Sinus thrombosis after a jump from a small rock and a sneezing attack: minor endothelial trauma as a precipitating factor for cerebral venous thrombosis?

Cerebral venous thrombosis (CVT) associated with minor or trivial head trauma has only been described in a few cases so far. We report two patients who developed CVT after a sudden intracranial pressure increase and head acceleration. A 49-year-old woman jumped from a small rock, 1 m in height, and developed instantaneous occipital headaches. Magnetic resonance imaging (MRI) confirmed confluens sinuum thrombosis. Risk factors consisted of smoking and oral contraceptives. Our second patient, an 18-year-old woman, experienced instantaneous headaches after a sneezing attack. Superior sagittal and right-sided transverse sinus thrombosis were confirmed by venous computed tomography angiography. She took oral contraceptives as an additional risk factor. In about 20% of CVT cases the cause remains unclear. As minor head trauma may not have been recognized during history taking, this may represent a so far under-recognized precipitating factor for CVT.     

以孤立性头痛为主要表现的颅内静脉窦血栓1例并文献复习

目的 探讨本病的病因、临床表现、影像学特征、治疗方法.方法 回顾性分析1例以反复孤立性头痛为主要表现的颅内静脉窦血栓病例,并复习相关文献.结果 患者男性,28岁,主因头痛10天,加重4天入院.头部MRI平扫+增强提示左侧乙状窦及横窦充盈缺损,T1及Flair呈高信号.数字减影血管造影证实为左侧横窦、乙状窦血栓.经抗感染...     

Cerebral Venous Thrombosis in Spontaneous Intracranial Hypotension

Background and Objective.— The occurrence of cerebral venous thrombosis has been reported among patients with spontaneous intracranial hypotension, but a causal relationship has not been clearly established. We reviewed our experience with spontaneous intracranial hypotension and cerebral venous thrombosis and we reviewed the relevant literature to evaluate the relationship between these 2 entities. Methods.— We reviewed the medical records and imaging studies of a consecutive group of patients with spontaneous intracranial hypotension evaluated at a tertiary care center between 1/1/2001 and 12/31/2007. The main search strategy was a systemic review of journal articles in MEDLINE (1966 to January 2008). Results.— Among 141 patients with spontaneous intracranial hypotension, 3 (2.1%) were also diagnosed with cerebral venous thrombosis. Among these 3 patients and the 17 reported in the literature there were 11 men and 9 women with a mean age of 39.5 years. Radiographic or clinical evidence for spontaneous intracranial hypotension preceding cerebral venous thrombosis was found in most patients, while there was no evidence for cerebral venous thrombosis preceding spontaneous intracranial hypotension in any patient. Eight (40%) of the 20 patients were found to have a change in their headache pattern believed to be due to the development of cerebral venous thrombosis. Complications of cerebral venous thrombosis, eg, cerebral venous infarction, occurred in 8 patients (40%). Conclusions.— Spontaneous intracranial hypotension is a risk factor for cerebral venous thrombosis, but cerebral venous thrombosis is found in only about 2% of patients with spontaneous intracranial hypotension. A change in headache pattern is not a reliable predictor of the development of cerebral venous thrombosis in patients with spontaneous intracranial hypotension.     

A 21-year-old white woman diagnosed with cerebral venous sinus thrombosis related to oral contraceptive and Factor V Leiden

Empirical research has established the fact that the use of oral contraceptives in young women with the Factor V Leiden mutation increases the relative risk of cerebral venous sinus thrombosis. Cerebral venous sinus thrombosis is a rare cerebral vascular injury whose ambiguous presentation contributes to delayed and often-inaccurate diagnosis. This case report presents a 21-year-old White woman with a severe headache who presented to the emergency department and was diagnosed with cerebral venous sinus thrombosis. The purpose of this article is to educate advanced practice emergency care nurses on the importance of understanding genetic and acquired risk factors in diagnosing cerebral venous sinus thrombosis. A genetic risk assessment tool is introduced that advanced practice nurses may incorporate into their routine assessments to evaluate the likelihood of a genetic predisposition for illness, such as shown in this case study.     

Traumatic intracerebral venous thrombosis associated with an abnormal golf swing

OBJECTIVES: To describe the occurrence of cerebral venous thrombosis in a 40-year-old man whose cerebral event was induced by a poor golf swing, to review the literature on possible mechanisms producing venous thrombosis, and to compare this case with the literature. BACKGROUND: Headache is the most frequent symptom in patients with cerebral venous thrombosis. However, patients presenting with a headache due to cerebral venous thrombosis are uncommon. The known risk factors for thrombosis include both acquired and genetic factors. When the interaction of these two groups occurs, the magnitude of this interaction is thought to produce a dynamic state that can favor thrombosis. Our case report illustrates that moderate levels of anticardiolipin antibodies together with the mild trauma of a golf swing can induce a cerebral venous thrombosis. This case also suggests that although headache is rarely due to cerebral venous thrombosis, it should be excluded by good medical acumen and testing. RESULTS: Minor trauma induced by a poor golf swing was chronologically related to the development of a progressive cerebral venous thrombosis. The patient had none of the risk factors associated with a predisposition to venous thrombosis: hypercoagulable state, concurrent infection, pregnancy/puerperium, collagen vascular disorder, malignancy, migraine, false-positive VDRL, previous deep vein thrombosis, renal disease, factor V Leiden, or a hematological disorder. There was no anatomical abnormality that would predispose the patient to a cerebral venous thrombosis. The only laboratory abnormality was a moderate anticardiolipin antibody level (25 GPL). The patient was placed on warfarin sodium therapy and is currently without clinical sequela from the venous thrombotic event. CONCLUSIONS: Under certain circumstances, minor trauma can induce cerebral venous thrombosis. A review of the literature indicates that cerebral venous thrombosis in the presence of anticardiolipin antibodies and in the absence of systemic lupus erythematosus is a rare event. Previously, only major traumatic events have been reported to be associated with cerebral venous thromboses. The chronological development of cerebral venous thrombosis after a faulty golf swing strongly indicates that given a background of moderate levels of anticardiolipin antibodies, even minor trauma can induce a venous thrombotic event.     

An unusual cause of cerebral venous sinus thrombosis: prothrombin G20210A gene mutation

Cerebral venous sinus thrombosis represents less than 1% of all strokes, being an uncommon entity with a wide spectrum of clinical scenarios. We present a 45-year-old Hispanic female with a history of long-term oral contraceptive use who was diagnosed with cerebral venous sinus thrombosis due to a heterozygous carrier mutation in the prothrombin G20210A gene. The patient was successfully managed with intravenous heparin with favorable clinical results without adverse effects. The prevalence of inherited primary thrombophilia increases with additional risk factors such as the use of oral contraceptives that can trigger or prothrombotic events in any vascular bed. An increased prevalence in the prothrombin G20210 gene mutation has been demonstrated in the Mexican-Mestizo population. Controversy exists regarding therapy of cerebral venous sinus thrombosis; according to experts, heparin remains the cornerstone of therapy with acceptable outcomes. More clinical trials are required to evaluate long-term outcomes in this subgroup of patients.     

MRI、磁共振静脉造影及弥散加权成像在不同时期脑静脉窦血栓中的诊断价值

目的探讨MRI、磁共振静脉造影（MRV）及弥散加权成像（DWI）在不同时期脑静脉窦血栓中的诊断价值。方法回顾性分析本院2015年11月~2019年8月经数字减影血管造影或临床随访确诊的27例脑静脉窦血栓患者的MRI资料,其中18例患者行DWI检查,9例患者接受MRI增强检查。结果27例静脉窦血栓患者MRI平扫表现流空信号消失,静脉窦出现异常信号,3例脑静脉窦血栓患者MRI增强后表现为空三角征,MRV则显示静脉窦血流高信号不同程度缺失,局限性或阶段性血栓以血流高信号变细、中断为主。DWI对急性和亚急性脑静脉窦血栓及继发静脉性脑梗塞敏感。结论MRI、MRV联合DWI有助于静脉窦血栓的早期诊断并可以反映血栓的演变过程,为临床及时治疗静脉窦血栓具有重要意义。      

Cerebral venous thrombosis after lumbar puncture and high steroid cycle in a patient with multiple sclerosis

The present case report underlies the importance of modifications in the characteristics of post-lumbar puncture headache, which led us to diagnose cerebral venous thrombosis in a 34-year-old woman affected by multiple sclerosis. The patient underwent a lumbar puncture for diagnostic purposes and successively was treated with megadoses of methylprednisolone (1 g intravenously for 6 days). After lumbar puncture, the patient developed an orthostatic headache sue to cerebrospinal fluid (CSF) hypotension. Eight days later, and two days after finishing the cycle of methylprednisolone, the headache worsened, became diffuse and persisting, and was longer modified by postural changes. This was associated with psychomotor slowing and, the day after, a partial epileptic status. Magnetic resonance imaging showed an alteration in the signal corresponding to the sagittal superior, transverse and sigmoid sinuses, indicative of venous thrombosis. The potential role of lumbar puncture, steroid treatment and other associated risk factors, and the importance of considering modifications in post-puncture headache as a condition which needs specific neuroradiological examinations are discussed. Received: 19 October 2000 / Accepted in revised form: 9 January 2001     

Changing pattern of headache pointing to cerebral venous thrombosis after lumbar puncture and intravenous high-dose corticosteroids

OBJECTIVE: To emphasize the diagnostic importance of change in the headache pattern which pointed to cerebral venous thrombosis in two patients after lumbar puncture and high-dose intravenous methylprednisolone for suspected multiple sclerosis. RESULTS: Both patients had a diagnostic lumbar puncture for suspected multiple sclerosis and were treated with high-dose intravenous methylprednisolone. Both developed a postlumbar puncture headache that was initially postural, typical of low cerebrospinal fluid pressure. Three days later, the headache became constant, lost its postural component, and was associated with bilateral papilledema. Magnetic resonance imaging of the brain disclosed superior sagittal and lateral sinuses thrombosis. The diagnostic difficulties of such cases and the potential role of lumbar puncture and corticosteroids as risk factors for cerebral venous thrombosis are discussed. CONCLUSIONS: When a typical postdural puncture headache loses its postural component, investigations should be performed to rule out cerebral venous thrombosis, particularly in the presence of other risk factors.     

Diagnosis and treatment of cerebral venous thrombosis

Dural sinus or cerebral venous thrombosis (CVT) is a frequently unrecognized cause of stroke affecting predominantly young women. Typical clinical signs include headache, visual problems and seizures. Both computed tomography and magnetic resonance venous angiography are suitable for the detection of CVT, although magnetic resonance angiography is more sensitive to detect small cortical venous thrombosis. Evidence for efficacy of initial treatment with heparin in acute CVT comes from two randomized placebo-controlled studies that together included 79 patients. Although not evidence-based, postacute treatment with oral anticoagulation is recommended for up to 12 months after CVT. Long-term anticoagulation is recommended only in patients suffering from a severe coagulopathy or with recurrent CVT.     

Upper-extremity deep venous thrombosis complicating whole-blood donation

BACKGROUND: Up to 36 percent of blood donors may experience a donation-related complication. Fatigue, bruises, hematomas, and vasovagal reactions comprise the great majority of donor reactions and injuries. Serious complications are rare. CASE REPORT: A 20-year-old female taking the third-generation oral contraceptive desogestrel/ethinyl estradiol and ethinyl estradiol (Mircette) developed bruising and increased pain and swelling of her right arm over a 5-day period after whole-blood donation. She was a first-time donor and the venipuncture was reported as being mildly traumatic. There was no personal or family history of thrombosis. RESULTS: Ultrasound examination of her upper extremity revealed the presence of a deep venous thrombosis that required treatment with enoxaparin sodium for 5 days and warfarin for 6 months. Evaluation for thrombophilia was negative. The only risk factor for thrombosis was use of oral contraceptives. CONCLUSION: Although serious complications from whole-blood donation are rare, they may occur. Deep venous thrombosis should be considered in a donor presenting with increasing pain and swelling after blood donation.     

脑静脉窦血栓形成65例临床与影像学分析

目的 探讨脑静脉窦血栓形成(CVST)的病因、临床表现及影像学特点.方法 回顾性分析65例CVST患者的临床表现、头颅CT、MRI、磁共振静脉血管造影及数字减影血管造影(DSA)特点.结果 本组65例CVST患者中,25例(38%)患者仅表现为单纯颅高压;头面部局部或全身感染者13例(20%);贫血4例(6%);服用避孕药史4例(6%);结缔组织及相关疾病4例(6%)(Behcet's病2例,系统性红斑狼疮2例),蛋白C缺乏2例(3%).9例急性患者的头颅CT平扫发现,2例存在"稠密三角征",3例存在"条带征".亚急性患者头颅MRI显示,静脉窦内主要为T1、T2高信号(33%,4/12).MRI发现急性、亚急性及慢性患者静脉性脑梗死的比例分别为38%(3/8)、33%(4/12)及18%(6/33).在行MRV检查的12例患者中,均发现静脉窦充盈缺损或中断(100%).DSA检查发现66%(40/61)累及2个或2个以上静脉窦,11%(7/61)累及大脑浅(深)静脉.结论 CVST病因复杂,起病形式多样,临床表现主要为颅高压等一些非特异性症状及体征;头颅CT及MRI分别对急性,亚急性CVST静脉窦内的血栓有较高的敏感性与特异性;MRV可快速、无创地诊断CVST.若以上检查仍不能明确诊断,应尽快行DSA检查,尤其是大脑浅(深)静脉血栓形成患者.     

Cerebral venous thrombosis initially considered as a complication of spinal-epidural anaesthesia

Cerebral venous thrombosis is an unusual condition characterized by headache, nausea, vomiting, focal deficits and epileptic seizures. In this case report we describe a patient who presented with headache and focal motor deficits after an uneventful Caesarean section, performed using combined spinal-epidural anaesthesia. Magnetic resonance imaging was performed because of the pronounced neurological symptoms, and a diagnosis of cerebral venous thrombosis was made. The patient was treated with anticoagulant agents and made a complete recovery. This case emphasizes the importance of considering cerebral venous thrombosis in the differential diagnosis of headache in the post-partum period prior to instituting conventional therapy.     

THE CLINICAL CHARACTERISTICS OF HEADACHE DURING IMPENDING CEREBRAL INFARCTION IN WOMEN TAKING ORAL CONTRACEPTIVES

Clinical characteristics of cerebral infarctions occurring in 15 women (aged 22-51) who had taken oral contraceptives for an average of 24.8 months are described. Aside from 5 atypical cases, the 10 remaining women suffered marked increases in headache pain for only 3 months before their strokes. The subjective severity increased progressively, and in at least 6, the duration of each headache increased. Frequency of headaches in 9 women increased noticeably during the prodrome, and in some was almost constant for a week before the infarct. However only 5 patients had or had just had headaches at the exact time of the stroke. The spatial aspects of headache locations imply etiological relationship to the infarct which follows. Upon recognition of the clinical characteristics of such headache in women taking oral contraceptives, the medication should be stopped immediately. Absolute withdrawal should be recommended for patients with increasing vascular headache and headache associated with focal neurological symptoms. Hypertension in patients with the slightest sign of increasing headache should be cause for discontinuation of the pill. Following withdrawal of the oral contraceptive, synthetic narcotics are the only therapy advised. Vasoconstrictor drugs may aggravate the vasoconstrictor phase leading to infarction.     

The combined vaginal contraceptive ring, nuvaring, and cerebral venous sinus thrombosis: a case report and review of the literature

Background

Combined oral contraceptives are known to confer a risk of venous thromboembolism, including cerebral venous sinus thrombosis (CVST), to otherwise healthy women. NuvaRing (Organon USA, Inc., Roseland, NJ) is a contraceptive vaginal ring that delivers 120 μg of etonogestrel and 15 μg of ethinyl estradiol per day. Its use has been associated with rare venous thromboembolic events, but few cases of CVST associated with NuvaRing have been reported.

Objective

To describe a case that illustrates the increased risk of CVST associated with use of NuvaRing. We describe the case of a NuvaRing user who presented to our emergency department with a headache, who was diagnosed with CVST.

Conclusion

Evidence suggests that NuvaRing has at least as much prothrombotic potential as combined oral contraceptives. Thus, emergency physicians should suspect serious venous thromboembolic events, including CVST, deep venous thrombosis, and pulmonary embolism, in NuvaRing users in the proper clinical setting.     

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.     

脑静脉窦血栓形成的影像学检查及临床特征

目的:探讨脑静脉窦血栓形成(CVT)的临床特征及影像学特点,以寻求早期识别的征象及影像策略。方法:对62例经MR或/和DSA确诊为CVT的患者临床资料及影像学特点进行回顾性分析,并予抗凝治疗。结果:62例患者中有60例有非特异性头痛,其中56例行MRI+MRV检查确诊为CVT的有54例,32例经DSA检查均确诊为DVT。结论:CVT的临床表现缺乏特异性,MRI+MRV检查是诊断DVT的首选方法,DSA是诊断CVT的"金标准"。     

Stenting for acute cerebral venous sinus thrombosis in the superior sagittal sinus

Endovascular treatment for superior sagittal sinus (SSS) thrombosis is not always successful because of difficult access and long thrombus lesions. We report the first two cases of patients with acute cerebral venous sinus thrombosis at the SSS that was not recanalized by anticoagulation, mechanical thrombectomy, or thrombolysis, but was successfully treated by stent placement. Case 1 was a 37-year-old woman with bilateral subdural hematomas. Digital subtraction angiography showed obstruction of the sinus from the SSS to the right transverse sinus. Recanalization was achieved by selective thrombolysis using urokinase followed by balloon angioplasty, but re-occlusion occurred on the next day of treatment. Repeated endovascular treatment including balloon angioplasty, thrombus aspiration and thrombolysis using recombinant tissue plasminogen activator failed to achieve recanalization. We thus placed intracranial stents in the SSS, which did achieve recanalization. Case 2 was a 69-year-old woman with a small infarction in the left parietal lobe. Digital subtraction angiography showed sinus obliteration from the SSS to the bilateral transverse sinuses. Recanalization was not achieved by balloon angioplasty, thrombus aspiration and selective thrombolysis. We thus placed intracranial stents in the SSS, which did achieve recanalization. Postoperative course was uneventful in both cases and venous sinus patency was confirmed by venography >1.5 years after treatment. When conventional endovascular strategies have been unsuccessful, placement of intracranial stents, which can easily gain access to the distal part of the SSS as compared with carotid stents, may be a useful treatment option for the acute sinus thrombosis in this region.     

Headache: cortical vein thrombosis and response to anticoagulation.

Cerebral venous thrombosis (CVT) is being diagnosed more frequently with the use of advanced radiologic imaging. The presentation of CVT includes a wide spectrum of nonspecific symptoms with headache predominating. We present a case with acute, severe headache. The evaluation included a head computed tomography (CT) scan that was normal. The presence of opacified sinuses led to treatment for sinusitis. The patient returned the following day with a generalized tonic-clonic seizure. A magnetic resonance imaging (MRI) study identified an isolated cortical venous thrombosis. This patient was treated with anticonvulsant and anticoagulation therapy. A CVT is an unusual cause of headache and should be considered in patients with atypical presentation or associated seizure, or who are refractory to current therapy. Diagnosis may be made with MRI. Resolution and complete recovery are possible with appropriate therapy.     

磁共振成像对脑静脉窦血栓形成的诊断

目的:探讨脑静脉窦血栓形成的MRI表现和成像特点。方法:回顾性分析2003年12月~2005年1月经临床确诊的13例脑静脉窦血栓形成患者的MRI表现,所有患者均行超导MRI检查,多平面图像采集,磁共振静脉造影(MRV)采用2D-TOF技术。结果:MRI特征性表现为平扫脑静脉窦内正常的流空信号消失,代之以异常的等信号或高信号。病变最常累及上矢状窦和横窦。MRV表现为受累的静脉窦的闭塞呈充盈缺损或再通后的模糊影,病变部位和范围与MRI相对应?熏 侧枝血管形成,深部静脉明显扩张或其他引流静脉显现。结论:MRI和MRV能准确诊断脑静脉窦血栓形成,而且可以用于病例的随诊观察。