Association of Cerebral Venous Thrombosis and Intracranial Hypotension: Review of 3 Cases

Intracranial hypotension as a contributor to isolated cortical vein thrombosis

BACKGROUND

Isolated cortical vein thrombosis (ICVT), a rare type of cerebral venous thrombosis (CVT), is diagnostically challenging in some cases, and intracranial hypotension (IH) is known to cause CVT.

METHODS

In this study, we reviewed the clinical and imaging characteristics of ICVT in patients with IH caused by spinal cerebrospinal fluid leakage, based on a literature review and investigation of cases from our hospital.

RESULTS

Between January 1, 2007, and November 1, 2019, 735 patients were diagnosed with IH at our hospital; three patients developed ICVT (incidence ~ 0.4%, 3/735), and the literature review yielded an additional 23 cases. Therefore, 26 patients (mean age 35.9 ± 11.4 years old) were included in this study. The most common symptoms were headache (100.0%, 26/26), focal neurological deficits (53.8%, 14/26), and seizure (34.6%, 9/26). The initial headache was orthostatic in 96.2% (25/26) of patients, and 38.5% (10/26) of patients reported a change in the headache pattern following diagnosis of ICVT. Neuroimaging findings associated with ICVT included the cord sign (61.5%, 16/26) and parenchymal brain lesions (46.2%, 12/26), such as intracerebral hemorrhage (30.8%, 8/26), hemorrhagic infarcts (11.5%, 3/26), and localized edema (11.5%, 3/26). The percentage of patients who received anticoagulation and epidural blood patch therapy was similar (69.2% [18/26] vs. 65.4% [17/26]), and most patients recovered completely (92.3%, 24/26).

CONCLUSION

IH should be considered in the differential diagnosis in patients with ICVT. Knowledge of the relevant clinical and neuroimaging features is important to facilitate early diagnosis for favorable prognosis.

Cerebral venous thrombosis in spontaneous intracranial hypotension: A report of 8 cases and review of the literature

BACKGROUND

The occurrence of cerebral venous thrombosis (CVT) in patients with spontaneous intracranial hypotension (SIH) raises difficult practical questions regarding the management of the two conditions. The first-line therapy for CVT is anticoagulation (AC); however, its potential benefit in SIH/CVT patients, especially if complicated by subdural haematoma, must be carefully evaluated taking account of the intracranial haemorrhage risk. Venous system recanalization and good prognosis in SIH/CVT patients treated with epidural blood patch (EBP), the main treatment option for SIH, have been already described.

METHODS

We reviewed our cases of SIH complicated by CVT among a cohort of 445 SIH patients observed and treated during the last years. All published case reports and case series reporting patients with SIH and CVT were also ascertained and reviewed.

RESULTS

Eight (2%) out of 445 patients suffering with SIH, were also diagnosed with CVT. All patients observed had orthostatic headache, three of them experienced a change in their headache pattern over the SIH course. Six out of eight patients received both AC and EBP treatments. Two patients were treated using only AC or EBP. A bilateral subdural haematoma enlargement after 1 month of AC was observed in one case. Complete CVT recanalization after treatment was obtained in three patients, including two with multiple CVT at baseline; partial CVT recanalization was achieved in two patients. Three patients experienced no CVT recanalization. After 6-48 months' follow-up all patients were still asymptomatic.

CONCLUSIONS

The use of AC therapy should be weighed against the intracranial haemorrage risk and should be monitored carefully if initiated. Effective and prompt EBP, even without AC therapy, might lead to a good prognosis in selected cases.

Delayed recurrence of spontaneous intracranial hypotension syndrome mimicking a Chiari I malformation: Case report with a review of the literature

INTRODUCTION

Cerebellar tonsils descent seen on brain MRI is, along with other findings, a recognized radiological sign of possible spontaneous intracranial hypotension (SIH). The short-term outcome of SIH is usually favorable with symptoms improvement and reversibility of the low-lying tonsils. Nevertheless, data on the long-term outcome are lacking or inconsistent.

CASE REPORT

A 32-year-old woman presented to her general practitioner with a six months history of non-specific headaches. An MRI brain with gadolinium showed a 12mm tonsillar descent with no other remarkable findings. Headaches were initially managed conservatively as migraines. Following the onset of progressive upper back and shoulder pain at rest, nausea, photophobia and fogging in her vision, the patient was referred to our Department with a suspicion of symptomatic Chiari I malformation. After an in-depth anamnesis, it emerged a previous history of SIH, 14 years earlier, successfully treated conservatively in another center. A whole spine MRI confirmed the suspicion of recurrent SIH showing an anterior cervico-thoracic epidural fluid collection. The patient underwent an epidural blood patch with complete resolution of the symptoms and radiological signs.

DISCUSSION

To our knowledge, this case is the first report of delayed recurrence of a SIH successfully treated conservatively over 10 years earlier. The etiopathogenesis and management of this rarity with literature review is discussed.

CONCLUSION

An isolated cerebellar tonsil descent with no other remarkable findings on brain MRI and a previous history of SIH should always alert the clinician of a possible late recurrence of a CSF leak and avoid unnecessary Chiari I malformation surgical procedures.

Dural venous sinus thrombosis after lumbar puncture in a patient with idiopathic intracranial hypertension

INTRODUCTION

Idiopathic intracranial hypertension (IIH) is one of the most common causes of papilloedema seen by ophthalmologists and neurologists. Patients with IIH routinely undergo lumbar puncture (LP) for diagnosis. Dural venous sinus thrombosis (DVST) is a rare complication of cerebrospinal fluid pressure (CSF)-lowering procedures such as lumbar puncture and epidural and may be an intracranial complication of IIH.

CASE DESCRIPTION

A 29-year-old obese woman was diagnosed with severe idiopathic intracranial hypertension (IIH) after she presented with new-onset headache, pulsatile tinnitus and blurred vision. Magnetic resonance imaging (MRI) and venography (MRV) were normal apart from signs of intracranial hypertension. Lumbar puncture (LP) revealed an opening pressure of 40 cm of water. Due to the severity of the papilloedema and vision loss, she was referred for a ventriculoperitoneal shunt and found to have venous sinus thrombosis involving the superior sagittal sinus on the pre-operative computed tomography (CT) head 5 days after the LP. CT venography (CTV) one day later and MRV 3 days later showed significant worsening as the thrombosis extended into the deep venous system. She was started on therapeutic heparin and her symptoms and vision improved and she did not develop any neurological complications.

CONCLUSIONS

DVST should be considered in IIH patients who have worsening papilloedema or symptoms of intracranial hypertension. Repeat venous imaging can prevent devastating consequences such as venous infarcts of haemorrhage in these patients.

Cerebral Venous Thrombosis: Review of Diagnosis, Follow-Up, Late Complications and Potential Pitfalls

Cerebral venous thrombosis is a less common but relevant cause of stroke in adults. The clinical manifestations are nonspecific leading frequently diagnostic delays, so imaging findings are is of vital importance. Conventional imaging modalities, namely computed tomography and magnetic resonance imaging (MRI), allow identification of the thrombus and parenchymal involvement due to venous congestion to a variable degree, but this entity may appears as a nonexpected finding in a nonvenographic study. computed tomography and MRI venographies allow noninvasive confirmation of the diagnosis and adequate characterization of the extent of the thrombus and acute complications, both of them being robust diagnostic techniques. MR venography also can be done without the use of contrast media, which is especially important in certain clinical situations. Cerebral venous thrombosis needs follow-up, and imaging plays a key role in detection of late complications of the disease, including dural arteriovenous fistulas and intracranial hypertension due to veno-occlusive disease. Knowledge of other diseases and conditions that may mimic a thrombus is needed to avoid wrong diagnosis. In this article, we conduct a pictorial comprehensive review of cerebral venous thrombosis, including also the technical aspects of different imaging modalities, diagnosis and acute complications, follow-up, late complications and potential imaging mimics.

Spontaneous intracranial hypotension associated with cerebral venous thrombosis detected by a sudden seizure: a case report

Background

Spontaneous intracranial hypotension (SIH) is rare but can lead to life-threatening complications including cerebral venous thrombosis (CVT). The concurrence of CVT and SIH raises questions regarding priority.

Case presentation

We present the case of a 52-year-old woman who developed sudden left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches over the prior 2 weeks. Imaging showed thrombosis in the left transverse and sigmoid sinuses, bilateral subdural hematomas, and a cervicothoracic cerebrospinal fluid leak. Low molecular weight heparin was administered, but it was discontinued 2 days later due to subarachnoid hemorrhage. She was transferred to our hospital where an epidural blood patch was applied immediately, which resulted in complete symptom relief.

Conclusion

CVT is a rare complication of SIH that may result in devastating consequences. Treatment of SIH should be the primary focus. Prompt diagnosis and EBP application can result in a good outcome.

Management of Subdural Hematohygromas in Abusive Head Trauma

BACKGROUND

The optimal management of nonacute subdural fluid collections in infantile abusive head trauma (AHT) remains controversial.

OBJECTIVE

To review the outcomes and costs of the various treatments for symptomatic subdural fluid collections in children with AHT at a single center.

METHODS

Our AHT database was queried to identify children requiring any intervention for hematohygromas. Demographic, hospital course, radiologic, cost, readmission, and follow-up information were collected.

RESULTS

From January 2009 to March 2018, the authors identified 318 children with AHT, of whom 210 (66%) had a subdural collection of any type (blood or cerebrospinal fluid). A total of 50 required some form of intervention specifically for chronic hematohygromas. The initial management consisted of transfontanelle percutaneous aspiration (n = 31), burr holes with (n = 12) or without (n = 3) external subdural drainage, and mini-craniotomy (n = 4). Of those who were initially managed with 1 or more needle aspiration, 23 (74%) required further intervention-12 subduroperitoneal shunts and 11 nonshunt procedures. No patient who underwent burr holes/external drainage required further intervention (n = 16). Overall, the average number of interventions needed in these 50 children for definitive treatment was 1.8 (range, 1-4). A total of 15 children ultimately required a subduroperitoneal shunt. Complications (infectious, hemorrhagic, and thrombotic) were significant and occurred in all treatment groups except burr holes without drainage (n = 3). The average hospital charge for the entire cohort was $166 300.25 (range, $19 126-$739 248).

CONCLUSION

Based on our experience to date, burr hole with controlled external subdural drainage is an effective and preferred treatment for traumatic hematohygromas; complications and need for additional intervention is low.

Cerebral venous thrombosis: a rare complication of herpes simplex encephalitis

We report a case of classic HSE with early neurological relapse 7 days after onset of acyclovir treatment secondary to cerebral venous thrombosis (CVT). The development of CVT after meningoencephalitis has been described with neurotropic viruses such as HSV, HIV, or enteroviruses and also bacterial or fungal agents. CVT is probably the consequence of the inflammation secondary to these infections. A diagnosis of CVT, although rarely described, should be systematically suspected in patients with HSE who present no or only moderate improvement, or early relapse of symptoms despite adapted acyclovir treatment.

Superior sagittal sinus thrombosis as a rare complication of spontaneous intracranial hypotension syndrome: a case report and review of the literature

In addition to an orthostatic headache, spontaneous intracranial hypotension syndrome can lead to subdural hematoma and diffusion, subarachnoid hemorrhage, and brain sag. However, cerebral venous sinus thrombosis is rarely reported in patients with spontaneous intracranial hypotension. We present the case of a 35-year-old male who developed an orthostatic headache, nausea, vomiting, and photophobia for 5 days. An enhanced brain magnetic resonance image showed extensive linear pachymeningeal enhancement in the bilateral cerebral hemispheres. Lumbar puncture showed that cerebrospinal fluid pressure was 80 mmH₂O. Subsequent magnetic resonance scans demonstrated subdural effusion of the bilateral frontoparietal lobes, hyperintense T1-weighted images, and T2WI lesions within the superior sagittal sinus in 17 days. The patient was given low molecular weight heparin and adverse events occurred. Head computed tomography showed cerebral external fluid accumulation in the bilateral frontoparietal lobes. Then, digital subtraction angiography was performed at 22 days, which confirmed superior sagittal sinus thrombosis, and the patient recovered fully after therapy. The evolution of the disease and radiological findings support the diagnosis of spontaneous intracranial hypotension with superior sagittal sinus thrombosis. To the best of our knowledge, there are very few case reports describing superior sagittal sinus thrombosis as a complication of spontaneous intracranial hypotension. When spontaneous intracranial hypotension and cerebral venous thrombosis occur together, difficult practical questions arise regarding the treatment of these two conditions.