significantly lower in puerperal group compared to non puerperal group. 4. Majority of post partum CVT patients presented with in 10-14 days after delivery. 5. Majority in our study presented subacutly (48 hrs – 30 days). There was no significant difference between puerperal and nonpuerperal group (non puerperal female and male CVT). 6. Headache (70/75), Seizures (42/75), and focal neurological deficits (33/75) were the major clinical features noted. There was no difference between puerperal, non puerperal female and male CVT in terms of frequency of these symptoms. 7. Haemoglobin value of less than 8 gm in 46.66% of total CVT. In puerperal group, this number was high (72.72%) compared to non puerperal female CVT and male CVT. 8. Cerebral infarction was the most common abnormality noted on the CT scan (56%) which was haemorrhagic in most of the cases. Deep seated venous thrombosis noted only in 2.66% (2/75) of patients. 1 in puerperal group and 1 in non puerperal female CVT group. 9. On MRI most common sinus involved in all the three groups was SSS (67/75) 89.33%. The next common sinus involved was LS (74.66%). There was no significant difference in puerperal, non puerperal and male CVT group in the frequency of SSS and LS involvement. 10. In MRI haemorrhagic infarction was present in 72.72%, 31.25%, 53.33% of patients in puerperal, non puerperal female and male CVT group respectively. Haemorrhagic infarction is most commonly present in the parietal region in 23/75 patients. Frontal haemorrhagic region was present less commonly (15/75 patients). One patient had occipital haemorrhagic infarct in puerperal group. Haemorrhagic infarction in more than one location was present in 4% (3/75) total patients with CVT. 11. 44 out of 75 patients the venous thrombosis was related to puerperium. Evaluating the risk factors for CVT in non puerperal group showed association with OCP intake in 2 patients, Related to cancer CVT in one, related to SLE in three (18.75%). Head injury was the risk factor for CVT in one non puerperal CVT patient. Among male patients with CVT nephritic syndrome, chicken pox, CSOM, Cancer each one was associated in CVT in single patient. Among male CVT group alcoholism was the major risk factor (53.33%). 12. Out come was better in male patients with CVT since no death or residual neurological deficit was reported. 2 out of 16 patients in nonpuerperal group had residual neurological deficit. In puerperal group, 1 patient died and 6 had residual neurological deficit