Thrombosis of the cerebral veins and sinuses

Chronic venous congestion following embolization of spinal dural arteriovenous fistula

The authors present a case of spinal dural arteriovenous fistula with fluctuations in symptoms following embolization. Superselective injection of 33% N-butyl cyanoacrylate into the feeding vessel resulted in the complete occlusion of the fistula with traversal of the nidus. The subsequent venous congestion was progressive and treatable with anti-thrombin therapy. Extended medication with dual antiplatelet therapy was required because dose reduction to aspirin monotherapy worsened symptoms. In this case, it took > 2 months for the patient's symptoms to stabilize. The duration of progressive venous thrombosis after embolization of a spinal dural arteriovenous fistula is not well known, nor is the most adequate treatment. Although it is presumed that prevention of venous thrombosis is best achieved with anticoagulation, dual antiplatelet therapy can be a substitute for patients with poor compliance.

[Sagittal sinus thrombosis as a rare cause of postpartum headache: a case report]

Postpartum cerebral vein thrombosis is a very rare entity (3-4 cases per million). Clinical manifestations vary, though persistent headache is almost always reported, meaning that differential diagnosis should be performed to rule out other causes of postpartum headache. Recognized risk factors for this disease are the prothrombotic state of pregnancy (third trimester), excess weight, and thrombophilia Accidental dural puncture, protein C and S deficiencies, factor V Leiden mutation, antiphospholipid syndrome, and the use of oral contraceptives have also been implicated. The diagnostic test of choice is magnetic resonance imaging, as it is convenient and harmless, though transcranial Doppler ultrasound can also be used. Pulmonary angiography is the gold-standard test. The treatment of choice is anticoagulant therapy with heparin (a treatment that is controversial, however, due to the high risk of rebleeding), followed by long-term treatment with antivitamin K drugs. We report a case of thrombosis of the upper longitudinal sinus associated with persistent postpartum headache and a history of a failed attempt at epidural puncture for analgesia during labor. The case posed interesting diagnostic questions.

Dural Entrance of the Bridging Vein into the Transverse Sinus Provides a Reliable Measure for Preoperative Planning: An Anatomic Comparison between Cadavers and Neuroimages

Objective:

Understanding the anatomy of the transverse sinus and its associated bridging veins (BVs) is essential to approaching the posterior and middle incisural space. The venous phase of neuroimages has received increasing attention in preoperative planning. The aims of this study are to identify anatomic features of the dural entrance of the BVs into the transverse sinus on the cadaver and to correlate such features with those of digital subtraction angiography (DSA), computed tomographic venography (CTV), and magnetic resonance venography (MRV).

Methods:

A total of 30 adult cadavers and 76 patients were examined through anatomic dissection and DSA, CTV, and MRV, respectively. The number, diameter, and location of the BVs entering the sinus were measured, and comparisons were made between the cadavers and neuroimages.

Results:

We found that the way BVs entered the transverse sinus varied but was identifiable in DSA, CTV, and MRV images. Compared with the cadavers, DSA, CTV, and MRV revealed less than 50% of the BV entering the sinus because the smaller BVs were not seen on the neuroimages. However, the distribution pattern of the dural entrance of the BVs into the transverse sinus was relatively consistent between cadavers and neuroimages.

Conclusion:

Unique anatomic features of the dural entrance of a BV into the transverse sinus in the cadaver correspond to those evident in neuroimages; thus, identification of the dural entrance of the BVs with neuroimaging modalities provides a reliable measure for preoperative planning.

[Case of transient cortical blindness due to thrombosis of the transverse sinus]

An 62-year-old man presented visual impairment and generalized seizure. Brain CT performed on the day of admission showed thrombus in the right transverse sinus, and DWI showed high intensity areas in the bilateral occipital and parietal lobes. According to bilateral occipital lobe lesions, we considered his visual impairment as cortical blindness. He was diagnosed as venous sinus thrombosis and intravenous heparin, edaravone and osmotic diuretics were administered. MR venography performed after starting of intravenous treatment showed flow gap in the left transverse sinus but no abnormalities in the right transverse sinus. On the second day of hospitalization, his cortical blindness showed improvement and thrombus in the right transverse sinus were disappeared. This indicated that his left transverse sinus originally hypoplastic, thrombus and hemostatis in the right transverse sinus (his dominant side) caused his cortical blindness and generalized seizure. There was a recanalization in the right transverse sinus after heparin therapy.

Neurocritical care of patients with central nervous system infections

Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure (ICP), hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. The importance of emergent administration of appropriate antimicrobial therapy cannot be overstated, but critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available to manage central nervous system (CNS) infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes. It is our opinion that ICP measurement should be strongly considered in selected patients with CNS infections, particularly those who are comatose. Treatments for intracranial hypertension, specifically in the setting of CNS infection, are described in this paper. For bacterial meningitis, intravenous dexamethasone should be administered, beginning concomitantly with the initial dose of antibiotics, at least until Streptococcus pneumoniae can be excluded as a pathogen. Clinicians should maintain a high index of suspicion for nonconvulsive seizures. Deterioration in neurologic status should also prompt early use of CT or magnetic resonance angiography and venography to exclude cerebrovascular complications.

Simultaneous presentations of deep vein thrombosis and cerebral sinus thrombosis in a case of primary antiphospholipid syndrome

Antiphospholipid syndrome is characterized with arterial and venous thrombosis. In this article, a 38-year-old man presented with headache and swelling of his left limb, which had lasted for 2 months. Duplex ultrasonography showed thrombosis of the left femoral vein. Cerebral magnetic resonance imaging also showed cerebral sinus thrombosis. Serological examination showed that antiphospholipid syndrome was the underlying disease condition in this patient. Despite adequate anticoagulant therapy, deep vein thrombosis and cerebral sinus thrombosis exacerbated, resulting in inferior vena cava occlusion, papilloedema, and abducent nerve paralysis. Optic canal decompression and cistern-peritoneal shunt operation were performed, following which his neurological symptoms were relieved. The occurrence of cerebral sinus thrombosis as initial presentation of antiphospholipid syndrome is extremely rare and remains a diagnostic challenge. Although the clinical presentation is highly variable, the diagnosis should be considered in patients with antiphospholipid syndrome presenting with recent unusual headaches. Improved diagnosis and treatment strategy may ultimately improve the clinical outcome of these patients.

Neuro-ophthalmology

Neuro-ophthalmologic disorders arise from all areas of the neuro-ophthalmologic tract. They may be expressed simply as loss of vision or double vision, or as complex syndromes or systemic illnesses, depending on the location and type of lesion. Problems may occur anywhere along the visual pathway, including the brainstem, cavernous sinus, subarachnoid space, and orbital apex, and may affect adjacent structures also. A firm understanding of the neuroanatomy and neurophysiology of the eye is essential to correct diagnosis.

Cerebral vein and dural sinus thrombosis in adults in Isfahan, Iran: frequency and seasonal variation

OBJECTIVE

To estimate the frequency of cerebral vein and dural sinus thrombosis (CVST) and its seasonal variation.

METHODS

A clinic-based prospective case-register study was conducted from 2001 to 2004. Hundred and twenty-two consecutive definite CVST patients (26 men and 96 women) treated in two major neurological centres of Isfahan, Iran, were included in the study. Part of examination included an assessment of CVST including conventional angiography and/or magnetic resonance imaging and self-reported medical history. Population data were obtained from the 1996 Iran Census. The mean (standard deviation) age of participants was 35.5 (11.9) years.

RESULTS

The annual frequency (95% confidence interval) of CVST was 12.3 (10.1, 14.5) per million in a population of 2,472,751, with higher rate in women than in men [19.9 (15.5, 23.9) women and 5.1 (3.2, 7.1) men] and with increasing age in women (up to 50 years), but not in men. The female/male ratio was 3.9 (2.5-6.0). The monthly frequency of CVST ranged from 0.6 per million (0.1, 1.1) in August to 2.1 (1.2, 3.0) in September. The seasonal CVST rate ranged from 2.2 per million (1.3, 3.2) in summer to 4.3 (3.1, 5.7) in autumn. The differences were statistically significant either for the months or season (P < 0.05).

CONCLUSION

The findings of this study show the CVST frequency in adults. More women than men are present with CVST and its frequency increased during autumn.

[Local intravenous fibrinolysis in deep cerebral vein thrombosis]

Acute cerebral vein and dural sinus thrombosis are usually treated with unfractionated intravenous heparin. Progression of symptoms after appropriate heparin dosage appears to be a rare event. In the literature only single case reports or small case series dealing with local intravenous fibrinolysis are available. Here we describe a 44-year-old woman with progressive thrombosis of the sinus rectus and right sinus transversus upon an appropriate dosage of heparin who was successfully treated with urokinase 12 h after symptom onset. This case demonstrates that local thrombolysis should be discussed in patients with progression of the clinical or radiological picture under sufficient heparin therapy.

A hypothesis of cerebral venous system regulation based on a study of the junction between the cortical bridging veins and the superior sagittal sinus

Object

The cerebral venous regulation involved in various physiological and pathological processes has received little attention. Here the authors describe the anatomy of the junction between the cortical vein and the superior sagittal sinus (SSS) and propose a new theory of cerebral venous regulation.

Methods

Ten adult human cadaveric heads (20 sides), including five specimens into which stained latex had been injected, were used for anatomical study. Formalin-fixed cadaver heads were dissected to demonstrate the cortical veins along the SSS. The characteristics of the cortical bridging veins and their openings into the SSS were established by anatomical, histological, immunohistochemical, and ultrastructural study of the junction.

Results

After their subarachnoid course, the cortical bridging veins penetrated the SSS at different points in the dura mater depending on their rostrocaudal position. The venous endothelium stretched beyond the sinus endothelium. The orientation of the collagen fibers changed at the level of the venous openings, with the luminal diameter becoming narrow and oval-shaped. The major finding was the organization of the smooth-muscle cells at the end of each cortical vein. At this site and particularly in the frontoparietal region, the vessel resembled a myoendothelial “sphincter.” The authors hypothesize that this organization is involved in cerebral venous system regulation.

Conclusions

The point of convergence between the cortical veins and the SSS is a key area. The authors also hypothesize that the myoendothelial junction acts as a smooth sphincter and that it plays a role in cerebral venous hemodynamics and pathological conditions.

Cerebral venous thrombosis: a case report

The incidence of cerebral venous thrombosis (CVT) is three to four cases per one million in adults and seven cases per one million among children. We discuss a case of CVT in a 19-year-old woman with a history of migraine headaches. A CVT most commonly presents acutely, with a wide variety of signs and symptoms in young adults and children. The most common presenting complaint in adults is severe headache. The most frequently thrombosed sinuses are the lateral, cavernous, and superior sagittal sinuses. Risk factors include any genetic or acquired prothrombotic conditions, including pregnancy and the peripartum period. Computed tomography may show the classic "delta sign," although magnetic resonance imaging with magnetic resonance venography is more sensitive. Treatment is controversial at this time. Options include fibrinolysis, anticoagulation, mechanical thrombectomy, or surgery. Despite the lack of agreement on management of CVT, the prognosis of CVT has improved, due to an increasing frequency of diagnosis.

An unusual cause of cerebral venous sinus thrombosis: prothrombin G20210A gene mutation

Cerebral venous sinus thrombosis represents less than 1% of all strokes, being an uncommon entity with a wide spectrum of clinical scenarios. We present a 45-year-old Hispanic female with a history of long-term oral contraceptive use who was diagnosed with cerebral venous sinus thrombosis due to a heterozygous carrier mutation in the prothrombin G20210A gene. The patient was successfully managed with intravenous heparin with favorable clinical results without adverse effects. The prevalence of inherited primary thrombophilia increases with additional risk factors such as the use of oral contraceptives that can trigger or prothrombotic events in any vascular bed. An increased prevalence in the prothrombin G20210 gene mutation has been demonstrated in the Mexican-Mestizo population. Controversy exists regarding therapy of cerebral venous sinus thrombosis; according to experts, heparin remains the cornerstone of therapy with acceptable outcomes. More clinical trials are required to evaluate long-term outcomes in this subgroup of patients.

Demonstration of significant resolution of cerebral sino-venous thrombosis associated with intravenous recombinant tissue plasminogen activator

BACKGROUND

Cerebral sino-venous thrombosis (CVT) is commonly treated with anticoagulant therapy. There are reports of response to endovascular thrombolysis with or without mechanical aspiration in patients with clinical deterioration.

CASE

We present a 29-year-old man with acute onset of severe headache, found to have extensive CVT by magnetic resonance venography (MRV). His atypical presentation led to cerebral angiography that was complicated by global aphasia and right hemiparesis from left middle cerebral artery distribution ischemia. He received intravenous rt-PA (recombinant tissue plasminogen activator) within an hour of the procedure followed, 24 hours later, by intravenous heparin infusion with significant clinical improvement. The headache severity and CVT, on follow-up MRV, resolved significantly within 2 days.

CONCLUSIONS

We demonstrate clinical and neuroimaging response to systemic rt-PA in CVT. Thrombolysis may have a role in CVT management with an extended therapeutic window.

Thrombophilic risk factors among 16 Lebanese patients with cerebral venous and sinus thrombosis

Cerebral venous and sinus thrombosis (CVST) is a multifaceted disorder. The frequency of inherited and acquired thrombophilia among 16 CVST patients was evaluated. The mean age of the patients was 22.9 years. Five out of the 16 CVST patients (31.2%) showed the G1691A mutation of factor V. The frequency of the C677T methylenetetrahydrofolate reductase (MTHFR) genotype was 50% (8/16) in patients (2 of them were homozygous). Four of the patients (25%) had both factor V Leiden and MTHFR mutation. Three of the patients had positive antiphospholipid antibodies. At the time of CVST, 2 female patients were taking oral contraceptive pills. Four patients were known to have malignancies. Despite the limitation of the sample size, we identified an inherited coagulopathy at high rate in our patients. Combined inherited thrombophilia was also present in 25% of patients. This finding supports the impression of a multifactorial process leading to CVST in Lebanese patients.

Recurrent venous thrombosis including cerebral venous sinus thrombosis in a patient taking sildenafil for erectile dysfunction

Acquired or hereditary prothrombotic risk factors may lead to cerebral venous sinus thrombosis (CVST), particularly when other predisposing factors coexist. A 57-year-old man experienced right leg deep venous thrombosis, severe thrombosis of the haemorrhoid plexus and CVST over a 12-month period during which he was taking sildenafil regularly twice a week. Sildenafil is a phosphodiesterase 5 (PDE5)-inhibitor used for erectile dysfunction (ED). A slight reduction in antithrombin III and free protein S levels was demonstrated. After suspension of sildenafil and six months on oral anticoagulants, clinical improvement was obtained. Recurrent venous thrombosis, including CVST, may complicate prolonged treatment with PDE5-inhibitors in subjects at risk. Periodic monitoring of clotting factors is recommended in these subjects.

Neurocritical care of patients with central nervous system infections

Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure, hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. Critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available in managing central nervous system infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes.

Spontaneous superior sagittal sinus thrombosis secondary to type II heparin-induced thrombocytopenia presenting as an acute subarachnoid hemorrhage

Cerebral sinus thrombosis is a rare cause of spontaneous subarachnoid hemorrhage. The development of cerebral sinus thrombosis as a complication of heparin-induced thrombocytopenia is even rarer. In this paper, we present a 59-year-old patient admitted to our service with cerebral sinus thrombosis secondary to type II heparin-induced thrombocytopenia. We also review the literature in regard to the incidence, pathophysiology and management of this rare clinicopathological entity.

The coagulation system in endocrine disorders: a narrative review

Endocrine disorders can influence the haemostatic balance. Abnormal coagulation test results have been observed in patients with abnormal hormone levels. Also unprovoked bleeding or thrombotic events have been associated with endocrine disease. The aim of the present review is to summarise the available evidence on the influence of common endocrine disorders on the coagulation system, and their possible clinical implications. We focus on thyroid dysfunction, hyper- and hypocortisolism and growth hormone disturbances, while other endocrine disorders are only briefly discussed. In the published literature a clear bleeding diathesis has only been associated with overt hypothyroidism, mainly mediated by an acquired von Willebrand syndrome. A clinically relevant hypercoagulable state may be present in patients with hyperthyroidism, hypercortisolism or abnormal growth hormone levels, but adequate prospective clinical studies are lacking. Also effects of pheochromocytoma, hyperprolactinaemia and hyperaldosteronism on the coagulation system have been described. It is apparent that unprovoked bleeding and thrombotic episodes can be secondary to endocrine disorders.

Trombofilia genética y trombosis de senos venosos cerebrales

BACKGROUND AND OBJECTIVE

Sinus cerebral venous thrombosis (SCVT) is an unfrequent disease, with variable clinical presentation and prognosis. The objective of this study was to analyze the relationship between factor V Leiden, prothrombin G20210A mutation (PT 20210A) and MTHR and SCVT.

PATIENTS AND METHOD

Cases and control study including 15 patients with diagnosis of SCVT. We performed a genetic analysis of the mutation of factor V Leiden, the PT G20210A and the C677T of the MTHR.

RESULTS

Factor V Leiden: 26.6% heterozygote in cases and only 8.3% in control group, thus showing odds ratio [OR] = 4,0. Mutation 20210A of the prothrombin: in patients, 13.3% of heterozygote, while a 6,6% in controls, finding an OR = 2.1 (95% confidence interval [CI], 1.67-10.04). Mutation of the MTHR: 40% heterozygote and 20% homozygote in patients group respect to 51.6% and 6,9%, respectively, in the control group, but no statistical differences were found.

CONCLUSIONS

The presence of factor V Leiden and PT 20210A are risk factors for SCVT, but not the mutation of the MTHR.

Incidence of the JAK2 V617F mutation among patients with splanchnic or cerebral venous thrombosis and without overt chronic myeloproliferative disorders

BACKGROUND

Thrombosis of splanchnic or cerebral veins is a typical manifestation of polycythemia vera (PV) or essential thrombocythemia (ET). The recently identified Janus kinase 2 (JAK2) V617F somatic mutation is closely related to chronic myeloproliferative disorders (CMD).

OBJECTIVE

To assess the incidence of the JAK2 V617F mutation among patients with splanchnic or cerebral venous thrombosis with or without overt CMD.

PATIENTS AND METHODS

We searched for the mutation in 139 adult patients (> 18 years old) with thrombosis of hepatic veins (HVT, n = 15), or extrahepatic portal vein (PVT) and/or mesenteric vein (MVT) (n = 79), or cerebral veins (CVT, n = 45). Only 19 patients fulfilled criteria for diagnosis of PV (n = 8) or ET (n = 11) at the time of thrombosis: four had HVT, 11 PVT and/or MVT, and four CVT.

RESULTS

The JAK2 V617F mutation was found in 94.7% [95% CI 75.3-99.0] of the patients with overt CMD at the time of thrombosis, in 21.5% (95% CI 13.8-31.7) of the patients with abdominal venous thrombosis and without overt CMD, and in 4.8% (95% CI 1.3-16.1) of the patients with CVT and without overt CMD. Among the patients without overt CMD or thrombophilia and with unprovoked thrombosis, 29.4% (95% CI 16.8-46.1) with splanchnic venous thrombosis and 42.8% (95% CI 24.4-63.4) with PVT had the JAK2 V617F mutation.

CONCLUSIONS

A substantial proportion of patients with splanchnic venous thrombosis and a small, but significant, number of patients with CVT can be recognized as carriers of the JAK2 V617F mutation in the absence of overt signs of CMD. The clinical significance of such findings deserves further investigation.

Molecular MRI of cerebral venous sinus thrombosis using a new fibrin-specific MR contrast agent

BACKGROUND AND PURPOSE

Imaging of cerebral vein thrombosis is still challenging. Currently, diagnosis is based on CT venography and MRI including MRA and conventional digital subtraction angiography. However, especially in chronic cases, each method has shown its limitations. Newer strategies for MRI are found on molecular imaging using targeted contrast agents. The aim of this study was to prove the feasibility of a novel fibrin-targeted MR contrast agent (EP-2104R; EPIX Pharmaceuticals) for selective imaging of sinus venous thrombosis in an animal model.

METHODS

Thrombosis of the superior sagittal sinus with human blood was induced in 6 pigs using a combined microsurgical and interventional approach. MRI was then performed before and up to 120 minutes after injection of 4 micromol/kg body weight EP-2104R. Molecular imaging was performed with a 3-dimensional high-resolution T1-weighted gradient echo sequence. Time courses of signal-to-noise ratio and contrast-to-noise ratio were analyzed. Thrombi were then surgically removed and the Gadolinium concentration was assessed.

RESULTS

In all cases the thrombosis could be successfully induced; the complete MR protocol could be performed in 5 animals. In these cases the thrombi showed selective enhancement after injection of the molecular contrast agent. However, a continuous contrast-to-noise ratio increase was seen up to 120 minutes after contrast administration, achieving a contrast-to-noise ratio of 14.2+/-0.7 between clot and the blood pool.

CONCLUSIONS

The novel fibrin-targeted molecular MR contrast EP-2104R allows selective and high-contrast imaging of cerebral sinus vein thrombosis in an animal model.

Fatal cerebral and cerebellar hemorrhagic infarction after thoracoscopic microdiscectomy

✓ The authors present a rare case of fatal cerebral and cerebellar hemorrhagic infarction following an uneventful thoracoscopic microdiscectomy. They hypothesize that this complication was associated with cortical venous thrombosis secondary to intracranial hypotension, which was caused by an unnoticed leak of cerebrospinal fluid (CSF) into the thoracic cavity. Cortical venous thrombosis and intrathoracic CSF were confirmed at autopsy. The former disorder is the most severe manifestation of the pathophysiological mechanism occurring to a lesser degree in patients affected by mild intracranial hypotension, and occurs more frequently in these patients. Intracranial hypotension (of an orthostatic nature or not) must be considered in the differential diagnosis of every patient who complains of headaches after thoracoscopic or open transthoracic microdiscectomy.

Cerebral venous thrombosis: an update

Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular disease that can occur at any age, including in neonates, and it accounts for 0.5% of all stroke. The widespread use of neuroimaging now allows for early diagnosis and has completely modified our knowledge on this disorder. CVT is more common than previously thought and it is recognised as a non-septic disorder with a wide spectrum of clinical presentations, numerous causes, and usually a favourable outcome with a low mortality rate. MRI with T1, T2, fluid-attenuated inversion recovery, and T2* sequences combined with magnetic resonance angiography are the best diagnostic methods. D-dimer concentrations are raised in most patients but normal D-dimers do not rule out CVT, particularly in patients who present with isolated headache. Heparin is the first-line treatment, but in a few cases more aggressive treatments, such as local intravenous thrombolysis, mechanical thrombectomy, and decompressive hemicraniectomy, may be required.

The dural entrance of cerebral bridging veins into the superior sagittal sinus: an anatomical comparison between cadavers and digital subtraction angiography

INTRODUCTION

Intracranial venous structures have received increasing attention due to improved neuroimaging techniques and increased awareness of cerebral venous disease. To date, few studies have attempted to investigate the dural entrance of the cerebral bridging vein (BV). The aim of this study was to use the superior sagittal sinus (SSS) as an example to identify anatomical features of the dural entrance of the BVs into the SSS in both human cadavers and digital subtraction angiography (DSA) images.

METHODS

A total of 30 adult and 7 fetal human cadavers and 36 patients were examined with anatomical dissections, vascular casting and DSA. The number, diameter and angle of the BVs entering the SSS were measured and compared between the cadavers and DSA images.

RESULTS

The results demonstrated that (1) the way a BV entered the SSS varied in three dimensions, and thus the BV dural entrance was difficult to precisely localize by DSA, (2) the distribution pattern of the dural entrance of the BVs into the SSS was relatively constant and a nontributary segment of the SSS was centered at the coronal suture and was identifiable by DSA, and (3) nearly all the BVs (97%, 561/581) entered the SSS at an angle opposite to the direction of blood flow.

CONCLUSION

Unique anatomical features of the dural entrance of a BV into the SSS should be considered in neuroimaging interpretation of the sinus and its associated veins.

Thromboses veineuses cérébrales

Venous thromboses in the cerebrum are rare, within the context of both cerebrovascular disease and all of the venous thrombotic diseases. Its clinical aspects are polymorphic in their onset and in their acute phase, making diagnosis difficult. MRI with angiographic sequences can show the presence of a thrombus within a venous vessel and its consequences on the cerebral parenchyma. Hemostatic disorders are the leading causes of cerebral venous thrombosis, in particular, constitutional thrombophilia often associated with one or several promoting factors such as use of oral contraception. This explains the incidence peak among young women. The cause of approximately 20% of cerebral venous thromboses is never identified. Antithrombotic treatment must be prescribed on an emergency basis when the diagnosis is made, even if potentially hemorrhagic lesions are also present. The risk of permanent neurologic damage is approximately 13%.

Contribution of multiple thrombophilic and transient risk factors in the development of cerebral venous thrombosis

INTRODUCTION

Cerebral venous thrombosis (CVT), deep vein thrombosis (DVT) and/or pulmonary embolism (PE) have been associated with thrombophilic defects. However, in contrast to DVT or PE, CVT is a rare disease. We performed a study to identify differences in thrombotic risk profile, predisposing to CVT rather than DVT or PE, particularly the contribution of oral contraception and 11 thrombophilic defects.

MATERIALS AND METHODS

A single center case-control study (63 CVT cases and 209 controls with DVT or PE) was performed.

RESULTS

Of CVT patients, 11% had experienced prior DVT or PE, and none had recurrent CVT at 5 years follow-up. CVT was more frequently observed in females (79% versus 51%, P<0.001). It was more often secondary (75% versus 50%, P<0.001), mainly due to the difference in age between both groups. At presentation of CVT and DVT/PE, oral contraceptives were used by 78% and 74% of non-pregnant fertile women (P=0.8), respectively. Any thrombophilic defect was demonstrated in 88% of CVT and 75% of DVT/PE patients (P=0.22), sex and age matched. Individual and two or more defects were equally distributed among both groups.

CONCLUSIONS

We conclude that a majority of CVT and DVT or PE patients show single or multiple thrombophilic defects. At presentation, oral contraceptive intake was observed more frequently in CVT patients. However, no differences were observed in thrombotic risk profile between both groups of comparable age. Hence, additional unknown risk factors should be considered to explain the different sites of thrombosis in these patients.

[Recommendations of the European Stroke Initiative for the diagnosis and treatment of spontaneous intracerebral haemorrhage]

This article summarises the recommendations for the management of managing patients with intracerebral haemorrhage published in 2006 by the European Stroke Initiative (EUSI) on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

Recurrent Cerebral Venous Thrombosis Associated with Elevated Factor VIII

Cerebral venous thrombosis (CVT) rarely recurs, and the factors associated with a recurrence remain unclear. Recently, however, elevated plasma coagulation factor VIII has been considered a factor related to recurrent venous thromboembolism. Here we report a patient who had recurrent CVT associated with significantly elevated levels of factor VIII despite the chronic use of an antiplatelet agent. Factor IX was also elevated in this patient. These findings suggest that elevated factor VIII is a factor underlying the recurrence of CVT, and that prolonged anticoagulation therapy may have to be considered in patients with elevated coagulation factor levels.

Cerebral venous thrombosis and hepatitis: case report

Among the many infective causes of cerebral venous thrombosis (CVT), viral hepatitis is been regarded as a rare associated condition. We report on a 56-years-old man presenting CVT associated with hepatitis B and C coinfections outlining probable pathogenic mechanisms. We suggest that virus B and C serology should be performed in the cases of cerebral venous thrombosis with unknown etiology.