颅内静脉窦和脑静脉血栓形成的临床和影像学诊断探讨

目的探讨诊断颅内静脉窦和脑静脉血栓形成的方法。方法对 6例颅内静脉窦和脑静脉血栓形成的临床及影像学资料进行分析。结果患者多表现颅内高压征象 ,伴有全脑症状或局灶神经功能异常。头颅MRI及磁共振静脉成像 (MRV)诊断颅内静脉窦和脑静脉血栓形成有肯定的价值 ,而血管数字减影 (DSA)是诊断该病的最可靠手段。结论根据临床表现及影像学检查可确诊颅内静脉窦和脑静脉血栓形成。     

妊娠不同阶段并发颅内静脉血栓形成的临床特征

目的:探讨妊娠不同阶段与颅内静脉血栓形成(CVT)的发病机制、临床特征。方法:收集妊娠及产后并发静脉窦血栓形成患者34例的临床资料,分析妊娠并发CVT的临床特征,复习相关文献。结果:本组34例患者中,妊娠期20例,产褥期14例,平均发病年龄为(26.4±4.1)岁。通常急性起病,数天内达高峰,头痛、癫痫发作、意识障碍为最常见的临床症状。妊娠剧吐、产褥感染、妊高症、剖宫产术并发症、贫血以及低蛋白血症均为妊娠并发CVT的危险因素。D-D二聚体异常及颅内静脉血管造影检查为诊断的金标准。及早诊断、尽早抗凝是治疗的关键。结论:妊娠不同时期均可发生CVT。     

Cerebral venous thrombosis: a case report

The incidence of cerebral venous thrombosis (CVT) is three to four cases per one million in adults and seven cases per one million among children. We discuss a case of CVT in a 19-year-old woman with a history of migraine headaches. A CVT most commonly presents acutely, with a wide variety of signs and symptoms in young adults and children. The most common presenting complaint in adults is severe headache. The most frequently thrombosed sinuses are the lateral, cavernous, and superior sagittal sinuses. Risk factors include any genetic or acquired prothrombotic conditions, including pregnancy and the peripartum period. Computed tomography may show the classic "delta sign," although magnetic resonance imaging with magnetic resonance venography is more sensitive. Treatment is controversial at this time. Options include fibrinolysis, anticoagulation, mechanical thrombectomy, or surgery. Despite the lack of agreement on management of CVT, the prognosis of CVT has improved, due to an increasing frequency of diagnosis.     

My headache does not get better when I lie down: spontaneous intracranial hypotension complicated by venous thrombosis

Two patients with spontaneous intracranial hypotension (SIH) subsequently developed cerebral venous thrombosis (CVT) when their headache lost its distinctive orthostatic characteristic. In addition to typical MRI features of tonsillar descent, subdural fluid collections, and diffuse pachymeningeal enhancement, hyperintense thrombi were detected in the dural sinuses, and filling defects on magnetic resonance venography. Knowledge of the typical neuroimaging features of SIH and CVT and change in headache characteristics are important for prompt diagnosis and treatment.     

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.     

May headache be the first sign of mutation in the MTHFR gene?

BACKGROUND:

Cerebral venous thrombosis (CVT) is a rare disease and it has different etiologies. Inherited or acquired prothrombotic state plays a key role in the development of CVT.

METHODS:

A 28-year-old man who presented to our emergency department with persistent headache and accompanied by complaints of nausea and vomiting over a week. Neurologic examination revealed bilateral papilledema. Brain computed tomography showed a hyperdense area on the posterior part of the occipital lobe. Brain magnetic resonance imaging and magnetic resonance venography revealed thrombosis of CVT. Homozygous mutations were found for methylenetetrahydrofolate reductase (MTHFR). MTHFR CG677T gene mutation and blood tests showed elevated homocysteine levels on the etiological screening. There was no other etiology for CVT.

RESULTS:

Headache and other complaints were improved after treatment of heparin, warfarin, and vitamin B12. No recurrence of symptoms was observed upon outpatient follow-up.

CONCLUSION:

Since CVT is an important cause of headache, we recommend etiology screening for patients who present with CVT for MTHFR gene mutations and family counseling should be provided.KEY WORDS: Cerebral venous thrombosis, Headache, Methylenetetrahydrofolate reductase gene mutation     

Subarachnoid Hemorrhage: A Rare Presentation of Cerebral Venous Thrombosis

Because of its large spectrum of clinical manifestations, diagnosis of cerebral venous thrombosis may be very difficult. Since appropriate treatment influences prognosis, early recognition of this condition is extremely important. We report a subarachnoid hemorrhage as a rare initial manifestation of cerebral venous thrombosis. A 58-year-old woman was admitted with severe headache of sudden onset, neck stiffness, dysarthria, and ataxia. Computed tomography scan showed a subarachnoid hemorrhage in the right posterior fossa. Magnetic resonance imaging coupled with magnetic resonance angiography revealed right transverse/sigmoid sinus thrombosis with hemorrhagic infarction of the right cerebellar hemisphere leading to a pseudotumoral appearance and displacing the fourth ventricle. Anticoagulant treatment resulted in rapid clinical recovery and in resolution of the radiological signs of infarction and of the subarachnoid and subdural hemorrhages.     

Cerebral Venous Thrombosis with Subarachnoid Hemorrhage: a Case Report

Cerebral venous thrombosis (CVT) presenting as subarachnoid hemorrhage (SAH) is infrequent. We present the case of a man with CVT of the right transverse sinus who presented with a SAH in the right parietal sinus. In this case, we describe a hyper-homocysteinemia in a heterozygous patient for the methylenetetrahydrofolate reductase C667T mutation. Our report highlights the value of an early diagnosis of CVT, the importance of identifying possible causes that could be reversed with an appropriate treatment, and the controversy about the timing for starting anticoagulation therapy in such cases.     

Cerebral venous sinus thrombosis

Summary

The cerebral venous system is an unusual site of thrombosis, with a particularly high incidence in young adults. This incidence has increased in past decades because of the improvement of neuroradiological techniques. Risk factors for cerebral venous sinus thrombosis overlap with those of other venous thromboembolism sites; however, some are specific for this particular anatomical district. Prognosis is favorable in most cases if diagnosis is made rapidly and treatment is promptly initiated, even if acute complications or chronic invalidity still occur in a quarter of patients. The mainstay of treatment is anticoagulation, which is necessary in order to block clot propagation and obtain recanalization. Intracranial bleeding does not contraindicate anticoagulation. Endovascular procedures are reserved for patients with a particularly severe presentation or rapidly declining neurological symptoms despite appropriate anticoagulation, although data from clinical trials are lacking. Specifically, this review addresses the epidemiology, clinical presentation and course, risk factors, and treatment of cerebral venous sinus thrombosis, with a special focus on the pediatric population.

     

Diagnosis of pregnancy-associated uterine venous plexus thrombosis on the basis of transvaginal sonography.

OBJECTIVE: To describe the sonographic signs of uterine venous plexus thrombosis. METHODS: Four pregnant patients had a diagnosis of uterine venous plexus thrombosis in the first half of gestation. The diagnosis was based on transvaginal sonography only in 3 cases, and the fourth had magnetic resonance imaging corroboration. RESULTS: All 4 patients had similar sonographic features of uterine venous plexus thrombosis on transvaginal sonographic examination. The thrombi within the dilated veins were shown as elongated echogenic structures along the lumen that appeared round on transverse views of the affected veins. They showed swinging movements provoked by gentle transducer pressure. Power and color Doppler sonography enhanced the uterine venous plexus thrombosis diagnosis by showing blood flow around the thrombi. There were no signs of thromboembolic disease. Sonographic findings in deep leg veins and iliac veins were normal in all cases. Complete thrombophilia studies did not reveal any abnormalities. The uterine venous plexus thrombosis could not be detected on transabdominal sonography and was shown better by transvaginal sonography compared with magnetic resonance imaging. During 3 months of anticoagulation therapy, the thrombi gradually disappeared in all cases. CONCLUSIONS: Focusing on the pelvic veins while performing a transvaginal sonographic study during pregnancy may reveal important findings, which may have clinical implications. The therapeutic treatment of uterine venous plexus thrombosis is controversial and still empirical.     

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"。     

儿童大脑静脉血栓诊断:3D Brainview T1W黑血序列与3D CE-MRV序列的对比研究

目的回顾性评价3D Brainview T1W黑血序列对儿童大脑静脉血栓的诊断价值。材料与方法回顾性分析25名临床症状提示大脑静脉血栓或已被诊断大脑静脉血栓的儿童病例,25名儿童均在3.0 T磁共振仪上扫描3D Brainview T1W黑血序列和三维磁共振增强静脉血管成像序列(3D contrast-enhanced magnetic resonance venography,3D CE-MRV),其中10名儿童还扫描了颅脑常规MRI和相位对比法三维磁共振静脉血管成像(3D magnetic resonance venography,3D MRV)序列。两名高年资神经放射医生独立双盲阅读3D Brainview T1W和3D CE-MRV图像进行大脑静脉血栓诊断,诊断参考标准基于最后的临床诊断。采用Kappa一致性分析评价3D Brainview T1W序列的观察者间一致性。将3D Brainview T1W和3D CE-MRV获得的最终诊断结果与参考标准对比,分别计算3D Brainview T1W和3D CE-MRV序列诊断的敏感度、特异度及95%CI。结果3D Brainview T1W序列具有非常高的观察者间一致性(k=0.95);3D Brainview T1W序列和3D CE-MRV序列诊断的敏感度及特异度分别为97.1%/99.6%和91.4%/99.2%,差异无统计学意义,但3D Brainview T1W可直接观察血栓,提供的血栓细节及诊断信息更多。结论3D Brainview T1W能够直接观察到血栓,在儿童大脑静脉血栓诊断中具有很高的诊断效能。     

颅内静脉系统血栓的临床和磁共振静脉血管成像的诊断

目的 探讨颅内静脉系统血栓的病因、临床特点、治疗及磁共振静脉血管成像对其早期诊断价值。方法 回顾分析32例经磁共振和(或)DSA检查确诊的静脉系统血栓患者的临床资料及影像学特点。结果 磁共振和磁共振静脉血管成像能直接显示静脉窦血管闭塞及血栓栓子及治疗后的血管再通状况；早期抗凝治疗观察组与对照组比较，二组好转率、治愈率及病死率均有显著性差异。结论 磁共振静脉血管成像对静脉系统血栓早期诊断具有重要意义，而早期抗凝治疗可以改善静脉系统血栓患者的预后。     

Thrombose veineuse cérébrale

Cerebral venous thrombosis (CVT) is a rare disease, requiring urgent diagnosis and treatment. Clinical presentation is highly variable but headache result in the most frequent presentation (90%). Diagnosis is based on magnetic resonance imaging which shows the thrombus and parenchymal lesions, completed by angiography, magnetic resonance angiography and/or CT angiography. A large spectrum of general and local causes or predisposing factors should be investigated. Treatment is based on full anticoagulation even in the hemorrhagic varieties. Prognosis is better in comparison to arterial stroke (death rate: around 5%). Some severe or even malignant cases need to be identified in order to prevent further complications like cerebral herniation leading to death. In these cases, management in the intensive care unit is indicated and decompressive craniectomy may be lifesaving, allowing a good final functional recovery.     

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.     

Severe Subarachnoid Hemorrhage Associated with Cerebral Venous Thrombosis in Early Pregnancy: A Case Report

Background

Cerebral venous thrombosis (CVT) rarely induces subarachnoid hemorrhage (SAH). During late pregnancy and puerperium, CVT is an uncommon but important cause of stroke. However, severe SAH resulting from CVT is extremely rare during early pregnancy.

Objective

We report on a rare case of severe SAH due to CVT, and discuss the potential pitfalls of CVT diagnosis in early pregnancy.

Case Report

A 32-year-old pregnant woman (9th week of pregnancy) presented with slight head dullness. Initial magnetic resonance imaging (MRI) revealed focal, abnormal signal intensity in the left thalamus. Nine days later, the patient developed a generalized seizure and severe SAH was detected with computed tomography (CT) scan. MRI and cerebral angiography revealed a completely thrombosed superior sagittal sinus, vein of Galen, straight sinus, and right transverse sinus. Transvaginal sonography indicated a missed abortion. The day after admission, the patient presented again with a progressive loss of consciousness and signs of herniation. The patient underwent emergency decompressive craniotomy, followed by intrauterine curettage. Two months later, she made an excellent recovery except for a slight visual field defect.

Conclusions

A rare case of severe SAH due to CVT is reported, with emphasis on the potential pitfalls of CVT diagnosis in early pregnancy.     

利用MRI的诊断避免对颅内静脉窦血栓的误诊

目的探讨经头颅MRI及磁共振静脉血管成像（MRV）用于检测脑静脉窦血栓（cVT）的应用价值。方法35例CVT患者均行MRI标准自旋回波T1WI、T2wI和VEN／3D／PCA。结果VEN／3D／PCA比标准sE序列T1WI和T2WI多检测出CVT12处,与脑血管造影的结果完全相符。结论头颅MRI和MRV是诊断CVT的主要依据。能够避免误诊和漏诊。     

Cerebral Venous Thrombosis: An Uncommon Cause of Papilledema on Bedside Ocular Ultrasound

Background

Cerebral venous thrombosis (CVT) is a rare, difficult-to-diagnose form of venous thromboembolic disease and is considered a type of stroke. Its presentation is highly variable and may be easily confused for more common and less debilitating or life-threatening diagnoses such as migraine, seizure, or idiopathic intracranial hypertension.

Enoxaparin-induced alopecia in patients with cerebral venous thrombosis

OBJECTIVE: To report three cases of alopecia induced by the anticoagulant enoxaparin in cerebral venous thrombosis (CVT) patients. CASE SUMMARY: Three female patients were treated initially with direct intrasinus urokinase, and then followed by low-molecular-weight heparin (LMWH) enoxaparin at 1 mg/kg given subcutaneously twice daily for 3 weeks. It was switched to oral anticoagulant warfarin at 5 mg daily for another 6 months. Nearly 3 weeks after the initiation of anticoagulation, all of the three patients complained of excessive hair loss with large areas of patchy, non-scarring alopecia. Hair growth returned to normal within 1 month after the completion of enoxaparin. DISCUSSION: Unfractionated heparin remains the first-line treatment of CVT because of its efficacy, safety and feasibility. Alopecia has been reported as a side effect of LMWHs dalteparin and tinzaparin. The pattern of hair loss, telogen effluvium, involves the induction of the hair follicle into a resting phase without apparent pathologic implication. In addition, this article also reviewed other medications taken by the patients that are possibly associated with hair loss. CONCLUSION: From the review of literature, there is no report of alopecia caused by urokinase. Using the Naranjo ADR Probability Scale, a score of 6 suggests that enoxaparin was the probable cause of alopecia in our three patients. This report introduces evidence of alopecia as a probable side effect of enoxaparin, but stresses the efficacy and safety of LMWH. As this is not a life-threatening disorder, we hope to increase the awareness of pharmacists and clinicians to this relatively rare but important side effect.     

脑静脉窦血栓形成的诊断及治疗

目的:探讨脑静脉窦血栓形成(CVST)的临床特点。方法:对20例CVST患者的一般情况、病因、临床表现、脑脊液特点、影像学特征、治疗及预后等资料进行回顾性分析。结果:20例患者多表现为头痛,可伴有癫疒间发作和各种神经功能缺损的症状体征,脑脊液压力明显升高,白细胞数和蛋白质定量可正常或升高,头颅CT示静脉窦高密度改变及脑实质异常信号,MRI示静脉窦异常信号,MRV示静脉窦闭塞或充盈缺损,DSA示静脉窦狭窄、血流中断或不显影。治疗以脱水、抗凝、溶栓为主,19例好转,1例死亡。结论:对于高颅压伴或不伴神经、精神障碍的患者,须高度警惕CVST,应尽早行MRV或DSA检查,治疗以抗凝、溶栓为主。