Treatment of the superior sagittal sinus and transverse sinus thrombosis associated with intracranial hemorrhage with the mechanical thrombectomy and thrombolytics: Case report

A Case Report of Simultaneous Intracranial Hemorrhage and Cerebral Venous Sinus Thrombosis in a Young Indian Male: Diagnostic and Therapeutic Challenges

This case report discusses the intricate diagnostic and therapeutic challenges faced by a 23-year-old Indian male who presented with altered consciousness, a holo-cranial headache, right-sided hemiparesis, and subsequent neurological symptoms. The patient's dietary habits, leading to vitamin B12 and folic acid deficiencies resulting in hyperhomocysteinemia, along with binge alcohol drinking leading to dehydration, were identified as the main causes of cerebral venous sinus thrombosis (CVST) in this case. The case was complicated by an additional cerebral hemorrhage. The patient received a comprehensive treatment regimen involving antiepileptic medications, intravenous fluids, and anticoagulation therapy. A decline in the Glasgow Coma Scale score prompted further interventions. Collaborative decision-making, involving neurologists, neurosurgeons, and the patient's relatives, steered the treatment course, ultimately favoring continued medical management over decompression surgery. Notably, the patient exhibited remarkable progress in mobility, achieving the ability to walk with support by the end. This case report contributes valuable insights to the understanding of CVST, emphasizing the significance of nutritional considerations, especially in vegetarians, and underscoring the importance of thorough diagnostic evaluations in complex clinical scenarios.

A dynamic nomogram for predicting intraoperative brain bulge during decompressive craniectomy in patients with traumatic brain injury: a retrospective study

OBJECTIVE

The aim of this paper is to investigate the risk factors associated with intraoperative brain bulge (IOBB), especially the computed tomography (CT) value of the diseased lateral transverse sinus, and to develop a reliable predictive model to alert neurosurgeons to the possibility of IOBB.

METHODS

A retrospective analysis was performed on 937 patients undergoing traumatic decompressive craniectomy. A total of 644 patients from Fuzong Clinical Medical College of Fujian Medical University were included in the development cohort, and 293 patients from the First Affiliated Hospital of Shantou University Medical College were included in the external validation cohort. Univariate and multifactorial logistic regression analyses identified independent risk factors associated with IOBB. The logistic regression models consisted of independent risk factors, and receiver operating characteristic curves, calibration, and decision curve analyses were used to assess the performance of the models. Various machine learning models were used to compare with the logistic regression model and analyze the importance of the factors, which were eventually jointly developed into a dynamic nomogram for predicting IOBB and published online in the form of a simple calculator.

RESULTS

IOBB occurred in 93/644 (14.4%) patients in the developmental cohort and 47/293 (16.0%) in the validation cohort. Univariate and multifactorial regression analyses showed that age, subdural hematoma, contralateral fracture, brain contusion, and CT value of the diseased lateral transverse sinus were associated with IOBB. A logistic regression model (full model) consisting of the above risk factors had excellent predictive power in both the development cohort [area under the curve (AUC)=0.930] and the validation cohort (AUC=0.913). Among the four machine learning models, the AdaBoost model showed the best predictive value (AUC=0.998). Factors in the AdaBoost model were ranked by importance and combined with the full model to create a dynamic nomogram for clinical application, which was published online as a practical and easy-to-use calculator.

CONCLUSIONS

The CT value of the diseased lateral transverse is an independent risk factor and a reliable predictor of IOBB. The online dynamic nomogram formed by combining logistic regression analysis models and machine learning models can more accurately predict the possibility of IOBBs in patients undergoing traumatic decompressive craniectomy.

A case of cerebral venous sinus thrombosis presented with SAH and isolated headache

Cerebral venous sinus thrombosis is a rare and challenging type of stroke. Coexistence of subarachnoid hemorrhage adds complexity to the diagnostic process leading to a missed or delayed diagnosis. Isolated headaches can be the only presentation and urgent neuroimaging using CT or MR venogram plays a pivotal role in the workup of these cases. We report a rare case of 64-years-old patient with subarachnoid hemorrhage and underlying cerebral venous sinus thrombosis who was presented with isolated headache where the management is different from arterial subarachnoid hemorrhage.

Diagnostic and Therapeutic Challenges of Concurrent Intracranial Hemorrhage and Cerebral Venous Thrombosis in a Patient With Acute Lymphoblastic Leukemia: A Case Report and Literature Review

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular condition due to the thrombosis of cerebral venous sinuses, leading to intracranial hemorrhage, increased intracranial pressure, focal deficit, seizure, toxic edema, encephalopathy, and death. The diagnosis and therapeutic approach of CVST remain challenging because of its highly nonspecific clinical presentation including headaches, seizures, focal neurologic deficits, and altered mental status, etc. Anticoagulation is the mainstay of CVST treatment and should be started as soon as the diagnosis is confirmed. Here, we present the case of a 34-year-old male construction worker who presented to the emergency department with a complaint of right chest wall pain and swelling. He was admitted to the hospital following a diagnosis of anterior chest wall abscess and mediastinitis. During hospitalization, his complete blood count revealed pancytopenia with blast cells, and bone marrow biopsy revealed 78.5% lymphoid blasts by aspirate differential count and hypercellular marrow (100%) with decreased hematopoiesis. He developed concurrent CVST and intracranial hemorrhage while receiving CALGB10403 (vincristine, daunorubicin, pegaspargase, prednisone) with intrathecal cytarabine induction chemotherapy for acute lymphoblastic leukemia (ALL). The patient failed two standard chemotherapy for ALL and achieved remission while on third-line chemotherapy with an anti-CD19 monoclonal antibody, blinatumomab. Although this patient had an MRI scan of the brain with multiple follow-up non-contrast CT scans, it was CT angiography that revealed CVST. This showed the diagnostic challenge in CVST, with CT and MRI venography having excellent sensitivity in diagnosing CVST. Risk factors for CVST in our patient were ALL and its intensive induction chemotherapy with pegaspargase.

Simultaneous occurrence of subarachnoid hemorrhage and cerebral venous sinus thrombosis: A systematic review of cases

Although the leading causes of subarachnoid hemorrhage (SAH) are aneurysm rupture and arteriovenous malformations, cerebral venous sinus thrombosis (CVST) can, in rare cases, be associated with SAH. This phenomenon is an uncommon presentation, with less than a hundred cases reported based on our review of the literature. The purpose of this review is to highlight what is known regarding these cases, how they are managed and to highlight the need for further studies that will serve as a basis for the development of a standard management guideline across board. The following databases were searched: PubMed and Ovid Embase. A complementary search of Google Scholar and AJOL was done. Gray literature search was also conducted on the Google search engine for any additional relevant papers. We were able to extract data regarding 33 cases from 29 identified studies. The mean age was 46.6 ± 14.08. 17 (51.5%) of the cases were female, and the female‐to‐male ratio is 1.1:1. Headache was by far the commonest symptom, occurring in 82% of cases followed by seizures in 42% of cases. Four patients (12%) had loss of consciousness while 5 patients (15%) had some form of focal neurologic deficit. Twenty patients had cerebral venous sinus thrombosis in at least two different sinuses. The superior sagittal sinus was the most common location for CVSTs (79%), followed by the transverse sinus (57.5%). Twenty‐nine cases (89%) were managed with anticoagulation alone and one case had a mechanical thrombectomy. We have performed a comprehensive review of cases that had the simultaneous occurrence of SAH and CVST and have identified their peculiarities and the challenges to management. Further research is needed in order to identify a causal relationship and to serve as a basis for the development of a standard management guideline across the board.