Use of thrombolytic therapy in cerebral venous sinus thrombosis with ulcerative colitis

Cerebral venous thrombosis developing concurrently with active ulcerative colitis poses a therapeutic dilemma. We report the case of a 31-year-old woman who developed dural venous sinus thrombosis during the course of active ulcerative colitis in whom we accomplished clot lysis using intrasinus urokinase. The success of the procedure was assessed by improvement in the patient''s neurological condition and resolution of imaging features without any bleeding complications. We also reviewed literature on various modalities of treatment of sinus venous thrombosis in patients with ulcerative colitis and outcome.     

Cerebral venous thrombosis in an adolescent with ulcerative colitis

We describe a 17-year-old Caucasian adolescent with ulcerative colitis who presented with cerebral venous sinus thrombosis. Laboratory investigation revealed low protein S levels. With successful management the patient remained without neurologic sequalae. Although there may be an association between ulcerative colitis and cerebral venous sinus thrombosis, the exact pathophysiologic mechanism remains unknown.     

颅内静脉窦血栓形成的诊治(附9例报告)

目的探讨颅内静脉窦血栓形成(CVST)临床表现、诊断及治疗。方法回顾性分析9例经影像学诊断为CVST的患者,行抗凝及血管内介入溶栓治疗。结果9例患者均有颅内压增高表现;3例癫痫发作;2例颅内出血;2例出现意识障碍;1例偏瘫。头部CT、MRI、MRV、DSA为诊断提供依据。8例应用低分子肝素治疗,1例进行血管内介入尿激酶溶栓治疗,同时进行肝素抗凝治疗。治疗后9例患者中7例症状完全缓解,2例症状明显好转。随访6例患者半年至2年,疗效稳定,无1例复发。结论CVST患者多有颅内压增高表现,及时行MRI、MRV及DSA检查,以明确诊断。抗凝治疗为首选治疗方法,血管内介入溶栓治疗协同抗凝治疗可提高疗效。     

Recurrent venous thrombosis including cerebral venous sinus thrombosis in a patient taking sildenafil for erectile dysfunction

Acquired or hereditary prothrombotic risk factors may lead to cerebral venous sinus thrombosis (CVST), particularly when other predisposing factors coexist. A 57-year-old man experienced right leg deep venous thrombosis, severe thrombosis of the haemorrhoid plexus and CVST over a 12-month period during which he was taking sildenafil regularly twice a week. Sildenafil is a phosphodiesterase 5 (PDE5)-inhibitor used for erectile dysfunction (ED). A slight reduction in antithrombin III and free protein S levels was demonstrated. After suspension of sildenafil and six months on oral anticoagulants, clinical improvement was obtained. Recurrent venous thrombosis, including CVST, may complicate prolonged treatment with PDE5-inhibitors in subjects at risk. Periodic monitoring of clotting factors is recommended in these subjects.     

脑静脉窦血栓形成24例临床分析

目的探讨脑静脉窦血栓形成（CVST）的临床的特点、诊断和治疗。方法回顾性分析武汉协和医院2007年1月~2010年11月24例CVST患者的发病年龄、起病形式、主要症状、实验室检查、影像学特征以及治疗情况。结果 CVST临床表现以颅内高压症状多见如头痛、恶心、呕吐（约占71%）,约67%患者存在局灶性神经系统损害的表现。CVST最常累及横窦和乙状窦,其次是上矢状窦。磁共振静脉造影（MRV）的影像质量高,能清晰显示病灶。9例患者接受抗凝治疗症状明显缓解,均未发生出血。死亡2例（约占8.3%）。结论 CVST是一种可能致命的神经系统急症,MRV是CVST较好的诊断方法,抗凝治疗安全有效。     

Superior sagittal sinus thrombosis and pulmonary embolism: a syndrome rediscovered

Pulmonary emboli as a fatal complication of superior sagittal sinus thrombosis was once well recognized in the literature but appears to have been forgotten. The sagittal sinus appeared to be the source of pulmonary emboli in previously reported cases. Even in patients with no evidence of systemic thrombosis, but who have sagittal sinus thrombosis, the possibility of dislodging pulmonary emboli should be strongly considered. We report a case of nontraumatic sagittal sinus thrombosis complicated by multiple pulmonary emboli and a fatal saddle embolism, likely originating from the thrombosed sinus. Our review of the literature between 1942 and 1990 yielded 203 cases of intracranial venous thrombosis. The overall mortality rate was 49.3%. In 23 cases (11.3%), the venous sinus thrombosis was associated with pulmonary emboli and in these the overall mortality rate was 95.6%. In the 203 cases in our review, those patients who received anticoagulation therapy also had a statistically significant better outcome. Therefore, the presence of pulmonary emboli in association with sagittal sinus thrombosis mandates a sober assessment of the need of anticoagulation therapy in the absence of obvious contraindication.     

颅内静脉窦血栓形成后昏迷患者预后相关因素研究

目的探讨影响颅内静脉窦血栓形成(CVST)后昏迷患者预后的相关因索。 方法对梧州市工人医院神经内科自2001年2月至2010年2月收治的以昏迷就诊或在入院6h内出现不同程度昏迷的30例CVST患者的临床资料进行回顾性分析。 结果随访0.5～10年,本组患者中12例无明显颅内压增高、脑深静脉血栓及相关脑血管意外,8例死亡,2例重残,8例遗留不同程度的偏瘫或智力语言障碍。CVST后昏迷患者伴有中枢神经系统感染、恶性肿瘤、脑深静脉血栓形成、癫痫及颅内出血等改变时患者预后差,其中恶性肿瘤患者重残或死亡率高达50％。 结论CVST后发生昏迷的患者预后差,病死率高,及早诊治并合理治疗有助于改善预后。     

磁共振静脉血管成像在脑静脉窦血栓形成诊断中的应用

目的 评价2D-TOF法磁共振静脉血管成像(MRV)在脑静脉窦血栓形成(CVST)诊断中的价值。方法 对10例CVST患者进行2D-TOP法MRV检查，并与MRI和数字减影血管造影(DSA)结果进行对照研究。结果 10例患者均为多发性CVST，最常累及上矢状窦和横窦。在MRV上CVST的直接征像为发育正常的静脉窦不显影、狭窄或再通后的模糊影，间接征像为病变以远侧枝血管形成、深部静脉明显扩张或其他引流静脉显现。本组MRV结果与DSA比较具有较高的一致性，且在血管变异的鉴别及对血栓的动态观察上要优于DSA。结论 MRV可替代DSA作为CVST诊断和随访的首选检查方法。     

Cerebral venous sinus thrombosis in an adolescent with Ewing sarcoma

BACKGROUND: Although thromboembolic complications are common in adult patients with malignant diseases, cerebral venous sinus thrombosis has been rarely described in cancer afflicted pediatric and adolescent population. CASE HISTORY: A 16-year-old adolescent girl referred for complaints of pain and swelling on her left leg. On physical examination, a solid tibial mass was discovered. After the diagnosis of Ewing sarcoma with a tru-cut biopsy, chemotherapy protocol consisting of cisplatin, ifosfamide, adriamycine, and vincristine was started. During the first course of the treatment, the patient expressed headache, diplopia, and ptosis. Contrast-enhanced magnetic resonance (MR) images and MR angiography showed superior sagittal and transverse sinus thromboses. After anticoagulant therapy, the thromboses disappeared within 1.5 months. She received her chemotherapy protocol with the anticoagulant prophylaxis. After a follow-up period of 12 months, she is still in a good neurological recovery without any sequel. CONCLUSION: Children and adolescents with cancer should be monitored closely for thrombotic complications. We discuss this uncommon case to draw attention to the importance of early diagnosis and adequate treatment of intracranial thrombosis in childhood cancer, and we review the relevant literature.     

Cerebral venous and sinus thrombosis

Introduction: Although anticoagulation (AC) reduces the risk of a fatal outcome or severe disability in patients with cerebral venous and sinus thrombosis (CVST), prognosis of severe cases is still difficult to predict. The authors studied the clinical course of patients with CVST who died despite AC therapy to look for clinical features that might explain the lethal course of these patients. Materials and Methods: Retrospective analysis of a series of 79 consecutive patients with CVST who were treated with a standard regimen of dose-adjusted iv heparin. Case histories of patients with a fatal outcome are presented. Results: The authors identified eight patients with a fatal outcome. All patients were stuporous or comatose at the start of AC, and four patients showed markedly delayed intracranial circulation times, indicating extensive venous thrombosis. Two patients improved, but deteriorated secondarily after reduction or discontinuation of AC. Sufficient activated partial thromboplastin time levels were reached only after a delay in three patients, and critical deterioration occurred in two of them during this time. Conclusion: Although inadequate AC may have contributed to the fatal outcome, some patients with extensive venous thrombosis who are stuporous or comatose at the start of AC may carry an increased risk of death, despite heparin therapy. More aggressive treatment approaches, such as endovascular thrombolysis, may be needed for this subgroup of patients with CVST.     

外伤性脑静脉窦血栓形成

目的 探讨外伤性颅内静脉窦血栓形成（CVST）的特点及治疗策略。方法 对11例外伤所致CVST的诊断、治疗进行回顾性分析。结果 11例CVST患者4例继发于颅骨未骨折的闭合性脑损伤，7例继发于颅骨线形骨折；以头部胀痛、视力下降、癫痫发作为其主要临床表现；头颅MRI及MRV和脑血管造影检查为该病提供确诊依据；11例患者中4例行抗凝治疗，7例行血管内治疗；治疗后6例患者痊愈，4例好转，1例无效，无严重并发症发生。本组中9例病人接受门诊和电话随访6个月至3年，疗效稳定，无一例复发。结论 颅脑损伤后不明原因颅内压增高，尤其是并发颅骨骨折时，应警惕CVST发生，尽早行神经影像学检查以明确诊断，血管内治疗协同抗凝治疗可提高其疗效。     

脑静脉窦血栓形成合并出血性脑卒中临床分析

目的 分析脑静脉窦血栓形成合并出血性脑卒中的诊断与治疗方法.方法 10例脑静脉窦血栓形成合并出血性脑卒中病人,CT常规头部OM基线扫描,颅底层厚5 mm,颅内层面10 mm,间距510 mm,共12～14幅图象.MRI常规T1WI、T2 WI及MRV序列扫描,根据病变范围扫描层数为19～20层,4例患者行增强扫描;所有患者入院后行血常规及生化检查,所有患者均给予甘露醇静滴脱水降颅压,低分子肝素钙针(5 000 U皮下注射,2次/d,)皮下注射抗凝,控制活化部分凝血酶原时间,延长2倍且不超过120 s,每日监测至少2次、并予营养神经药物、尼莫地平预防脑血管痉挛、支持对症治疗及护理.低分子肝素钙针应用1周后改为阿司匹林片口服.结果 脑静脉窦血栓形成合并出血性脑卒中临床较为少见,临床表现以急性严重头痛多见,出血部位常位于大脑凸面,静脉窦累及以矢状窦、乙状窦、横窦.10例患者给予相应的抗凝与综合治疗后,有效率为100％.结论 脑静脉窦血栓形成合并出血性脑卒中,临床表现不典型,急性严重头痛和静脉窦累及矢状窦、乙状窦、横窦出血是诊断的线索,抗凝治疗应根据病情进行.     

26例脑静脉窦血栓形成临床分析

目的分析脑静脉窦血栓形成(CVST)的病因、临床特点,提高对脑静脉窦血栓形成的诊断和治疗水平。方法回顾性分析2008-01-2016-01我院经头CT、MRV及脑血管造影(DSA)确诊的26例CVST患者,分析其病因、临床症状、腰椎穿刺结果、影像学特点及预后。结果病因有产褥期、妊娠期、长期服避孕药、重度脱水、肺癌、血液病、肥胖、自身免疫性疾病,另有病因不明者。首发症状表现为头痛、视乳头水肿、恶心呕吐、意识障碍、癫痫、偏瘫、发热及复视、视力下降。脑脊液检查示颅压增高、蛋白轻度增高,头CT示弥漫性脑水肿、蛛网膜下腔出血、空三角症、静脉性梗死致出血及未见异常。结论 CVST的临床症状多样化,确诊需影像学检查,积极治疗预后好,以综合治疗为主,包括脱水降颅压、降纤、抗凝及原发病的治疗和血管介入治疗。     

临时夹闭加促凝法制作颅内静脉窦血栓形成的动物模型研究

目的探讨临时夹闭加促凝法制作颅内静脉窦血栓形成（CVST）的动物模型。方法30只新西兰家兔分为3组：临时夹闭上矢状窦组、结扎静脉窦对照组和假手术对照组,每组10只。临时夹闭上矢状窦组用血管夹夹住家兔上矢状窦的前、后部,注入脑磷酯白陶土悬液促凝．建立CVST的动物模型。结扎静脉窦对照组通过结扎上矢状窦建立CVST模型,假手术对照组不作任何处理。术中监测血压、心率、呼吸,术后检测脑组织含水量、静脉窦的血流速度。结果临时夹闭上矢状窦组家兔上矢状窦夹闭5h后完全栓塞,血流速度为零：在夹闭1h后．该组家兔血压、心率、呼吸均在正常范围内。临时夹闭上矢状窦组和结扎静脉窦对照组的脑组织含水量和基底静脉血流速度,分别与假手术对照组比较,差异均有明显的统计学意义（P〈0．01）,临时夹闭上矢状窦组与结扎静脉窦对照组比较无明显差异（P〉0．05）。结论临时夹闭加促凝法制作CVST模型模拟上矢状窦血栓形成,重复性和稳定性好,可满足CVST实验研究的需要。     

Cerebral venous sinus thrombosis in pregnancy and puerperium: A pooled,systematic review

Pregnancy and puerperium are risk factors for cerebral venous sinus thrombosis (CVST); however studies describing diagnosis and management in this population are limited. The objective of this study was to amalgamate published case reports and series regarding diagnosis and management of CVST in pregnancy and puerperium. Searches of PubMed and the Cochrane library were performed using search terms “pregnancy”/“puerperium” and “sinus occlusion”/“sinus thrombosis”. Studies were included in our pooled analysis if they included individual patient symptoms, management approach and follow-up condition. Multivariate regression was utilized to assess the effect of non-modifiable factors on excellent outcome (mRS 0). Sixty-six patients were included. Mean duration of symptom onset to diagnosis was 5.9 days (95% CI 4.2–7.6). Clot involvement of the superior sagittal sinus was seen in 67% of cases, the transverse/sigmoid in 64% and of the deep venous system in 15% of cases. Management approaches included anticoagulation (91% of patients), IA (intra-arterial) thrombolysis alone (26%), and IA thrombectomy with IA thrombolysis (8%). Fifty-nine percent of patients were mRS 0 at follow-up; 94% were mRS 0-2. Presentation with headache alone was associated with excellent outcome on multivariate analysis (p = 0.04); coma/obtundation predicted against excellent outcome (p = 0.03). As compared to IA thrombolysis alone, patients undergoing IA thrombolysis with IA thrombectomy demonstrated a trend toward better outcome (p = 0.10).     

脑静脉窦血栓形成并发癫痫的常见临床表现及其发病的预测因素

目的调查脑静脉窦血栓形成(CVST)后癫痫的发病率、临床表现形式和预测因素。方法2010年1月到2015年1月本院神经科住院CVST的患者90例。按有无继发癫痫,将90例CVST患者分为两组,通过病例报道表收集患者的人口学信息,症状和体征,以及辅助检查结果脑电图(EEG)、磁共振(MRI)和全脑血管造影(DSA)和诊断治疗方法,对是否并发癫痫进行单因素分析和多因素分析。应用受试者工作曲线(ROC)的曲线下面积(AUC)评价多因素模型,并和CVST预后量表的预测价值相比较。结果 CVST继发癫痫的发病率为34.4%,单因素分析显示,孕妇或产褥期(χ~2=5.517,P=0.019)、视物模糊(χ~2=6.103,P=0.013)、意识障碍(χ~2=32.505,P0.001)、脑出血(χ~2=4.822,P=0.028)、上矢状窦血栓形成(χ~2=5.908,P=0.015),以及横窦血栓形成(χ~2=6.669,P=0.010),在是否并发癫痫两组中比较差异有统计学意义。多因素分析显示,孕妇或产褥期(OR=3.64,95%CI 1.65~8.53)、脑出血(OR=3.02,95%CI 1.43~6.18),以及上矢状窦血栓形成(OR=1.98,95%CI 1.23~4.36)是CVST继发癫痫的独立危险因素。本研究预测模型的预测准确性AUC为0.73(95%CI 0.63~0.81,P0.05),CVST预后量表AUC为0.78(95%CI 0.65~0.86,P0.05),两模型的预测价值差异无统计学意义(P0.05)。结论癫痫是CVST患者的常见临床表现,孕妇或产褥期,脑出血和上矢状窦血栓形成是CVST并发癫痫的独立危险因素。本研究预测模型和CVST预后量表能较好的预测是否继发癫痫。     

儿童颅内静脉窦血栓形成的诊疗策略

目的 探讨儿童颅内静脉窦血栓形成的高危因素、常见临床表现、影像学特征及诊疗策略。方法 对2014年1月-2018年12月收住西安交通大学第一附属医院儿科的3例颅内静脉窦血栓形成患儿病例资料进行回顾性分析。结果 持续而严重的头痛是颅内静脉窦血栓形成最常见的临床表现; 3例患儿发病原因不一,与文献报道感染为主要原因不符,可能与病例数较少有关; 影像学最常见的受累部位为乙状窦和横窦; 经降颅内压、抗凝及对症治疗,1例痊愈,1例死亡,1例遗留颅神经功能异常。结论 儿童以急性发作的头痛起病伴孤立性颅内压增高综合征表现者均应警惕颅内静脉窦血栓形成的可能; 对脑脊液压力轻度升高的患儿仍需动态监测颅内压的变化; 儿童目前推荐的影像学检查方法为颅脑磁共振成像联合磁共振静脉成像,并具有长期随访优势; 全脑血管造影术在儿童中并非禁忌,在严格控制操作时间及造影剂剂量的前提下由技术熟练的专科医生操作亦是可行的; 强调早期抗凝治疗,治疗药物的选择、剂量及持续时间仍有待大样本病例的研究。     

Dural sinus thrombosis: a mechanism-based classification and review of 42 cases

Cranial venous outflow obstruction due to dural sinus thrombosis may result in venous hypertension, cerebral infarction, cerebral haemorrhage or impaired cerebrospinal fluid (CSF) absorption with consequent pseudotumour syndrome. We propose a mechanism based classification of dural sinus thrombosis from these four outcomes. Forty two cases of dural sinus thrombosis presenting to Royal Prince Alfred Hospital between 1986-1997 were retrospectively reviewed. These cases were classified according to mechanism of presentation and relevance of this to site of thrombosis, treatment and prognosis. This study shows that the superior sagittal sinus and transverse sinus are the commonest sites of thrombosis, and multiple sites of thrombosis (69%) are more frequent than a single site. Magnetic resonance imaging (MRI) with venous flow studies is the investigation of first choice for diagnosis but angiography remains the gold standard. A pseudotumour syndrome is the commonest presentation (43%) followed by cerebral haemorrhage (31%). The overall prognosis for sinus thrombosis is good, with 71% of cases recovering to normal function.     

Cerebral venous sinus thrombosis complicated with acute development of dural arteriovenous fistula: A case report

Development of dural arteriovenous fistula (dAVF) after cerebral venous sinus thrombosis (CVST) was very uncommon and for all these reported cases, the dAVF was a chronic complication. We present a case of acute development of dAVF after CVST. A 40-year-old female was admitted into our department with 2 day’s headache and vomiting for 9 h. Head computed tomography (CT) scan showed only scattered minor hematomas over the right frontal lobe. Blood test indicated an elevated D-dimer. The patient experienced transient paralysis (Todd’s paralysis) after intermittent focal epilepsy from day 3, which progressed into sustained epilepsy on day 6. Magnetic resonance imaging (MRI) on day 7 confirmed the thrombosis of the superior sagittal sinus and a large area of infarction and edema in the left frontal and parietal lobe. She was then treated with heparin and warfarin. Cerebral angiography on day 9 demonstrated a dAVF which was classified as Borden Type II and fed by the left occipital artery. Subsequently, endovascular occlusion of the fistula was conducted and the patient recovered well with only slight right limbs weakness at 1 year follow up.     

脑静脉窦血栓形成的MR诊断及MRV的应用

目的探讨脑静脉窦血栓形成（cerebral venous sinus thrombosis, CVST）的MR征象及磁共振脑静脉系血管成像（magnetic resonance venography, MRV）的技术方法。方法4例脑静脉窦血栓形成患者,男2例,女2例,年龄32～51岁,全部经常规MRI及MRV检查,2例患者行增强扫描,全部患者经DSA检查证实。结果4例患者平扫SE序列均可见静脉窦内正常流空信号消失,代之以异常等或高信号。出血性脑梗死3例;广泛脑肿胀及脑水肿1例。MR增强可见静脉窦异常低信号或闭塞;对比增强磁共振血管造影检查（contrast enhanced magnatic resonance venography, CE-MRV）见受累静脉窦腔内血流信号不规则或信号完全消失。结论MRI结合3D-CE-MRA是诊断脑静脉窦血栓形成的有效手段。