Cerebral Venous Sinus Thrombosis 2010 - Dr. Rajiv Jha (Neurosurgeon Nepal)
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Transcript of Cerebral Venous Sinus Thrombosis 2010 - Dr. Rajiv Jha (Neurosurgeon Nepal)
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Cerebral Venous Sinus Thrombosis
Dr Rajiv Jha, MSSenior Resident M Ch Neurosurgery
National Neurosurgical Referral CenterNational Academy Of Medical Sciences
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Introduction
A rare condition,3-4 cases / million./year The first description -French physician Ribes in
1825. Until the second half of the 20th century remained a
diagnosis generally made after death. In the 1940s-Dr Charles Symonds et all.
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Introduction
< 2% of all strokes Predominantly affects young adults and children Male: Uniform age distribution 75% of adult patients are women (ISCVT study) Accounts for up to 50% of strokes during pregnancy and
puerperium Most sensitive examination: MRI + MR Venography Treatment usually with anticoagulation
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Objectives
To describe the features of a series of patientwith CVST treated at National NeurosurgicalReferral Center and to find the risk factors,
presentation, and outcome of the disease
process.
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Study design
Retrospective study September 2008 – September 2010 National Neurosurgical Referral Center,
National Academy of Medical Sciences, Bir Hospital
Group assignment – all ages / sex Outcome measured at 3 months
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Age
0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 >600
2
4
6
8
10
12
1 1
11
8
32 2
Age
Nu
mb
er o
f cas
es
7
Sex
61%
39%
Female
Male1711
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Clinical presentation
Dutch-European study
Our study
0 50 100
Headache
Vomiting
LOC
Seizure
FND
Fever
Neck pain
96
46
43
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18
7
3.5
9
GCS < 7, 8
GCS 8 - 13, 6
GCS > 13, 14
Papilloedema, 5
Slurred speech,
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Hemianopia, 1
Hemiparesis, 4
Neck Rigidity, 4
Objective Findings
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Risk factors
Dehydration → 8 [29%] Estrogen containing
contraception → 9 [32%] Puerperium → 2 [7%] Sinusitis → 1 [3.6%] Mastoiditis→ 1 [3.6%] Pituitary adenoma → 1
[3.6%] Undiagnosed → 7 [25%]
ISCVT study: International Study on Cerebral Vein & Dural Sinus Thrombosis
43.6% of patients had multiple risk factors
Thrombophilia (acquired or inherited) 34.1 %
Oral contraceptives 54.3% IBD 1.2%-6.1%
Dutch study : (Lancet 352 (9124) p 326)OCP’s – 56%IBD - Rate of thromboembolism 1.2 - 6.1%, up to 39%
Our Study
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Diagnosis
CT Scan brain Non-contrast / Contrast MRI/MRV Angiography LP Blood work (protein C and S levels,
antiphospholipid antibodies, CBC, factor II level, serum homocystine level, PNH panel, leukocyte, alk.phosphotase, D-dimer)
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CT/MRI
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MRV
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MRI
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MRI
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MRI
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MRI
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Unusual association of a pituitary adenoma and a neurological emergency: case report and diagnostic step.
Internal and Emergency Medicine Volume 3, Number 3 / September, 2008
The action of PRL as a platelet aggregation co-activator is recognized; previous studies suggested that increased PRL concentrations could concur to the hypercoagulable state observed in pregnancy and the puerperium or other hyperprolactinemic conditions
Dural sinus thrombosis is a rare but dangerous complication of estroprogestin assumption; in this case the hyperprolactinemia associated to the pituitary macroadenoma might have concurred to the thrombophilic state
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Frequency of Thrombosis of the Major Cerebral Veins and Sinuses
Our SeriesNew England Journal of Medicine Volume 352:1791-1798 April 28, 2005 Number 17
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Treatment• General: supportive, symptomatic correct underlying abnormalities(antibiotic for infection) Avoid steroids Anticonvulsants to control seizure Hydrate aggressively
• Anticoagulation with IV Heparin – 15 cases loading dose of 50-100 units/kg of heparin constant infusion of 15-25 units/kg/hr – next 24 hrs Maintenance dose of 50-100 units/kg of heparin,
• LMWH(Fragmin) – 3 cases 5000 IU qd s/c for 5-10 days
• warfarin initiated on day 5 - minimum upto 6 months
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The Controversy of Anticoagulation
• No data comparing the effect of Unfractionated Heparin with Low molecular weight heparin
• Tendency for venous infarcts to become haemorrhagic• 40% of patients with sinus thrombosis – haemorrhagic infarct
prior to anticoagulation commencing• Weak Evidence for anticoagulation• BUT – anticoagulation is safe, even in the setting of ICH• 3 small randomised clinical trials (NEJM
2005;352:1791-8)/ ISCVT: • All showed non-significant benefit of anticoagulation as
compared with placebo• All included patients who had haemorrhagic infarcts prior to
treatment, no increased or new cerebral haemorrhages developed after treatment with heparin
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After 2 weeks After 6 weeks
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Thrombolysis
The 2006 European Federation of Neurological Societies guideline :
Thrombolysis is only used in patients who deteriorate despite adequate treatment, and other causes of deterioration have been eliminated.
It is unclear which drug and which mode of administration is the most effective.
Bleeding into the brain and in other sites of the body is a major concern in the use of thrombolysis.
American guidelines: Makes no recommendation with regards to thrombolysis, stating
that more research is needed.
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Surgery
When all measures fail… Decompressive craniectomy /decompressive
lobectomy Direct attack on clotted sinusDirect surgical treatment (thrombectomy and sinus
reconstruction) – rarely indicated, “rethrombosis “is common
Surgical technique for direct treatment of SSS thrombosis
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Outcome
Important prognostic factors for death or dependence
Coma (GCS < 9) Cerebral Haemorrhage Malignancy Male sex Age > 37 years Mental status disorder Thrombosis of deep cerebral
venous system – straight sinus CNS infection ISCVT- death/dependency 13.4%
Complete recovery 79%96%
4%
Favorable (27) Unfavorable(1)
Conclusion
CVST is not an uncommon disease, but needs extreme degree of suspicion
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Thank You
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