Epidemiology of cerebral venous sinus thrombosis and cerebral venous sinus thrombosis with thrombocytopenia in the United States, 2018 and 2019

Cerebral Venous Sinus Thrombosis During Pregnancy and the Postpartum Period: A Review of Pathophysiological Mechanisms, Clinical Manifestations, and Treatment Approaches

Cerebral venous sinus thrombosis (CVST) is a rare neurological emergency associated with significant morbidity and mortality. CVST has been found to account for up to 57% of pregnancy-related strokes. Pregnancy and the postpartum period are associated with physiological changes that lead to a hypercoagulable state, increasing the risk for CVST. The pathophysiological mechanism for CVST involves increased venule and capillary pressure as well as intracranial pressure, which lead to clinical manifestations such as headaches, seizures, and focal neurological deficits. Diagnosis involves imaging including computed tomography, magnetic resonance imaging, venography, and in some cases, cerebral angiography. Treatment options during pregnancy and postpartum include anticoagulation with low molecular weight heparin and symptomatic management. Further research is needed to elucidate the safety and efficacy of endovascular treatment techniques in severe or refractory cases of CVST, particularly during pregnancy and puerperium. In this review, we describe the physiological changes of pregnancy, outline the pathophysiological mechanisms and clinical findings of CVST, and discuss treatment approaches specific to pregnancy and the postpartum period.

Sinus vein thrombosis conundrum: Persistent empty sella vs. flexible optic nerve sheath

INTRODUCTION

Our objective was to investigate the potential effect of thrombotic burden on pituitary gland height, bony sella and optic sheath width, taking into consideration the various venous sites and dominant drainage pattern.

PATIENTS AND METHODS

This retrospective cohort study followed patients diagnosed with cerebral sinus vein thrombosis in a single primary healthcare center between the years 2000 and 2022. Data was collected from both CT/V and MR/V scans available on the local PACS system. Dural sinuses were divided into main anatomical sites and scored for patent, partially or totally blocked lumen. Dominant drainage flow was noted for each patient. For most scans, pituitary mid height, maximal depth and AP width of the bony sella and dorsum sella to tuberculum sella distance were assessed. Optic sheath width was measured for both sides at the maximal retrobulbar diameter. Regression methods, including linear mixed models, and non-parametric tests were used to analyze the data.

RESULTS

90 patients (mean age, 44 years ±16.8, 54 women) were evaluated. Overall thrombus burden did not correlate with pituitary mid-height, however a relationship was observed between the change (from presentation) in the superficial thrombus score and the average width of the optic nerve sheath; the width of the optic sheath tended to decrease as thrombus burden improved and vice versa (p = 0.010).

CONCLUSIONS

Thrombus recanalization had a favorable effect on the optic nerve sheath diameter but did not appear to reverse the flattening of the pituitary gland, regardless of temporal improvement.

Anticoagulation Status and Outcome in Cerebral Venous Thrombosis: A Single-Center Retrospective Study from South India

BACKGROUND AND OBJECTIVES

Early initiation and maintenance of anticoagulation appears to be the mainstay of treatment of cerebral venous thrombosis (CVT), but the evidence supporting the intensity and duration of anticoagulation is limited.

METHODS

We retrospectively collected data of patients admitted with CVT over a 5-year period, who had a minimum of 6 months of clinical follow-up and three or more prothrombin time international normalized ratio (INR) values spread over 6 months. Data collected included demographic, clinical, and radiologic parameters, anticoagulation status during the follow-up, complications, and clinical status at the last follow-up.

RESULTS

We identified 204 patients, and the mean age was 34.4 ± 11.1 years. The majority had a provoked etiology (194, 95.1%) for CVT. After initial anticoagulation with unfractionated heparin, all patients transitioned to acenocoumarol or warfarin and this was maintained for a mean duration of 16.02 ± 11.2 months. Time in therapeutic range of INR 2-3 was only 5.1 ± 11.8 percent days and time spent in an INR of 1-1.5 was 68.7 ± 31.8 percent days. The average INR over 6 months was 1.37 ± 0.33. Duration of follow-up was 18.9 ± 13.25 months, and a good outcome was noted in 183 (89.7%) patients. Complications were seen in 29 (14.2%) patients. Multivariate analysis showed only the CVT grading scale score to be an independent predictor of good outcome.

CONCLUSIONS

Maintenance of an intensive level of anticoagulation may not be required in patients with CVT and may be particularly true when a transient and treatable risk factor is the provoking etiology.

Cerebral Venous Sinus Thrombosis Following Scrub Typhus Meningoencephalitis in a Pregnant Woman

Background

Scrub typhus, a mite-borne zoonosis caused by Orientia tsutsugamushi, is prevalent in the Asia Pacific region and presents with various neurological manifestations, including meningoencephalitis, polyneuropathy, and, rarely, cerebral venous sinus thrombosis (CVST).

Case Report

We report a unique case of CVST following scrub typhus meningoencephalitis in an 18-year-old pregnant woman from West Bengal, India. Her condition was complicated by fever, headache, neck stiffness, and altered sensorium. Laboratory tests revealed leukopenia and thrombocytopenia, while serologies for other infectious diseases were negative. Cerebrospinal fluid analysis was significant for lymphocytic pleocytosis and elevated protein, with a positive O tsutsugamushi-IgM assay. Treatment with azithromycin resulted in initial improvement; however, persistent headaches led to the discovery of CVST. The patient responded well to anticoagulation therapy with low molecular weight heparin and was discharged asymptomatic, with subsequent uneventful pregnancy and delivery.

Discussion

Cerebral venous sinus thrombosis should be ruled out in pregnant women with refractory scrub typhus meningoencephalitis despite antibiotic therapy. Because scrub typhus is treatable with intravenous doxycycline and azithromycin, it should be considered in the workup of febrile patients with acute onset neurological disorders in the tropics or subtropics or travelers coming back from endemic areas, despite the absence of eschar and unremarkable neuroimaging findings.

Sex differences in clinical profile and risk factors of cerebral venous sinus thrombosis at a high-altitude area: A 10-year retrospective cross-sectional study

Cerebral venous sinus thrombosis (CVST) is an uncommon disorder with an increased mortality risk. Data on the sex-specific clinical profile and related factors can be practical in clinical diagnosis and management. Thus, we aimed to assess CVST characteristics in Shahrekord, the most elevated city among the centers of the provinces of Iran, referred to as the Roof of Iran. In this retrospective cross-sectional study, we reviewed the hospital records of 127 CVST patients between April 2013 and June 2023 to analyze the demographic characteristics, clinical profile, disease outcomes, and risk factors. STROBE guidelines were used to report this study. Females comprised 65.3% of the study. Females' age was almost equal to male patients (37.51 ± 13.95 years vs 38.09 ± 16.18 years, P = .832), and more than half of the patients (59.1%) were married. Clinical characteristics showed no significant difference between the sexes. In contrast to males, females had multifarious risk factors. However, the main risk factors for both sexes were CVST and hypertension. Most patients had 1 sinus affected (55.9%), and the location of thrombosis was mainly in the right transverse sinus in males (38.63%) and superior sagittal sinus in females (33.73%). However, those with more than 2 affected sinuses were mostly women. Regarding radiological findings, sinusitis was significantly seen in men (18.18% vs 3.61%). Among laboratory data, females significantly had higher erythrocyte sedimentation rate levels than males (21.66 ± 24.39 vs 9.60 ± 8.55). This study indicates that among CVST patients, men have significantly higher occurrences of sinusitis, and higher levels of erythrocyte sedimentation rate were observed in women. However, no other significant differences were found. More extensive studies are essential to fully comprehend the sex-specific aspects of CVST.

Alcohol Emergence: A Study on Various Risk Factors and Clinical Characteristics in Patients With Cerebral Venous Sinus Thrombosis From a Tertiary Care Hospital in South India

Objective and aim Cerebral venous thrombosis (CVT) is a rare condition with significant morbidity and mortality risk involving the thrombosis of cerebral veins and dural sinuses. Its symptoms vary widely, ranging from headaches to focal neurological deficits, posing significant challenges to its diagnosis. Various contributing factors are involved in its etiology, some of which are gender specific. The clinical presentation varies widely and differs based on geographic distribution. This diversity makes CSVT challenging to diagnose, as it manifests in different ways and requires keen medical observation. Early detection is crucial for prognosis, as addressing the underlying cause can prevent further complications. This study aims to identify various causative factors and clinical presentations observed in individuals diagnosed with cerebral venous sinus thrombosis (CVST). Material and methods This prospective observational study was conducted at the Department of Neurology for a year, involving 55 patients admitted to the Neurology OPD/ER. Sample selection was done using non-probability convenience sampling. Patients aged 18 years or older presenting with symptoms indicative of CVST, confirmed by neuroimaging, were included in the study. Patients with arterial stroke, space-occupying lesions, and CVST related to pregnancy or puerperium were excluded. A detailed and structured medical history was obtained, and relevant blood investigations were conducted to find the underlying etiology. Results The study population had a mean age of 33 ± 2.04 years. The gender distribution is inclined towards 78.1% males due to the exclusion of pregnancy- or puerperium-related CVST to identify other predominant risk factors. 87.2% of the patients presented acutely, primarily with headaches (94.54%), and 67.2% had seizures within a week of admission. Prothrombotic conditions (45.4%) were the prevalent risk factor in the study group. Second, infections accounted for 21.8%. Alcoholism was seen in 52.7% of the study population, but its correlation with CVST remains unclear. The superior sagittal sinus (34.5%) and transverse sinus (20%) were commonly involved in neuroimaging, with multiple sinus involvement observed in some cases. Conclusion Cerebral venous sinus thrombosis (CVST) presents with a wide range of symptoms, making diagnosis challenging. However, with modern imaging and lab tests, we can detect and treat it effectively, often with positive outcomes and minimal long-term effects. This study seeks to understand the risk factors associated with CVST, contributing to its diagnosis and management.

Safety and Efficacy of Newer Oral Anticoagulants Versus Vitamin K Antagonists in the Management of Cerebral Venous Thrombosis: A Single-Center Ambispective Study from South India

INTRODUCTION

Cerebral Venous Thrombosis (CVT) poses a rare but life-threatening challenge, warranting meticulous treatment approaches. Traditional therapy involves Vitamin K Antagonists (VKAs), but Newer Oral Anticoagulants (NOACs) offer potential advantages. This study addresses a crucial knowledge gap in the Indian context, analyzing real-world data to guide CVT management decisions.

METHODS

A single-center, ambispective cohort study included consecutive adult CVT patients. Data collection encompassed demographics, clinical data, imaging, and treatment details. Patients were categorized into VKA and NOAC groups. Outcomes measured recanalization status, functional outcomes, bleeding events, and adverse drug reactions.

RESULTS

Among 181 enrolled patients, NOAC-treated (Group B) individuals had significantly higher rates of complete recanalization (58.5% vs. 31.1%) with a similar incidence of adverse events and also displayed better functional outcomes at weeks 8 and 12 compared to VKA-treated (Group A) patients. Recurrent thromboembolic events were absent in both groups during follow-up.

CONCLUSION

This study highlights NOACs' potential advantages in CVT management, including improved functional outcomes, enhanced recanalization, and similar bleeding risk. Adverse events were milder with NOACs. While acknowledging limitations, these findings support NOACs as a promising alternative to VKAs, advancing CVT care and outcomes.

Cerebral venous sinus thrombosis and thrombocytopenia due to heparin-independent anti-PF4 antibodies after adenovirus infection

Not available.

Effectiveness of rivaroxaban in preventing cerebral venous thromboembolism: a systematic review and meta-analysis

Background

Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even death. The optimal treatment regimen for patients with CVT remains unclear.

Methods

MEDLINE, Embase, Google Scholar, Web of Science (WoS), and Cochrane Central databases were searched for randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of rivaroxaban in patients with CVT. All-site venous thromboembolism (VTE), risk of clinically relevant non-major bleeding, incidence of partial recanalization, complete recanalization and major haemorrhage were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs.

Results

The analysis included 1 RCT and 3 observational studies containing 211 patients. Compared to vitamin K antagonists (VKAs), rivaroxaban did not significantly decrease the all-site VTE [RR 0.31 (95% CI 0.01, 8.43); P=0.49, I2=0%]. Compared with VKAs, patients on rivaroxaban did not show a significantly reduced risk of recurrent cerebral venous thrombosis. In terms of incidence of partial recanalization, there was no discernible difference between rivaroxaban and VKAs [RR 0.90 (95% CI 0.66, 1.22); P=0.49, I2=0%]. There was no discernible difference in incidence of complete recanalization [RR 0.98 (95% CI 0.32, 3.03); P=0.97, I2=28%] and incidence of major haemorrhage [RR 0.19 (95% CI 0.01, 4.54); P=0.30].

Conclusion

Rivaroxaban was found to have similar efficacy to VKAs. Due to its lower risk of severe bleeding and no need for INR monitoring, rivaroxaban may be a preferable treatment option for CVT.

Incidence rates of thrombosis with thrombocytopenia syndrome (TTS) among adults in United States commercial and Medicare claims databases, 2017-2020

BACKGROUND

Increased risk of thrombosis with thrombocytopenia syndrome (TTS) following adenovirus vector-based COVID-19 vaccinations has been identified in passive surveillance systems. TTS incidence rates (IRs) in the United States (U.S.) are needed to contextualize reports following COVID-19 vaccination.

METHODS

We estimated annual and monthly IRs of overall TTS, common site TTS, and unusual site TTS for adults aged 18-64 years in Carelon Research and MarketScan commercial claims (2017-Oct 2020), CVS Health and Optum commercial claims (2019-Oct 2020), and adults aged ≥ 65 years using CMS Medicare claims (2019-Oct 2020); IRs were stratified by age, sex, and race/ethnicity (CMS Medicare).

RESULTS

Across data sources, annual IRs for overall TTS were similar between Jan-Dec 2019 and Jan-Oct 2020. Rates were higher in Medicare (IRs: 370.72 and 365.63 per 100,000 person-years for 2019 and 2020, respectively) than commercial data sources (MarketScan IRs: 24.21 and 24.06 per 100,000 person-years; Optum IRs: 32.60 and 31.29 per 100,000 person-years; Carelon Research IRs: 24.46 and 26.16 per 100,000 person-years; CVS Health IRs: 30.31 and 30.25 per 100,000 person-years). Across years and databases, common site TTS IRs increased with age and were higher among males. Among adults aged ≥ 65 years, the common site TTS IR was highest among non-Hispanic black adults. Annual unusual site TTS IRs ranged between 2.02 and 3.04 (commercial) and 12.49 (Medicare) per 100,000 person-years for Jan-Dec 2019; IRs ranged between 1.53 and 2.67 (commercial) and 11.57 (Medicare) per 100,000 person-years for Jan-Oct 2020. Unusual site TTS IRs were higher in males and increased with age in commercial data sources; among adults aged ≥ 65 years, IRs decreased with age and were highest among non-Hispanic American Indian/Alaska native adults.

CONCLUSION

TTS IRs were generally similar across years, higher for males, and increased with age. These rates may contribute to surveillance of post-vaccination TTS.

Vaccine-Induced Immune Thrombotic Thrombocytopenia: Clinicopathologic Features and New Perspectives on Anti-PF4 Antibody-Mediated Disorders

INTRODUCTION

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare yet severe adverse complication first identified during the global vaccination effort against SARS-CoV-2 infection, predominantly observed following administration of the ChAdOx1-S (Oxford-AstraZeneca) and Ad26.CoV2.S (Johnson & Johnson/Janssen) adenoviral vector-based vaccines. Unlike other anti-platelet factor 4 (PF4) antibody-mediated disorders, such as heparin-induced thrombocytopenia (HIT), VITT arises with the development of platelet-activating anti-PF4 antibodies 4-42 days post-vaccination, typically featuring thrombocytopenia and thrombosis at unusual sites.

AIM

To explore the unique properties, pathogenic mechanisms, and long-term persistence of VITT antibodies in patients, in comparison with other anti-PF4 antibody-mediated disorders.

DISCUSSION

This review highlights the complexity of VITT as it differs in antibody behavior and clinical presentation from other anti-PF4-mediated disorders, including the high incidence rate of cerebral venous sinus thrombosis (CVST) and the persistence of anti-PF4 antibodies, necessitating a re-evaluation of long-term patient care strategies. The nature of VITT antibodies and the underlying mechanisms triggering their production remain largely unknown.

CONCLUSION

The rise in awareness and subsequent prompt recognition of VITT is paramount in reducing mortality. As vaccination campaigns continue, understanding the role of adenoviral vector-based vaccines in VITT antibody production is crucial, not only for its immediate clinical implications, but also for developing safer vaccines in the future.

Ten-year Causes of Cerebral Venous Sinus Thrombosis in Patients Referred to Ghaem Hospital from 2009 to 2019

Objective

Cerebral Venous Sinus Thrombosis (CVST), a complex and infrequent cerebrovascular disorder characterized by the formation of clots within the cerebral venous sinuses, occurs as a result of multiple risk factors and casualties, and its epidemiological picture should be investigated.

Methods

This descriptive study was conducted retrospectively on patients with a final diagnosis of cerebral vein thrombosis, who were referred to the emergency room of Ghaem Hospital (Mashhad, Iran) between 2009 and 2019. The study included all patients with cerebral vein thrombosis who were older than 18 years. Clinical symptoms and causes were documented and contrasted according to demographics.

Results

During the 10 years of this study, 749 cases of cerebral vein thrombosis were observed, with women accounting for the majority (72.8%). The most prevalent symptom was headache (554 cases; 74.0%), followed by seizures (23.1%), blurred vision (16.0%), nausea (7.5%), vomiting (6.9%), double nose (4.9%), and dizziness (3.3%). There was no significant difference in the frequency of symptoms between the two genders (p<0.05). The most commonly identified risk factors were OCP (110 cases; 14.7%), followed by infection (103 cases; 13.8%), malignancies (78 cases; 10.4%), and fasting (15 cases; 2.0%). There was no significant difference in risk factors between the two genders, with the exception that all cases of fasting were in women, and the differences were significant (p=0.015). The most common site of involvement according to Magnetic Resonance Venography (MRV) was the upper sagittal sinus (427 cases; 57.0%). There was no significant difference in terms of the site of the conflict between the two genders (p<0.05).

Conclusion

The findings of the present study showed that deep vein thrombosis occurred mainly in women and manifested itself mostly as a headache. Moreover, the upper sagittal sinus was the most common site of involvement.

Sex Differences and Clinical Outcomes of Patients with Coronavirus Disease 2019 Infection and Cerebral Venous Sinus Thrombosis: A Systematic Review

Cerebral venous sinus thrombosis (CVST) is a rare neurovascular condition that has been observed in individuals with coronavirus disease 2019 (COVID-19). This systematic review aimed to explore the sex differences and characteristics of concurrent COVID-19 and CVST cases. A total of 212 CVST patients were included in the study. Women with CVST had a slightly higher mean age compared to men (47.359 years vs 46.08 years). Women were more likely to report symptoms such as fever (56.1%) and decreased sense of smell or taste (71.4%), while men more frequently experienced nausea or vomiting (55.6%), headache (62.9%), and seizures (72%). Notably, current smokers, who were predominantly men, had a higher occurrence of CVST. On the other hand, women had a higher likelihood of CVST risk factors such as oral contraceptive pill (OCP) use and autoimmune diseases. Treatment approaches also showed sex-based differences. Unfractionated heparin was administered more often to women with CVST (63.2%). The in-hospital mortality rate for CVST patients was 21.3%, with men having a significantly higher mortality rate than women (65.2% vs 34.8%, P = .027). Survival analysis revealed that factors such as smoking history, diabetes mellitus, hypertension, OCP use, COVID-19 symptoms, CVST symptoms, and the need for intubation significantly influenced survival outcomes. Understanding these sex differences in COVID-19-related CVST is crucial for accurate diagnosis and effective management, ultimately leading to improved patient outcomes. Our findings highlight the importance of considering sex as a factor in the evaluation and treatment of individuals with COVID-19 and concurrent CVST.

Cerebral Venous Sinus Thrombosis Following an mRNA COVID-19 Vaccination and Recent Oral Contraceptive Use

Rising concerns of cerebral venous sinus thrombosis (CVST) and other forms of venous thromboembolism have been associated with the SARS-CoV-2 vaccinations. Adverse effects with vector-based vaccines are well documented in the literature, while less is known about the mRNA vaccines. This report documents a case of CVST in a 32-year-old female patient who received her second Pfizer mRNA COVID-19 vaccination 16 days prior to hospital admission and had started oral combined contraceptives approximately 4 months beforehand. Clinicians should be cognizant of the possibility that mRNA vaccines, when combined with other risk factors like oral contraceptive pill use, may enhance one's hypercoagulable status.

Antithrombotic and antiplatelet effects of plant-derived compounds: a great utility potential for primary, secondary, and tertiary care in the framework of 3P medicine

Thromboembolism is the third leading vascular disease, with a high annual incidence of 1 to 2 cases per 1000 individuals within the general population. The broader term venous thromboembolism generally refers to deep vein thrombosis, pulmonary embolism, and/or a combination of both. Therefore, thromboembolism can affect both - the central and peripheral veins. Arterial thromboembolism causes systemic ischemia by disturbing blood flow and oxygen supply to organs, tissues, and cells causing, therefore, apoptosis and/or necrosis in the affected tissues. Currently applied antithrombotic drugs used, e.g. to protect affected individuals against ischemic stroke, demonstrate significant limitations. For example, platelet inhibitors possess only moderate efficacy. On the other hand, thrombolytics and anticoagulants significantly increase hemorrhage. Contextually, new approaches are extensively under consideration to develop next-generation antithrombotics with improved efficacy and more personalized and targeted application. To this end, phytochemicals show potent antithrombotic efficacy demonstrated in numerous in vitro, ex vivo, and in vivo models as well as in clinical evaluations conducted on healthy individuals and persons at high risk of thrombotic events, such as pregnant women (primary care), cancer, and COVID-19-affected patients (secondary and tertiary care). Here, we hypothesized that specific antithrombotic and antiplatelet effects of plant-derived compounds might be of great clinical utility in primary, secondary, and tertiary care. To increase the efficacy, precise patient stratification based on predictive diagnostics is essential for targeted protection and treatments tailored to the person in the framework of 3P medicine. Contextually, this paper aims at critical review toward the involvement of specific classes of phytochemicals in antiplatelet and anticoagulation adapted to clinical needs. The paper exemplifies selected plant-derived drugs, plant extracts, and whole plant foods/herbs demonstrating their specific antithrombotic, antiplatelet, and fibrinolytic activities relevant for primary, secondary, and tertiary care. One of the examples considered is antithrombotic and antiplatelet protection specifically relevant for COVID-19-affected patient groups.