LETTERS TO THE EDITOR
|Year : 2022 | Volume
| 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
Ishita Desai, Ashutosh Tiwari, Mritunjai Kumar, Jagbir Singh, Nikita Dhar, Niraj Kumar
Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||11-Jun-2022|
|Date of Decision||01-Aug-2022|
|Date of Acceptance||25-Aug-2022|
|Date of Web Publication||3-Dec-2022|
Additional Professor, Department of Neurology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
|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
Cerebral venous sinus thrombosis (CVST) primarily affects young and middle-aged population. It accounts for 0.5–1% of all strokes. It has an annual incidence of 3–4/million population. Due to its rarity, large population-based studies are sparse, although several case series have been reported from India. 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. 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. Hyperhomocysteinemia was defined as plasma homocysteine level >15 μmol/L. 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. 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. 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, with dehydration, enhanced coagulability, and increased platelet reactivity likely precipitating acute CVST. 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.
Headache was the most common presenting symptom in all three CVST groups similar to previous reports.,, Up to 50% of CVST patients develop seizures,,,, 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. 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., 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Idiculla PS, Gurala D, Palanisamy M, Vijayakumar R, Dhandapani S, Nagarajan E. Cerebral venous thrombosis: A comprehensive review. Eur Neurol 2020;83:369-79.
Guenther G, Arauz A. Cerebral venous thrombosis: A diagnostic and treatment update. Neurol 2011;26:488-98.
Dash D, Prasad K, Joseph L. Cerebral venous thrombosis: An Indian perspective. Neurol India 2015;63:318-28.
] [Full text]
Kuo HK, Sorond FA, Chen JH, Hashmi A, Milberg WP, Lipsitz LA. The role of homocysteine in multisystem age-related problems: A systematic review. J Gerontol A Biol Sci Med Sci 2005;60:1190-201.
Narayan D, Kaul S, Ravishankar K, Suryaprabha T, Bandaru VC, Mridula KR, et al
. Risk factors, clinical profile, and long-term outcome of 428 patients of cerebral sinus venous thrombosis: Insights from Nizams Institute Venous Stroke Registry, Hyderabad (India). Neurol India 2012;60:154-9. [Full text]
Balci K, Utku U, Asil T, Büyükkoyuncu N. Deep cerebral vein thrombosis associated with iron deficiency anaemia in adults. J Clin Neurosci 2007;14:181-4.
Duman T, Uluduz D, Midi I, Bektas H, Kablan Y, Goksel BK, et al
. A multicenter study of 1144 patients with cerebral venous thrombosis: The VENOST study. J Stroke Cerebrovasc Dis 2017;26:1848-57.
Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F. Prognosis of cerebral vein and dural sinus thrombosis: Results of the international study on cerebral vein and dural sinus thrombosis (ISCVT). Stroke 2004;35:664-70.
Rajendran A, Bose JA, Ponnu SD, Jayasankar VR, Shameer P. Clinical and Etiological Profile of Cerebral Venous Sinus Thrombosis. Int J Contemp Med Res 2020;7:5-8.