Dural puncture and activated protein C resistance: risk factors for cerebral venous sinus thrombosis

Cerebral Venous Sinus Thrombosis Following Lumbar Puncture

Cerebral venous sinus thrombosis (CVST) is a rare and potentially fatal condition. It is believed to be one of the rare complications of lumbar puncture (LP), however other causes and risk factors should be considered and ruled out. Diagnosis can be challenging after an LP as it can mimic low pressure or post dural puncture. We present a 23-year-old patient diagnosed with CVST following a diagnostic lumbar puncture, in the absence of other risk factors. The patient presented with a persistent headache that was initially attributed to low CSF pressure, as well as a transient episode of right hemi-body paresthesia. Neuroimaging including contrasted MRI with venography confirmed the diagnosis. The patient had negative hypercoagulable evaluation and was placed on anticoagulation on discharge. Our report highlights the importance of considering CVST in refractory headaches after LP and the value of neuroimaging when indicated.

Post-lumbar puncture cerebral vein thrombosis

Lumbar puncture (LP) is rarely complicated by cerebral vein thrombosis (CVT), especially if other risk factors coexist. We describe the case of a 28-year-old woman who developed CVT after corticosteroid treatment and LP performed for suspected multiple sclerosis. The day after LP, she developed intense headache and on Day 8 generalized tonic-clonic seizures. A brain computed tomography scan showed thrombosis of the superior sagittal sinus and cortical veins. Thrombophilia screening showed heterozygous G20210A prothrombin mutation. Anticoagulant therapy with low molecular weight heparin and then warfarin was administered until Day 16 after LP, when a brain magnetic resonance imaging showed a subdural hematoma. Warfarin was interrupted and dabigatran was started. The patient recovered completely, both from the initial thrombotic event and the hemorrhagic complication. This case highlights the importance to keep in mind CVT in the differential diagnosis of post-LP headache not responsive to standard therapy, and suggests that dabigatran can be considered an effective and safe treatment of CVT.

Intracranial thrombosis after ventriculoperitoneal shunting

We report a case of intracranial thrombosis (IT) after ventriculoperitoneal shunting (VPS). We reviewed the literature to highlight the importance of considering the possibility of cerebral venous thrombosis following VPS, even though it is a rarely reported complication. A 14-year-old boy underwent distal catheter replacement due to its short size that was detected during a routine consultation. Five days postoperatively, he experienced nausea, vomiting, seizures, and headache. Although a diagnosis of meningitis was considered, diagnosis of IT was eventually confirmed through computed tomography venography and gadolinium magnetic angioresonance. The patient subsequently underwent anticoagulant therapy, which led to complete resolution of symptoms. In this report, we suggest a possible association between VPS and IT, which is a complication that is not commonly reported. The literature suggests that decreased blood flow due to over-drainage of CSF after VPS causes decreased head pressure, culminating in venous stasis and consequent thrombosis. In addition, the literature describes associations between IT and lumbar puncture (LP); therefore, it is important to consider the possibility of IT following these procedures.

Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block.

METHODS

Medline, CINAHL and EMBASE databases were searched to identify postpartum cases of CVST following neuraxial block. The aim was to delineate the characteristics, presentation, investigations, and outcomes of postpartum women who presented with CVST.

RESULTS

Forty-nine articles with 58 case reports were identified. Forty-two women (72.4%) had an epidural attempted whilst 16 women (27.6%) received a spinal anaesthetic. Accidental dural puncture (ADP) was reported in 17 women (40.5%). Headache was the presenting symptom in 57 women (98.3%); 26 women (44.8%) also experienced seizures. Post-dural puncture headache was reported in 46 (79.3%) and an epidural blood patch was performed in 26 women (44.8%). Superior sagittal sinus, transverse sinus, and cortical veins were the most common sites of thrombosis. The median time to diagnosis was 6.5 days from delivery. Magnetic resonance imaging was the most common diagnostic neuro-imaging modality. Full neurological recovery was reported in 48 (82.8%), whilst neurological deficits were reported in six (10.3%) women.

DISCUSSION

The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.

Cerebral venous thrombosis as a complication of intracranial hypotension after lumbar puncture

Background

Optic neuritis is recognised by the international classification of headache disorders as a painful cranial nerve lesion. A lumbar puncture may be performed in the investigation of optic neuritis. Postdural puncture headache (PDPH) due to intracranial hypotension is a frequent complication of this procedure. In contrast, cerebral venous thrombosis (CVT) is a rare but potentially fatal complication of dural puncture. A few studies have identified an association between iron deficiency anaemia and venous thrombosis. There are no reports linking CVT with lumbar puncture and iron deficiency anaemia.

Methods and results

We present a 32-year-old woman with optic neuritis and iron deficiency anaemia complicated by a PDPH and CVT.

Conclusion

CVT should be considered in a patient with persistent headache, recent lumbar puncture and iron deficiency anaemia. Early recognition and treatment of this condition are vital to avoiding mortality and morbidity.

CVT in the Peripartum Period: A Diagnostic Dilemma

Women in the peripartum period can develop headache with a variety of etiologies that require a multidisciplinary approach if unresponsive to treatment (Stella et al. 2007). Neuroimaging needs to be undertaken even occasionally in the absence of focal neurologic signs to rule out life-threatening causes of headache. We present the case of a 23-year-old woman who presented postpartum with severe frontal headache without other neurologic symptoms. Treatment was initiated for tension type, then subsequently postdural puncture headache (PDPH), and finally preeclampsia. When CT venogram was obtained ten days later, the diagnosis of cerebral venous thrombosis (CVT) was made. She was started on anticoagulation and achieved complete recovery.

Risk factors and predictors of outcomes in 243 Chinese patients with cerebral venous sinus thrombosis: A retrospective analysis

OBJECTIVES

To investigate the risk factors and predictors of outcomes in a cohort of Chinese patients with cerebral venous sinus thrombosis (CVST), so as to provide a reference for customized clinical decision.

PATIENTS AND METHODS

A total of 243 Chinese patients, diagnosed as a first CVST were enrolled in this retrospective study from March 2013 through April 2017. Risk factors and predictors of outcomes for CVST were summarized and analyzed by Chi-square test and logistic regression analysis.

RESULTS

Of the 243 cases, obstetric cause (19.8%) was the leading risk factor for CVST, followed by infection (17.7%) and anemia (17.7%). Gender differences in the risk factors for CVST were analyzed, showing that obstetric cause was the top risk factor in female, while hyperhomocysteinemia (22.3%) was the top risk factor in male. In age subgroups, obstetric cause (26.3%) and anemia (17.6%) were more commonly observed in age ≤ 44 years and age > 44 years subgroup, respectively. The ratio of poor outcomes (mRS = 3-6) in this cohort was 23.0%, and central nervous system (CNS) infection was closely related to poor outcomes at discharge (p = 0.023).

CONCLUSION

The predominant risk factor for CVST, in this Chinese cohort, may still be obstetric cause in female and hyperhomocysteinemia in male. In addition, CNS infection may predict poor outcomes in CVST patients.

Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch

The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.

A rare cause of postpartum headache

Postpartum women can develop headache, and their assessment requires a thorough and multidisciplinary approach. If the headache is unresponsive to treatment and accompanied by neurological deficit, neuroimaging needs to be undertaken to rule out other life-threatening causes. ¹ We present a case of 35-year-old woman with pre-eclampsia and diet-controlled gestational diabetes mellitus, who had normal vaginal delivery at 40 weeks. She had an epidural analgesia for pain relief during labour, but had inadvertent dural puncture during the procedure and developed headache 24 hours after delivery. The headache was managed conservatively and she was discharged home, but was readmitted 8 days later with worsening headache. The headache was postural on admission but became continuous, developed neurological symptoms in the form of ataxic hemiparesis and convulsions. After neuroimaging, she was found to have cerebral venous sinus thrombosis. She was commenced on anticoagulants and anticonvulsants and made a complete recovery.

Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP), the absence of structural lesions on neuroimaging, and normal cerebrospinal fluid composition. Cerebral venous sinus thrombosis (CVST) is a common cause of increased ICP and can be differentiated from IIH with magnetic resonance venography. We describe a young woman with typical IIH who underwent lumbar puncture and was treated with a short course of high-dose corticosteroids followed by acetazolamide. She subsequently developed CVST, subarachnoid hemorrhage, and stroke. Risk factors that may have resulted in CVST are discussed.

[Cerebral venous thrombosis]

There is ample evidence that arterial and venous links of the vascular bed are interrelated, with the venous part, as the highly organized reflexogenic zone, responsible for the development of complex reactions providing the stability of the cerebral blood flow. There is few publications devoted to the venous pathology of the brain however the prevalence of cerebral venous thrombosis (CVT) is relatively high. The annual prevalence of CVT is 4-7 per 1 million of population. Timely recognition and early diagnosis of CVT are most important for successful treatment of patients. It can lead to effective therapy, decrease the consequences of this disease and the fatal outcomes. The review and systematization of the literature on the epidemiology, etiology, risk factors, clinical presentations, diagnosis and treatment of CVT are presented.

A Rare Case of Transverse Sinus Venous Thrombosis Simulating Postdural Puncture Headache After Cervical Epidural Injection

Postdural puncture headache (PDPH) is a feared complication related to epidural steroid injections. We report a unique case in which all subjective and objective findings indicated the diagnosis of PDPH. However, the patient failed appropriate conservative and interventional management. Therapeutic failure prompted further investigation to establish the correct diagnosis of cerebral venous sinus thrombosis. Cerebral venous sinus thrombosis is a rare, difficult to diagnose, but potentially lethal disorder with nonspecific and variable clinical presentations, including headache and focal neurological deficits. Performing magnetic resonance imaging and magnetic resonance venogram should be considered early, especially in patients who fail to respond to standard interventions for PDPH.

Cerebral venous thrombosis and demyelinating diseases: report of a case in a clinically isolated syndrome suggestive of multiple sclerosis onset and review of the literature

Cerebral venous thrombosis (CVT) has been described in several cases of clinically definite multiple sclerosis (MS). In the majority of these, lumbar puncture followed by intravenous corticosteroid treatment was suspected as the cause. We report what is, to our knowledge, the first case of a patient with a multifocal clinically isolated syndrome suggestive of MS onset, who developed multiple CVT after lumbar puncture and during high-dose i.v. corticosteroid treatment. We conclude that the sequence ‘lumbar puncture followed by corticosteroid treatment’ may be a contributory risk factor for the development of CVT when associated with other risk factors.

Plasma and CSF oxytocin levels after intranasal and intravenous oxytocin in awake macaques

Oxytocin (OT) is a neuropeptide that mediates a variety of complex social behaviors in animals and humans. Intranasal OT has been used as an experimental therapeutic for human conditions characterized by deficits in social functioning, especially autism spectrum disorder and schizophrenia. However, it is currently under intense debate whether intranasal delivery of OT reaches the central nervous system. In this study, four female rhesus macaques were implanted with chronic intrathecal catheters and used to investigate the pharmacokinetic profile of OT in the central nervous system and the peripheral vasculature following intravenous (IV) and intranasal (IN) administration of OT. In a randomized, crossover design, OT was given to four awake monkeys at three different doses based on body weight (0.1 IU/kg; 1 IU/kg; 5 IU/kg). A time course of concurrent cerebrospinal fluid (CSF) and plasma samples were taken following administration. We found a dose-dependent effect of IV OT treatment on plasma OT levels, which peaked at 5 min post-dose and gradually returned to baseline by 120 min. In contrast, a change in CSF OT was only observed at the highest IV dose (5 IU/kg) at 15 min post-dose and gradually returned to baseline by 120 min. After IN administration, there was no significant change in plasma OT at any of the three doses. However, at the highest dose level, we found a significant increase in CSF OT at 15-30 min post- dose. The results of this study in light of recent, similar publications highlight the importance of methodological consistency across studies. This study also establishes a non-human primate model that can provide a stable platform for carrying out serial sampling from the central nervous system and peripheral vasculature concurrently.

Factor V Leiden, factor V Cambridge, factor II GA20210, and methylenetetrahydrofolate reductase in cerebral venous and sinus thrombosis: A case-control study

Background:

Factor V G1691A (FV Leiden), FII GA20210, and methylenetetrahydrofolate reductase (MTHFR) C677T mutations are the most common genetic risk factors for thromboembolism in the Western countries. However, there is rare data in Iran about cerebral venous and sinus thrombosis (CVST) patients. The aim of this study was to evaluate the frequency of common genetic thrombophilic factors in CVST patients.

Materials and Methods:

Forty consequently CVST patients from two University Hospital in Isfahan University of Medical Sciences aged more than 15 years from January 2009 to January 2011 were recruited. In parallel, 51 healthy subjects with the same age and race from similar population selected as controls. FV Leiden, FII GA20210, MTHFR C677T, and FV Cambridge gene mutations by polymerase chain reaction technique were evaluated in case and control groups.

Results:

FV Leiden, FII GA20210, and FV Cambridge gene mutations had very low prevalence in both case (5%, 2%, 0%) and control (2.5%, 0%, 0%) and were not found any significant difference between groups. MTHFR C677T mutations was in 22 (55%) of patients in case group and 18 (35.5%) of control group (P = 0.09).

Conclusion:

This study showed that the prevalence of FV Leiden, FII GA20210, and FV Cambridge were low. Laboratory investigations of these mutations as a routine test for all patients with CVST may not be cost benefit.

Postdural Puncture Superior Sagittal Sinus Thrombosis in a Juvenile Case of Clinically Isolated Syndrome

Background. The causes of cerebral venous thrombosis (CVT) are manifold as is its clinical presentation. Case. We report the case of a CVT following lumbar puncture and intravenous glucocorticosteroid therapy in a female adolescent with a clinically isolated syndrome and risk factors for thrombosis. Conclusion. In adolescent patients with acute inflammatory disease undergoing lumbar puncture followed by intravenous high-dose glucocorticosteroid therapy, one should be aware of the elevated risk for thrombosis. A persistent headache with change in the headache pattern and loss of a postural component might be a sign for CVT, requiring emergency imaging of the brain.

Dural puncture: an overlooked cause of cerebral venous thrombosis

Cerebral venous thrombosis (CVT) accounts for 0.5-1 % of all strokes. Although dural puncture is proposed as one of the rare risk factors, this association has only been mentioned in anecdotal reports. Headache, i.e., usually the first and the most frequent clinical symptom on admission, is often attributed to the dural puncture itself. We investigated the frequency of CVT following a recent dural puncture in our stroke database, together with the other risk factors. The computerized medical records of patients (n = 10,740) registered in our tertiary-care neurology clinic stroke database were reviewed retrospectively. Patients diagnosed with CVT were reanalyzed. Patients who had a dural puncture in the preceding 7 days were included in the study. A total of 46 patients were diagnosed with CVT. Nine patients (19.6 %) had a recent dural puncture before the onset of the symptoms. Patients were younger than 45 years and had at least one more predisposing condition for thromboembolism other than the dural puncture. All patients have received either spinal anesthesia or intrathecal chemotherapy. Dural puncture seems to trigger CVT particularly in patients with predisposing disorders. Although reported as an extremely rare complication, our data indicate a much higher association. This case series emphasize the importance of reevaluation of patients with persistent/progressive headache following dural puncture. The effect of change in the biochemical composition of CSF due to intrathecal drug administration in pathogenesis is not known. Larger controlled trials are warranted to clarify the causal relationship between lumbar puncture and/or intrathecal drug administration and CVT.

A rare localization of cerebral venous sinus thrombosis. Case report

In this work the Authors report their experience on the treatment of a case of cavernous venous sinus thrombosis. The diagnosis is clinical and neuroradiological, CT, MRN, cerebral angiography and orbital venography have aided in establishing the diagnosis during life. Very interesting is the therapeutic approach.

Cerebral venous thrombosis complicating severe preeclampsia in the postpartum period: a diagnostic challenge

A 26 year old primigravida with preeclampsia was diagnosed with a cerebral venous thrombosis 6 days following Cesarean section. The diagnosis was initially challenging due to the patient's history of migraines, the preeclampsia, multiple attempts at spinal anesthesia for Cesarean section, and a dural puncture while performing epidural blood patch.

Cerebral venous thrombosis in post-lumbar puncture intracranial hypotension: case report and review of literature

The spectrum of presentation of intracranial hypotension is clinically perplexing. We report a case of 31-year-old post-partum woman who underwent an uneventful caesarean section under spinal anesthesia. From the second day of surgery she developed postural headache, the headache lost its postural character after few days. She then developed seizures and ataxic hemiparesis. Magnetic resonance imaging showed features of severe intracranial hypotension in the brain and the spinal cord, and magnetic resonance venography showed cortical vein and partial superior sagittal sinus thrombosis. Prothrombotic (etiological) work-up showed Protein C and S deficiency. She responded to anticoagulation therapy and recovered completely. On review of literature two distinct groups could be identified obstetric and non-obstetric. The non-obstetric group included patients who underwent diagnostic lumbar puncture, intrathecal injection of medications and epidural anesthesia for non-obstetric surgeries. Poor outcome and mortality was noted in non-obstetric group, while obstetric group had an excellent recovery.

Neuraxial Anesthesia in Parturients with Intracranial Pathology

Parturients with intracranial lesions are often assumed to have increased intracranial pressure, even in the absence of clinical and radiographic signs. The risk of herniation after an inadvertent dural puncture is frequently cited as a contraindication to neuraxial anesthesia. This article reviews the relevant literature on the use of neuraxial anesthesia in parturients with known intracranial pathology, and proposes a framework and recommendations for assessing risk of neurologic deterioration, with epidural analgesia or anesthesia, or planned or inadvertent dural puncture. The authors illustrate these concepts with numerous case examples and provide guidance for the practicing anesthesiologist in determining the safety of neuraxial anesthesia.

Venous thrombosis in multiple sclerosis patients after high-dose intravenous methylprednisolone: the preventive effect of enoxaparin

Aim. This study was designed to examine the possible role of high-dose intravenous methylprednisolone (IVMP) in the development of venous thrombosis (VT). The cerebral one anecdotally had been reported in patients with relapsing remitting multiple sclerosis (RRMS) in acute attacks and the possible preventive role of enoxaparin. Material and Methods. From a pool of 520 patients, 388 patients with definite RRMS who fulfilled entry characteristics were selected and randomly received either a 5-day course of daily 1 gr IVMP or the aforementioned plus 5 days of daily subcutaneous 40 units of enoxaparin according to a predefined protocol. Results. Mean age, gender ratio, mean relapse rate, and EDSS were similar in both groups of patients (P > 0.05). Finally, 366 patients remained in the study. Of 188 patients treated with IVMP with 855 relapses, 5 developed VT (0.37% per patient per year and 0.58% per each course of IVMP) within 3 to 15 days of starting therapy. None of the 178 patients who experienced 809 relapses who received IVMP plus enoxaparin developed such complications. Conclusion. The study implies that high-dose IVMP in MS exacerbation may increase the risk of VT and prophylactic anticoagulant treatment in this setting is warranted.

Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND

The purpose of this statement is to provide an overview of cerebral venous sinus thrombosis and to provide recommendations for its diagnosis, management, and treatment. The intended audience is physicians and other healthcare providers who are responsible for the diagnosis and management of patients with cerebral venous sinus thrombosis.

METHODS AND RESULTS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represent different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 1966 and used the American Heart Association levels-of-evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee.

CONCLUSIONS

Evidence-based recommendations are provided for the diagnosis, management, and prevention of recurrence of cerebral venous thrombosis. Recommendations on the evaluation and management of cerebral venous thrombosis during pregnancy and in the pediatric population are provided. Considerations for the management of clinical complications (seizures, hydrocephalus, intracranial hypertension, and neurological deterioration) are also summarized. An algorithm for diagnosis and management of patients with cerebral venous sinus thrombosis is described.

Isolated cortical vein thrombosis after epidural anesthesia: report of three cases

Cerebral venous thrombosis rarely develops after lumbar puncture and spinal anesthesia with accidental dural puncture, however, occurrence of isolated cortical vein thrombosis after epidural anesthesia is extremely rare. We report three cases who developed postural headache and isolated cortical vein thrombosis after epidural anesthesia. We postulate that intracranial hypotension is the cause of compensatory venous dilatation and resultant thrombosis.

Cerebral venous sinus thrombosis following cervical disc arthroplasty

Cerebral venous sinus thrombosis is a rare condition, which is difficult to diagnose. It has not previously been reported following surgery to the cervical spine . We report such a case in a 45-year-old man after cervical disc replacement. A high index of suspicion, with early imaging of the brain and prompt treatment, can produce a favourable outcome, albeit not in this case.

An unusual case of cerebral venous sinus thrombosis in a pediatric patient

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is a rare, but potentially devastating illness. It is important for emergency physicians to be aware of the classic and most common risk factors leading to this illness, including genetic and acquired prothrombotic states, infection, inflammatory conditions, and certain drugs.

OBJECTIVES

The objectives of this article are to discuss a case of CVST and describe the signs and symptoms of CVST as well as the radiologic modalities used to diagnose this disease. Finally, we will discuss the causes and risk factors that lead to this potentially devastating diagnosis.

CASE REPORT

An 11-year-old girl was found unconscious and without pulses in an apparent drug overdose. Emergency Medical Services responders and Emergency Department personnel resuscitated the patient to a return of spontaneous circulation. The patient was intubated and admitted to the intensive care unit. As part of an altered mental status work-up, a magnetic resonance imaging scan of the head was performed and showed a cerebral venous sinus thrombosis. This was thought to be due to the drug overdose and the low-flow state that occurred during loss of circulation. After anticoagulation therapy and antibiotic treatment for sinusitis, the patient had a full recovery.

CONCLUSION

Rapid diagnosis of CVST was essential to the appropriate care of this patient. Being aware of signs, symptoms, and risk factors leading to CVST will assist the emergency physician in making this diagnosis.

Cerebral venous sinus thrombosis risk factors

Cerebral venous sinus thrombosis is an uncommon disease marked by clotting of blood in cerebral venous, or dural sinuses, and, in rare cases, cortical veins. It is a rare but potentially fatal cause of acute neurological deterioration previously related to otomastoid, orbit, and central face cutaneous infections. After the advent of antibiotics, it is more often related to neoplasm, pregnancy, puerperium, systemic diseases, dehydration, intracranial tumors, oral contraceptives, and coagulopathies are the most common causes, but in 30% of cases no underlying etiology can be identified. It has been found in association with fibrous thyroiditis, jugular thrombosis after catheterization, or idiopathic jugular vein stenosis. Other factors include surgery, head trauma, arterio-venous malformations, infection, paraneoplastic, and autoimmune disease. This article presents a comprehensive review of cerebral venous sinus thrombosis etiologies.

Cerebral Venous Thrombosis After Epidural Blood Patch: Coincidence or Causal Relation? A Case Report and Review of the Literature

We report on a female patient who developed post-dural puncture headache (PDPH) after epidural analgesia for delivery. Treatment with epidural blood patch led to complete headache remission and the patient was discharged. Two days later the patient was readmitted with hemihypaesthesia and mild hemiparesis of the right side. Magnetic resonance imaging showed a small left parietal cortical haemorrhage probably following cerebral venous thrombosis (CVT). Coagulation screening detected heterozygous Factor V mutation. Headache is a common symptom of PDPH and CVT. Review of the literature revealed five patients in puerperal state, who developed CVT in close temporal relationship after blood patch treatment for PDPH. Change of headache character with loss of postural influence was reported frequently before diagnosis of CVT was confirmed. These findings may indicate a causal relationship.

Spontaneous intracranial hypotension: clinical and neuroimaging findings in six cases with literature review

Spontaneous intracranial hypotension (SIH) is an uncommon but increasingly recognized syndrome. Orthostatic headache with typical findings on magnetic resonance imaging (MRI) are the key to diagnosis. Delayed diagnosis of this condition may subject patients to unnecessary procedures and prolong morbidity. We describe six patients with SIH and outline the important clinical and neuroimaging findings. They were all relatively young, 20-54 years old, with clearly orthostatic headache, minimal neurological signs (only abducent nerve paresis in two) and diffuse pachymeningeal gadolinium enhancement on brain MRI, while two of them presented subdural hygromas. Spinal MRI was helpful in detecting a cervical cerebrospinal fluid leak in three patients and dilatation of the vertebral venous plexus with extradural fluid collection in another. Conservative management resulted in rapid resolution of symptoms in five patients (10 days-3 weeks) and in one who developed cerebral venous sinus thrombosis, the condition resolved in 2 months. However, this rapid clinical improvement was not accompanied by an analogous regression of the brain MR findings that persisted on a longer follow-up. Along with recent literature data, our patients further point out that SIH, to be correctly diagnosed, necessitates increased alertness by the attending physician, in the evaluation of headaches.

[Dural sinus thrombosis: case report]

We report the case of a 24 year-old pregnant woman, seen at the neurology service by presenting agitation, hallucinations, mental confusion, headache, vision loss, aphasia and seizures. The neuroradiologic exam was compatible with thrombosis in dural sinus and cortical veins. Treatment with abciximab was accomplished and the mechanical lysis of the thrombus was made obtaining restoration of cerebral vein flow. After the procedure, she presented frontal hematoma which was withdrawn surgically. We discuss this infrequent pathology in clinical picture, pathogenesis, image exams and therapeutics.

Postural Headache in the Presence of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) can present with a headache similar to that after a dural puncture. We report on a patient who developed postural headache after epidural anesthesia for delivery. The headache became more intense during the following 6 days, and the patient had a tonic clonic seizure. A magnetic resonance angiogram demonstrated CSVT, and anticoagulation therapy was started, with resolution of the symptoms over 2 wk. Any postdural-puncture headache that loses its positional character, becomes persistent, or does not improve with a properly performed blood patch should raise the suspicion of CVST.

Post-dural puncture headache: pathogenesis, prevention and treatment

Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache.

Extensive experience with dural sinus thrombosis

OBJECTIVE

Dural sinus thrombosis (DST) is an uncommon cause of stroke. The safest and most effective therapy for DST has not been conclusively identified.

METHODS

A retrospective chart review of data for 31 patients who were treated for DST at our institution between 1992 and 2001 was performed. Four treatment strategies were identified, i.e., 1). medical observation only, 2). systemic anticoagulation (AC) therapy with heparin, 3). endovascular chemical thrombolysis with urokinase or tissue plasminogen activator and concurrent systemic AC therapy, and 4). mechanical endovascular clot thrombolysis with concurrent systemic AC therapy. Complications and clinical outcomes were assessed for each group.

RESULTS

Patients treated solely with medical observation fared the worst; four of five patients experienced intracranial hemorrhagic complications, and only two of five exhibited clinical improvement. Patients who received systemic AC therapy experienced no hemorrhagic complications, even when pretreatment hemorrhage was present; 75% (six of eight patients) exhibited improvement with AC therapy alone. Chemical thrombolysis was very effective in restoring sinus patency (90% of patients); however, 30% of patients (3 of 10 patients) experienced hemorrhagic complications. Sixty percent of patients (6 of 10 patients) who underwent chemical thrombolysis exhibited clinical improvement. Patients who underwent mechanical thrombectomies demonstrated a low hemorrhagic complication rate, and most (88%) made good recoveries.

CONCLUSION

Therapy directed at the underlying clot in DST must begin without delay. Our results suggest that supportive medical management of DST, without therapy directed at the clot or clotting process, is not effective. Systemic AC therapy, even in the presence of intracerebral hemorrhage, seems to be safe. Heparin can be safely titrated to yield partial thromboplastin times of 60 to 70 seconds. Chemical clot thrombolysis is efficacious in opening occluded sinuses but may cause intracranial hemorrhage. We currently recommend either systemic AC therapy or systemic AC therapy in conjunction with mechanical clot thrombectomy as a safe effective treatment for DST.

Cerebral venous thrombosis in four patients with multiple sclerosis

We report four new cases of cerebral venous thrombosis (CVT) occurring in patients with multiple sclerosis (MS). Each patient had undergone lumbar puncture at varying times prior to clinical presentation (4 days to over 1 year). Only two of the patients had received intravenous (i.v.) methylprednisolone 48 h prior to CVT and were under oral contraception, a risk factor for cerebral thrombophlebitis. The other two patients had not undergone recent lumbar puncture, were not taking corticosteroids and did not present vascular risk factors. The patients all had normal routine blood work-ups and none had thrombophilia. All patients dramatically improved with full systemic heparinization. Minor sequelae were noticed in two patients. The pathogenesis underlying the occurrence of CVT in MS patients remains unclear and we discuss the relationship between lumbar puncture, steroid treatment and CVT.

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.

Cerebral Venous Thrombosis

Cerebral venous thrombosis is a rare disorder with highly variable and nonspecific clinical presentations. For these reasons, specific treatment should be given only when the diagnosis has been firmly established. Etiologic diagnosis should begin in the emergency department to identify underlying conditions that require specific treatment. The mainstay of treatment is anticoagulation with heparin, even in the case of cerebral hemorrhage, followed as soon as possible by oral anticoagulant administration. The optimal duration of oral anticoagulation has not been established. By analogy with systemic venous thrombosis, it should be prolonged 3 to 6 months. When a high risk of recurrence is present, treatment should be continued until the risk disappears. In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation even when the clinical situation seems desperate. For the same reason, aggressive treatment of intracranial hypertension and seizures or status epilepticus is warranted. Screening for extraneurologic venous thrombosis should be done by means of clinical examination and, if necessary, specific imaging procedures. Local thrombolysis is not yet of proven efficacy and safety. It can be used in patients with clinical worsening related to documented extension of the venous thrombosis despite anticoagulation and in the absence of cerebral hematoma. Surgical treatment is limited to external ventricular drainage and suboccipital craniotomy in the very rare cases of cerebellar vein thrombosis with edematous cerebellar infarct.

Dural puncture and corticotherapy as risks factors for cerebral venous sinus thrombosis

Dural puncture with corticosteroid could be a predisposing factor for cerebral venous thrombosis (CVT). A 35-year-old woman using oral contraception was treated with corticosteroid epidural infiltration for L5 radiculalgia. The following day a postural headache developed and accidental dural puncture was suspected. Four days later, she presented with fever and consciousness impairment requiring mechanical ventilation. Magnetic resonance angiography (MRA) confirmed thrombosis of the superior sagittal sinus. Recanalization was observed three weeks later and the patient fully recovered. Blood tests for thrombophilia showed a moderate decrease in the C protein level (chronometric activity 44%, N = 65-130). CVT has been reported after spinal anaesthesia or peridural anaesthesia with accidental puncture. After dural puncture the decrease of cerebrospinal fluid pressure induces a rostrocaudal sagging effect with traumatic damage to the fragile venous endothelial wall, and may trigger a venous vasodilatation with resultant stasis. CVT has also been described in patients after lumbar puncture and oral corticoid treatment for multiple sclerosis and after corticosteroid intrathecal infiltration. Therefore, corticosteroids can be considered as a potential additional procoagulant stimuli.

Cerebral venous sinus thrombosis associated with hepatic cirrhosis

Cerebral venous sinus thrombosis is not a recognized complication of end-stage liver disease. A case of sagittal sinus thrombosis in a 44-year-old male with end-stage hepatic cirrhosis is described. Recurrent seizures were the only manifestation. Work-up revealed severe deficiency of protein C, protein S, and antithrombin III. He was treated with low molecular weight heparin and underwent an orthotopic liver transplant after three months. Follow-up helical CT venogram showed resolution of the sinus thrombosis.

Factor V Leiden mutation is a risk factor for cerebral venous thrombosis: a case-control study of 55 patients

BACKGROUND AND PURPOSE

Different coagulation disorders have been associated with cerebral venous thrombosis (CVT). Until now, fewer than 50 patients have been reported with CVT and the factor V Leiden (FVL) mutation. Although the prevalence of FVL-positive patients with CVT ranged from 10% to 25%, it was as low as 0.5% to 3% in the control groups. Most other studies had not systematically searched for concomitant risk factors or previous thromboembolic events. To better define the relevance of the FVL mutation in conjunction with additional risk factors in CVT, we conducted the present case-control study.

METHODS

Fifty-five patients with CVT were compared with 272 healthy controls. A standardized interview regarding established risk factors for venous thrombosis and the patients' and their families' histories for thromboembolic events was performed. The presence of the FVL mutation was determined by polymerase chain reaction on DNA obtained from peripheral blood leukocytes.

RESULTS

Of 55 patients, 8 (14.5%) were heterozygous for the FVL mutation compared with 17 of 272 controls (6.25%). The relative risk for the presence of FVL was 2.55 (95% confidence interval, 1.04 to 6.26; P=0.04). Additional risk factors for CVT were frequently found in both the presence and absence of FVL. Recurrence of venous thromboembolic events was more frequent in patients with the FVL mutation (5 of 8 patients, 62.5%) than in those without this anomaly (8 of 47 patients, 17%; P<0.005).

CONCLUSIONS

Our study confirms the FVL mutation as the most relevant hereditary risk factor for CVT. Coexisting risk factors are usually involved in the initiation of CVT. Patients with the FVL mutation are at an increased risk for recurrent venous thrombosis.

Frequency of the 20210 G-->A mutation in the 3'-untranslated region of the prothrombin gene in 35 cases of cerebral venous thrombosis

BACKGROUND AND PURPOSE

A novel sequence variation in the 3'-untranslated region of the prothrombin (factor II) gene (nucleotide 20210 G-->A) has been recently described as a risk factor for deep vein thrombosis and pulmonary embolism. It is found in approximately 1% to 4% of healthy subjects. We studied the frequency of this factor II variant in patients with cerebral venous thrombosis.

METHODS

The 20210A allele of the prothrombin gene was studied after DNA extraction, polymerase chain reaction amplification, and HindIII digestion in 35 patients with magnetic resonance imaging or angiographically confirmed cerebral venous thrombosis (23 women and 12 men, aged 11 to 71 years).

RESULTS

Two patients (5.7%) had the 20210A allele of the prothrombin gene. Both had other risk factors for thrombosis (use of oral contraceptives and of intrathecal steroids).

CONCLUSIONS

The 20210A allele of the prothrombin gene in association with other prothrombic factors may increase the risk of cerebral venous thrombosis, but case-control studies will be necessary to clarify these associations.