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cerebrovenous thrombosis
- 1. CASE BASED DISCUSSION- CVT Discussed on 28 Sep 2022
- 2. 24 years oldlady 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 MIRoom (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 - 2day 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 PresentIllness 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 ofmuscle 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 NoSpeech 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 historyof 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 • Nohistory of • Similar illness in the past • Bleeding manifestations in past • Diabetes Mellitus, Hypertension, RHD • Tuberculosis • Vaccination in past 03 months
- 10. Nonveg diet Normal Boweland bladder habits Normal sleep and appetite No addictions or high-risk behavior Personal history
- 11. No h/o similarillness 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, Conjunctivanormal 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 Nosigns 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 S2normally 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 youngdue to Cerebrovenous thrombosis Probable APS without rheumatological illness DIAGNOSIS
- 22. Admitted in ICU InjLMWH 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 GeneralizedTonic-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 07days 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 olddocument: 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 youngdue to Cerebrovenous thrombosis Definitive APS without rheumatological illness With generalized onset motor seizures (recurrent) FINAL DIAGNOSIS
- 27. Strict compliance tooral warfarin & AED PT INR monitoring monthly APLA screening after 3 months Indefinite life long medication under supervision Plan
- 28.
- 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 EncompassesBoth 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 arethe 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 Severedehydration 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.
- 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 unusualfeatures Signs of Increase ICT Focal Deficits in absence of arterial risk factors H’gic infarcts – Nonvascular territories
- 37. • Normal inmajority 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 normalflow 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 betterthen 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
Editor's Notes
- #35 Cytotoxic edema