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LETTERS TO THE EDITOR
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 1233-1235
 

Comparison of risk factors, clinico-radiological profile and outcome in patients with acute, subacute and chronic cerebral venous sinus thrombosis


Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission11-Jun-2022
Date of Decision01-Aug-2022
Date of Acceptance25-Aug-2022
Date of Web Publication3-Dec-2022

Correspondence Address:
Niraj Kumar
Additional Professor, Department of Neurology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.aian_516_22

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How to cite this article:
Desai I, Tiwari A, Kumar M, Singh J, Dhar N, Kumar N. Comparison of risk factors, clinico-radiological profile and outcome in patients with acute, subacute and chronic cerebral venous sinus thrombosis. Ann Indian Acad Neurol 2022;25:1233-5

How to cite this URL:
Desai I, Tiwari A, Kumar M, Singh J, Dhar N, Kumar N. Comparison of risk factors, clinico-radiological profile and outcome in patients with acute, subacute and chronic cerebral venous sinus thrombosis. Ann Indian Acad Neurol [serial online] 2022 [cited 2023 Jan 29];25:1233-5. Available from: https://www.annalsofian.org/text.asp?2022/25/6/1233/361560




Sir,

Cerebral venous sinus thrombosis (CVST) primarily affects young and middle-aged population. It accounts for 0.5–1% of all strokes.[1] It has an annual incidence of 3–4/million population.[2] Due to its rarity, large population-based studies are sparse, although several case series have been reported from India.[3] Unlike arterial stroke, only one-third CVST patients present acutely. Nearly half have subacute CVST and one-fifth develop symptoms gradually over more than a month.[2] To date, no Indian studies has discussed differences in risk factors, clinical profile, neuroimaging findings, and outcome of acute, subacute, and chronic CVST. Herein, we have compared the same.

This retrospective study involved CVST patients at a tertiary care hospital in North India from May 2018 to March 2020. All CVST patients aged 18 years were included. CVST was confirmed by brain magnetic resonance imaging (MRI) and MR venography (MRV) or computed tomography scan of brain venous sinuses (CTV). Patients with non-venous cerebral stroke and infection-related CVST were excluded. Demographic and clinical features including risk factors, obstetric history in females, neuroimaging findings, treatment, and outcome details were collected. In-hospital complications including need for decompressive craniectomy, intensive care unit (ICU) and mechanical ventilation were recorded. Modified Rankin Score (mRS) was used to assess neurological severity and outcome at discharge and 6-month follow-up, with a score of 0–1 defining “good functional outcome.” We categorized patients in acute (<8 days), subacute (8–30 days) and chronic (>30 days) groups according to symptom duration at presentation. Hemoglobin <11 g/dl in pregnant, <12 g/dl in non-pregnant females and <13 g/dl in males was considered anemic.[4] Hyperhomocysteinemia was defined as plasma homocysteine level >15 μmol/L.[5] The analysis was done using Statistical Package for Social Sciences (SPSS) v28.0. Descriptive statistics was calculated. Chi-Square or Fisher's exact test was used to compare categorical variables.

The 36 included patients were grouped into acute (n = 16;44.5%), subacute (n = 15;41.7%) and chronic (n = 5;13.9%) CVST [Supplementary Figure 1]. Mean age of patients was 31.94 years (range = 20–70), with 19 (52.8%) being males. [Supplementary Table 1] shows risk factors and clinic-radiological profile of entire cohort. [Supplementary Table 2] compares the risk factors, clinico-radiological profile, and outcome of CVST patients in the three groups.



While proportion of acute and subacute CVST patients with obstetrical risk factors were comparable, it was absent in chronic CVST [Supplementary Table 2]. A comparable proportion in each group had anemia with iron deficiency and history of alcohol consumption. Alcohol consumption was more frequent in male patients (P = 0.09). Hyperhomocysteinemia was detected in 13 (36.1%) patients, with two showing methylenetetrahydrofolate reductase mutation. A significantly higher proportion of males had hyperhomocysteinemia (male: female = 52.6%:17.6%; P = 0.04). Amongst 5 (13.9%) patients with thrombophilia, antiphospholipid syndrome, Protein S, and Protein C deficiency was seen in 2 (5.6%), 2 (5.6%), and 1 (2.8%) patient, respectively [Supplementary Table 1].

Headache (88.9%), seizures (58.3%), altered sensorium (25%), and visual impairment (19.4%) were common presenting symptoms. While a similar proportion in all three groups reported headache, a significantly higher proportion of acute CVST patients manifested seizures (P = 0.048) [Supplementary Table 2]. Although a comparable proportion of patients in all three groups showed infarction on neuroimaging, a significantly higher proportion of acute CVST patients developed hemorrhagic infarction (P = 0.04). While superior sagittal sinus (SSS) and transverse sinus (TS) was involved in two-third patients, sigmoid sinus (SdS) was involved in 55.6% patients [Supplementary Table 1]. SSS was most commonly involved in acute, and TS in subacute and chronic CVST. Initial anticoagulation with either subcutaneous low-molecular-weight heparin (LMWH) (n = 31;86.1%) or intravenous heparin (n = 5;13.9%) was followed by oral anticoagulation. Two patients, one presenting acutely and another subacutely, underwent decompressive craniectomy, with the former failing to survive. Although subacute CVST had a higher median mRS at admission compared to acute and chronic CVST, 92% of all patients attained good functional outcome at 6 month. Two (5.5%) patients, both with acute CVST, could not survive [Supplementary Table 2].

Acute, subacute, and chronic CVST was seen in 44.5%, 41.7%, and 13.9% of our patients, respectively. The same was reported in 14.2%, 72.8%, and 12.3%, respectively, in a previous Indian study, where patients presenting within 48 hours of symptom onset were included in acute group.[6] Puerperal state, anemia, alcohol consumption, hyperhomocyteinemia, antiphospholipid syndrome, Protein S, and Protein C deficiency was seen in 25%, 25%, 19.4%, 36.1%, 5.6%, 5.6%, and 2.8% of our cases, respectively, with Narayan et al. reporting the same in 9.8%, 18.4%, 15.6%, 18.2%, 7.2%, 12.3%, and 9.1% patients, respectively.[6] Although, the risk factors were comparable in the three groups, alcohol consumption was seen in higher proportion of acute CVST. Post-partum state and anemia with iron deficiency was common in subacute CVST. Alcoholism has been reported in male CVST patients previously,[6] with dehydration, enhanced coagulability, and increased platelet reactivity likely precipitating acute CVST.[6] Subacute CVST in post-partum females appear related to a delay in seeking consultation due to lack of awareness in primary physicians and general population. Anemia with iron deficiency may result in thrombocytosis, reduced red blood cell deformability and increased viscosity, thereby contributing towards CVST.[7]

Headache was the most common presenting symptom in all three CVST groups similar to previous reports.[6],[8],[9] Up to 50% of CVST patients develop seizures,[6],[8],[9],[10] and was seen in 58.3% of our patients. While most clinical features were comparable in the three groups, seizures manifested in a significantly higher proportion of acute CVST patients, probably related to increased parenchymal involvement, especially hemorrhagic infarction.

Neuroimaging showed SSS and TS involvement in two-third patients and was comparable to 54.3% and 48% involvement, respectively, reported previously.[6] While SSS was most commonly involved sinus in acute, TS thrombosis was most frequent in subacute and chronic CVST. Since SSS is the primary drainage site for cortical veins and CSF, its blockage may result in early decompensation and appearance of clinical symptoms. Development of adequate collaterals and gradual compensation due to patent SSS might have delayed the symptoms despite TS involvement in subacute and chronic cases.

Majority of patients (92%) reported a good functional outcome at 6-month. In-hospital mortality in 2 (5.6%) patients, both acute CVST, was comparable to 4–8% mortality in acute phase reported previously.[2],[6] Single-center study, retrospective design, and small sample size are the major limitations of our study.

Authors' contributions to the manuscript

Dr. Desai I: Writing the first draft; data collection; statistics

Dr. Tiwari A: Writing the first draft; review and critique

Dr. Kumar M: Statistics; review and critique

Dr. Singh J: Data collection; review and critique

Dr. Dhar N: Data collection; review and critique

Dr. Kumar N: Conception; design; writing the first draft; statistics; review and critique

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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