case discussion on CVT

1. CASE BASED DISCUSSION - CVT
Discussed on 28 Sep 2022

2. 24 years old lady with no known co-morbidities
Right handed
Resident of Talegaon
Educated till class 12th
Informant: Self, Reliability: Good
Full Term Normal Vaginal Delivery on 17 Aug 2022
Case Based Discussion

3. Brought to MI Room (28 Aug 2022) with
complaints of:
Headache x 2 days
Weakness of the left side of the body x 8
hours
Chief Complaints

4. Headache - 2 day
Acute onset, dull aching/boring
Constant initially in occipital area
Became intense globally over 08 hours
One episode of vomiting without nausea
No aura/autonomic symptoms
No exacerbating or relieving factors
No blurring of vision
History of Present Illness

5. History of Present Illness
Weakness of the left side of body - 8 hours
• Acute onset weakness
• With static course
• Weakness in Left side of the body
• Difficulty in movement of Lt lower limb on bed
• Able to raise arm above head and was able to hold cup in
hand and tie gown
• Difficulty in turning side to side in bed
• Deviation of face to the right side

6. No history of muscle wasting
Coordination in upper limbs was normal
No involuntary movements were seen
No h/o paraesthesia/ numbness/ shooting/ burning
pain in limbs
No bowel/ Bladder incontinence
No diplopia, vertigo, tinnitus, hoarseness of voice,
nasal twang, difficulty in swallowing or speaking
History of Present Illness

7. No alter sensorium
No Speech disturbance
No seizures – however had intense myalgia at
presentation ( ? Post ictal) hence possibly a
unwitnessed tonic clonic movement of body earlier
couldn't be ruled out. No tongue bite or injury.
History of Present Illness

8. • No history of
Fever, weight loss
Rash, mucosal ulcers, joint pains or swelling
Ear ache or ear discharge
Breathlessness, palpitations, Cough, Sputum, Syncope
Trauma
History of Present Illness

9. Past History
• No history of
• Similar illness in the past
• Bleeding manifestations in past
• Diabetes Mellitus, Hypertension, RHD
• Tuberculosis
• Vaccination in past 03 months

10. Nonveg diet
Normal Bowel and bladder habits
Normal sleep and appetite
No addictions or high-risk behavior
Personal history

11. No h/o similar illness in family
Menstrual History
Attained menarche at 14 yrs of age
Regular cycles of 30 days with 3 days of flow
Family history
Menstrual history

12. P1 L1 A3
 2018: IUFD at 4 months POG
Treated in Civil
 2020: IUFD at 7 months POG
Treated in Civil
 2021: IUFD at 4 months POG
Treated in Civil
 2022: FTNVD at 38 weeks POG
On Tab Ecosprin and Inj LMWH 40 mg S.C. in view of
BOH, irregular follow up and poor compliance
Obstetric History

13. Examination:
In intense pain, but following verbal commands
Averagely built, well nourished
Afebrile
Pulse: 98 per min BP: 156/84 mmHg
RR: 22/min SpO2: 97% @ room air
No pallor, icterus, cyanosis, Lymphadenopathy,
clubbing, or pedal oedema
No neurocutaneous marker
General Examination

14. Eyes: Cornea, Conjunctiva normal
Pupil normal, reacting to light
Fundus - Normal
ENT No mastoid tenderness
Tympanic membrane – Intact
No Rash
Joints – No Arthritis
General Examination

15. HMFs : Normal
Speech : Normal
Cranial Nerves: UMN palsy of the 7th cranial
nerve on the left side, rest all normal
Motor Examination:
Bulk : Normal
Tone: Increased on left side
Power: RUL: 5/5 LUL: 1/5
RLL: 5/5 LLL: 1/5
Coordination: Normal
No involuntary movements
CNS Exam

16. Sensory Examination: Normal
Reflexes
No signs of meningeal irritation
Spine & Skull: Normal
Gait: can’t be assessed
CNS Exam (contd)
B T S K A Plantar
Right 2+ 2+ 2+ 2+ 2+ Normal
Left 2+ 2+ 2+ 2+ 2+ Extensor

17. Cardiovascular System:
S1 S2 normally heard, No murmurs
Respiratory System:
Vesicular breath sounds, No crackles
Abdominal Examination:
No hepatosplenomegaly, Ascitis
Systemic Examination

18. INVESTIGATION DATE (28/ Aug/2022)
Hb 11.5 gm/dL
TLC 13500/ cumm
DLC P88 L6 M4 E1
Platelet count 245000/cu mm
Urea/ Creatinine 22/0.6 mg/dL
Na+/K+ 139 / 3.9 mEq/L
Total Bilirubin 0.3 mg/dL
AST/ ALT/ ALP 21/10/116 IU
Total Protein/ Albumin 7.3/3.6 g/dL
TSH/ T3/ T4 Normal
Urine RE WNL
Initial Investigations

19. PT/ INR – WNL
HIV/HBsAg/ Anti HCV – WNL
ECG – WNL
Chest X-ray: Normal Study
USG Abdomen & Pelvis: Normal study
Initial Investigations

20. NCCT Head: ? Delta sign present
Urgent MRI with MR Venogram was performed:
Cerebral Venous Thrombosis involving the entire
superior sagittal sinus and draining cortical veins with
associated infarct in the right parietal area
Urgent Neuroimaging
Images – removed to limit file size

21. Stroke in young due to
Cerebrovenous thrombosis
Probable APS without rheumatological illness
DIAGNOSIS

22. Admitted in ICU
Inj LMWH 60 mg S.C. BD
Inj Levetiracetam 500mg IV BD
Inj IV Mannitol 100 gm IV TDS
IV fluids AEDs and supportive measures.
Infection prevention and prophylaxis, prevention
for DVT, and chronic bed-bound care.
TREATMENT

23. Had witnessed Generalized Tonic-Clonic
Seizure on D1 after admission in ICU
Had persistent severe headache
Increased Tab Levetiracetam 1 gm BD 
had another seizure recurrence on D2 with
no relief in headache  Neuro-physician
opinion was taken; she was stabilized by
increasing dose of mannitol and Tab
Levetiracetam 1.5 gm BD
Course at this hospital

24. Gradually over 07 days she became
ambulant with support, There was no
headache, no seizure recurrence
Lower limb power increased from over 07 to
10 days 1/5  3/5  4-/5 and upper limb
power increased to 4/5  5/5
Switched on Oral warfarin 5 mg OD (Target
INR of 2-3)
Tab Levetiracetam 1.5 g BD
On physiotherapy and supportive care
Course at this hospital

25. On revisiting old document:
Rest pro-coagulant work - up: Not done
Course at this hospital
2021 Anti CCP & ANA: Negative
Lupus anticoagulant by DRVVT
was positive
B2 microglobulin - negative
Anti cardiolipin-2 Ab - negative
2022 APLA screening - negative

26. Stroke in young due to
Cerebrovenous thrombosis
Definitive APS without rheumatological illness
With generalized onset motor seizures (recurrent)
FINAL DIAGNOSIS

27. Strict compliance to oral warfarin & AED
PT INR monitoring monthly
APLA screening after 3 months
Indefinite life long medication under
supervision
Plan

28. DISCUSSION - CVT

29. CARDIAC
• Arrhythmias
• Cardiomyopathy, Valvular Heart disease, Prosthetic valves, Atrial myxomas
HAEMATOLOGICAL
• Hyper viscosity – Polycythemia
• Inherited prothrombotic states
• Acquired prothrombotic states – APLA, OCP, Pregnancy, MAlignancy
VASCULAR
• Arterial dissection, fibromuscular dysplasia, Moya moya disease
• Connective tissue disorder
INFLAMMATORY
• Large vessel & small vessel vasculitis
• Infections
METABOLIC
• CADACIL, MELAS, hyperhomocysteinemia
• Ingestion - Cocaine

30. CEREBRAL VENOUS THROMBOSIS
Encompasses Both Dural Sinus Thrombosis
& Cortical Vein Occlusion
DURAL SINUS THROMBOSIS
Refers to clots in large, dural venous conduits
CORTICAL VEIN THROMBOSIS
Refers to occlusion of veins on the surface of the cortex

31. INTRACRANIAL
VEINS
No valves
These are the
veins of the
A. Brain
Cerebral
Cerebellar
Brainstem,
B. Dural venous
sinuses
C. Diploic veins
D. Emissary
veins
EXTRACRANIAL
VEINS
These are the
veins of the scalp,
face and neck

32. Stasis
Hypotension – persistent
Severe dehydration
Endothelial injury
Infections – adjacent ear &
paranasal sinus, Mastoiditis
Meningitis
Head & Neck infections
COVID-19
Sepsis
Neurosurgical procedures
Jugular catheterization
Head Injury
Prothrombotic States
(COMMONEST)
OCP
Pregnancy, Postpartum
APLA syndrome
Hyper-homocysteinemia
Genetic – hypercoagulable state
Cancer- esp adenocarcinoma,
Nephrotic syndrome, IBD, SLE,
Bechet’s syndrome, Sarcoidosis,
Polycythaemia
PNH, Sickle cell disease
Rare: HIT, aHIT, Vaccine-induced
immune thrombotic
thrombocytopenia (VITT)

33. • CLINICAL CRITERIA
A. VASCULAR THROMBOSIS
Venous
Arterial
B. PREGNANCY MORBIDITY
> 3 consecutive abortions < 10 weeks
Death of normal fetus > 10 wks
Placental insufficiency < 34 wks
Premature birth due to preeclampsia < 34 wks
LAB CRITERIA
A. Anti Cardiolipin IgM/ Ig G
B. Lupus Anticoagulant (LAC)
C. Anti beta 2 glycoproteins1 (GP1)
Medium titers to high titres
12 weeks apart
DEFINITE APS: 1 CLINICAL + 1 LAB CRITERIA
APS with or without rheumatological disease

34. Impaired
Venous
Drainage
CVT
Decrease
CSF
Absorption
Cytotoxic
Edema
Increase
Venous &
Capillary
Pressure
Vasogenic
Edema
Venous
Infarct &
H’rage

35. • Headache + Vomiting
• Visual disturbances, Papilledema
Intracranial
Hypertension
• Focal or generalized seizures (40%)
Seizures
• Weakness with monoparesis or hemiparesis
• Aphasia, in particular of the fluent type
• Visual Field defects
Focal Deficits
• Cerebral edema, Venous infarction, Venous Hage
• Multifocal signs, Stupor, Coma
Encephalopathy

36. Headache with unusual features
Signs of Increase ICT
Focal Deficits in absence of arterial risk factors
H’gic infarcts – Nonvascular territories

37. • Normal in majority of patients
• May have few findings
Venous Infarct
With Hemorrhage
Temporal Lobe
Cord Sign
Dense clot
sign
Empty Delta sign
Hemorrhage
Non vascular
territory

38. • Good visualization - major Dural sinuses
• Readily available & quicker than MRI
• Helpful in subacute or chronic CVT
• Limited use –
• Low resolution of the deep venous system & cortical veins
• The risk of contrast reactions
• Radiation exposure

39. Absence of normal flow void
Best seen in T2 & FLAIR
images
Venous Infarction

40. Time of flight (TOF) venography is routinely performed in suspected cases.
(Done by MRI techniques without contrast but prone to artifacts)
Contrast MR venography is more sensitive in detecting dural venous sinus
thrombosis than TOF venography.

41. • LMWH better then IV Heparin
• Use even in venous hemorrhage
• Bleeding risk very low
• Intracranial infection- identify & treat
• Treat Seizures
• Treat elevated ICP

42. • Small series – Not yet recommended as
standard of routine care in AHA/ASA
guidelines
• Large parenchymal lesions  herniation
• Decompressive craniectomy

43. • Provoked CVT
3-6
months
• Unprovoked CVT
6-12
months
• Recurrent CVT
• Severe Thrombophilia
• APLA
Indefinite

44. • Young women – OCT, Pregnancy, Puerperium
Patients with thrombophilia
• Pathophysiology: Increase venular & Capillary
pressure and decreased CSF absorption
• Characteristic clinical syndromes
• MR Venography (May have normal CECT head/ MRI
Brain)
• Anticoagulation is mainstay – regardless of whether
intracranial venous hemorrhage present
• Treat for 3-6 months