Headache in cerebral venous thrombosis

Postoperative Cerebral Venous Sinus Thrombosis Following a Retrosigmoid Craniotomy-A Clinical and Radiological Analysis

Postoperative cerebral venous sinus thrombosis (CVST) is a rare complication of the retrosigmoid approach. To address the lack of literature, we performed a retrospective analysis. The thromboses were divided into those demonstrating radiological (rCVST) and clinical (cCVST) features, the latter diagnosed during hospitalization. We identified the former by a lack of contrast in the sigmoid (SS) or transverse sinuses (TS), and evaluated the closest distance from the craniotomy to quantify sinus exposure. We included 130 patients (males: 52, females: 78) with a median age of 46.0. They had rCVST in 46.9% of cases, most often in the TS (65.6%), and cCVST in 3.1% of cases. Distances to the sinuses were not different regarding the presence of cCVST (p = 0.32 and p = 0.72). The distance to the SS was not different regarding rCVST (p = 0.13). However, lower exposure of the TS correlated with a lower incidence of rCVST (p = 0.009). When surgery was performed on the side of the dominant sinuses, rCVSTs were more frequent (p = 0.042). None of the other examined factors were related to rCVST or cCVST. Surgery on the side of the dominant sinus, and the exposing of them, seems to be related with rCVST. Further prospective studies are needed to identify the risk factors and determine the best management.

Retrospective review COVID-19 vaccine induced thrombotic thrombocytopenia and cerebral venous thrombosis-what can we learn from the immune response

Introduction

Cerebral Venous Thrombosis (CVT), prior to the COVID pandemic, was rare representing 0.5 of all strokes, with the diagnosis made by MRI or CT venography.^1-,3 COVID-19 patients compared to general populations have a 30–60 times greater risk of CVT compared to non-affected populations, and up to a third of severe COVID patients may have thrombotic complications.^4–8 Currently, vaccines are the best way to prevent severe COVID-19. In February 2021, reports of CVT and Vaccine-induced immune thrombotic thrombocytopenia (VITT) related to adenovirus viral vector vaccines including the Oxford-AstraZeneca vaccine (AZD1222 (ChAdOx1)) and Johnson & Johnson COVID-19 vaccine (JNJ-78436735 (Ad26.COV2·S)), were noted, with a 1/583,000 incidence from Johnson and Johnson vaccine in the United States.^{11, 12} This study retrospectively analyzed CVT and cross-sectional venography at an Eastern Medical Center from 2018 to 2021, and presents radiographic examples of CVT and what is learned from the immune response.

Methods

After IRB approval, a retrospective review of cross-sectional CTV and MRVs from January 1st 2018 to April 30th 2021, at a single health system was performed. Indications, vaccine status, patient age, sex, and positive finding incidence were specifically assessed during March and April for each year. A multivariable-adjusted trends analysis using Poisson regression estimated venogram frequencies and multivariable logistic regression compared sex, age, indications and vaccination status.

Results and discussion

From January 1, 2018 to April 30, 2021, (Fig. 1), a total of n = 2206 in patient and emergency room cross-sectional venograms were obtained, with 322 CTVs and 1884 MRVs. In 2018, 2019, 2020, respective totals of cross-sectional venograms were 568, 657, 660, compared to 321 cross-sectional venograms in the first four months of 2021. CTV in 2018, 2019, 2020, respective totals were 51, 86, 97, MRV totals were 517, 571, 563, compared to the 2021 first four month totals of 88 CTVs and 233 MRVs. March, April 2018, 2019, 2020, CTVs respectively were 6, 17, 11, compared to the 2021 first four months of 59 CTVs, comprising 63% of the total 93 CTVs, respective MRVs were 79, 97, 52, compared to 143 MRVs in the first four months of 2021 for 39% of the total 371 MRVs. In March, April 2020 during the pandemic onset, cross-sectional imaging at the East Coast Medical Center decreased, as priorities were on maintaining patient ventilation, high level of care and limiting spread of disease. In March/April 2021, reports of VITT and CVT likely contributed to increased CTVs and MRVs, of 39.65% [1.20–1.63] increase (P < 0.001) from prior. In March, April 2021 of 202 venograms obtained, 158 (78.2.%) were unvaccinated patients, 16 positive for CVT (10.1%), 44 were on vaccinated patients (21.7%), 8 specifically ordered with vaccination as a clinical indication, 2 positive for CVT (4.5%), (odds ratio = 0.52 [0.12–2.38], p = 0.200).

Conclusion

CTV prior to the COVID pandemic, was rare, responsible for 0.5 of all strokes, at the onset of the pandemic in the East Coast, overall cross-sectional imaging volumes declined due to maintaining ventilation, high levels of care and limiting disease spread, although COVID-19 patients have a 30–60 times greater risk of CVT compared to the general population, and vaccination is currently the best option to mitigate severe disease. In early 2021, reports of adenoviral vector COVID vaccines causing CTV and VITT, led to at 39.65% increase in cross-sectional venography, however, in this study unvaccinated patients in 2021 had higher incidence of CVT (10.1%), compared to the vaccinated patients (4.5%). Clinicians should be aware that VITT CVT may present with a headache 5–30 days post-vaccination with thrombosis best diagnosed on CTV or MRV. If thrombosis is present with thrombocytopenia, platelets <150 × 10⁹, elevated D-Dimer >4000 FEU, and positive anti-PF4 ELISA assay, the diagnosis is definitive.¹³ VITT CVT resembles spontaneous autoimmune heparin induced thrombocytopenia (HIT), and is postulated to occur from platelet factor 4 (PF4) binding to vaccine adenoviral vectors forming a novel antigen, anti-PF4 memory B-cells and anti-PF4 (VITT) antibodies.^14–17

Different patterns of white matter lesions among patent foramen ovale, atherosclerotic cerebral small vessel disease and cerebral venous thrombosis

None of studies are available on the predictive ability of white matter lesions (WMLs) among patent foramen ovale (PFO), atherosclerotic cerebral small vessel disease (aCSVD) and cerebral venous thrombosis (CVT). Herein, we aimed to uncover the difference of the WML patterns among the three disease entities in a real-world setting to provide clinical references for predicting probable WML etiologies. We retrospectively reviewed data from consecutive patients with imaging-confirmed PFO, aCSVD, or CVT enrolled from 2014 through 2020. WMLs presented on fluid-attenuated inversion recovery (FLAIR) maps were compared among the three groups based on visual evaluation, Fazekas and modified Scheltens scales. Propensity score matching (PSM) was implemented to correct age and hypertension differences among groups. A total of 401 patients were entered into final analysis, including PFO (n = 112, 46.5 ± 12.8 years), aCSVD (n = 177, 61.6 ± 11.8 years) and CVT (n = 112, 37.4 ± 11.4 years) groups. In this study, WMLs occurred in all of the involved patients in the three groups (100%), which were independent to age, symptom onset and disease durations. On visual evaluation, PFO-WMLs were multiple spots distributed asymmetrically around bilateral subcortex and peri-ventricles. aCSVD-WMLs were dots or sheets distributed symmetrically in subcortex and peri-ventricles, and often coexisted with lacunar infarctions. CVT-WMLs were cloud-like around bilateral peri-ventricles, and enabled to attenuate after recanalization. Fazekas and modified Scheltens scores of PFO-WML vs. aCSVD-WML were significantly different even after being matched by 1:2 PSM (all p < 0.05), meaning that the WML burden in aCSVD was considerably heavier than that in PFO. WML patterns induced by PFO, aCSVD and CVT were obviously different, and were therefore of great clinical significance to preliminarily predict and differentiate the three diseases entities.

Cerebral venous thrombosis: a retrospective unicentric analysis of clinical and neuroimaging characteristics

Thrombosis of dural sinuses and/or cerebral veins (CVT) is an uncommon form of stroke, usually affecting young individuals. It has a variable clinical presentation ranging from mild cases presenting only headaches, to severe cases featuring encephalopathy, coma or status epilepticus. A retrospective cross-sectional study of patients treated in the outpatient department and in-hospital during the period from 2014 to 2020 at the Neurology Clinic-University Clinical Centre of Serbia was conducted. Forty-nine patients (24 men; 25 women) were included in the study. Twenty-three patients (46.9%) suffered a subacute form of CVT (48 h-4 weeks), 19 (38.8%) presented with an acute form (< 48 h) and 7 (14.3%) with a chronic form (> 4 weeks). Around 75% of patients reported headaches during disease course. Focal neurological deficit (FND) was observed in 27 (55.1%) patients. Patients who did not report headaches (22.4%) presented with more severe symptoms (seizures and coma). More than 70% of patients had no radiologically evident brain parenchymal lesion. The most frequent locations of CVT were transverse sinus (79.6%), sigmoid sinus (44.9%) and superior sagittal sinus (36.7%). Thrombosis of more than one sinus/vein occurred in 33 (67.3%) patients. Hereditary thrombophilia was observed in 9 (18.4%) patients, 11 (22.4%) patients had some type of infection and 20% of women reported OCT usage. As much as 25% of cases remained without evident risk factors. The most common symptom in our cohort was acute unilateral throbbing headache of high intensity, while patients without headaches had more severe symptoms.