This document discusses a case of cerebral venous thrombosis (CVT) in a 15-day-old female neonate presenting with poor feeding, decreased activity, and decreased urine output. Investigations revealed hypernatremia, acute renal failure, and CVT involving the straight sinus and intraventricular hemorrhage. The neonate was treated with IV fluids, low molecular weight heparin, and made a full recovery. Risk factors for CVT include sepsis, dehydration, and genetic factors. Management involves anticoagulation and monitoring for resolution, with surgery rarely used in newborns.

1. CEREBRAL VENOUS
THROMBOSIS
• BY:DR SHIVOM VERMA
NICU FELLOW
• MENTOR-DR RATNA SHARMA
PAEDIATRIC HEMATOLOGIST

2. Present complaints
• 15 days old female neonate was brought to us
with complaints of:-
Poor feeding since 3 days.
Poor activity since 3 days.
Decreased urine output since 3 days.
1 episode of convulsion.

3. Birth History
Patient delivered to a 34 year old Gravida 2 mother by normal conception.
Delivered at term (38wks)/female/ NVD/Cried after birth.
Breastfeeds established 1 hour of life and discharged at 3rd day of life.
Birth weight: 3250 gram
Present weight: 2700 gram
ANC HISTORY: Not significant
POSTNATAL HISTORY - No history of any postnatal illness

4. Examination
VITALS:
Temperature:
97.2 f
Hr:108 bpm
RR:40/ min CRT: 3 secs
BP: 58/32/(
mean 42) mm Hg
Spo2: 95% on
room air

5. General
examination
No pallor, icterus, cyanosis, oedema, noted.
AF sunken.
All peripheral pulses poorly palpable.
Sunken eyes +.
Skin pinch: goes back very slowly.
Lips and skin were remarkably dry.
Doughy sign +.
No purpuric skin rash present.

6. Systemic
examination
CNS:
Lethargic.
Poor activity.
Hypotonic.
Not responding to painful stimuli.
Poor sucking.
Other systems: WNL

7. Investigations
Na: 190 meq/l
K: 5.1 meq/l
Blood Urea Nitrogen: 65 mg/dl
Creatinine: 1.6 mg/dl
USG brain with doppler: S/o cerebral sinus venous
thrombosis with IVH grade I confirmed with MRI.
2D-ECHO: Normal
USG KUB: Stasis nephrophathy+

8. USG SKULL

9. Thalamic hemorrhage in the coronal AND
sagittal view. The associated intraventricular
hemorrhage.

10. MRI WITH VENOGRAM

11. • Small intraventricular hemorrhage and a left-
sided thalamic hemorrhage.A repeat MRI on
follow up shows resolution of the hemorrhage
and mild ex-vacuo dilatation of the left
ventricle.

12. Thrombosis of the straight sinus.
Resolved on follow up

13. Diagnosis
Cerebral sinus
Thrombosis
• Hypernatremic dehydration
• Sepsis

14. Treatment
Treated for hypernatremic
dehydration and acute renal failure
with appropriate iv fluid.
Low molecular weight heparin for
thrombosis (1.5mg/kg/dose)
subcutaneous twice a day.

15. Outcome
and
follow up
LMW heparin given for 14 days
in NICU then patient was given
DOPR and taught mother how
to give heparin and asked to
come on follow up.
After 6 weeks of Heparin, MRI
with venogram scan was done
which is suggestive of normal
study.

16. QUESTION
FOR
AUDIENCE
RISK FACTORS FOR CEREBRAL VENOUS
THROMBOSIS?
A.SEPSIS
B.DEHYDRATION
C.PROTEIN C DEFICIENCY
D.FACTOR V LEIDEN MUTATION
E.ALL OF ABOVE

17. Discussion
Risk factor - asphyxia,
septicemia, dehydration and
maternal diabetes.
The main neurological
manifestations are decreased
level consciousness, and local
neurological signs such as
cranial nerve palsies.

18. • How are CNS thrombosis managed?

19. Management
Different approaches vary
depending on the location and
extent of the thrombus.
Asymptomatic thrombosis -
close monitoring of the size of
thrombus and supporting care.
Severe symptomatic
thromboembolic events -
anticoagulants
Surgical thrombectomy is rarely
performed in newborn

20. ???
Choice of
anticoagulant
Monitoring of
thrombus
resolution
Monitoring for the
anticoagulant
therapy

21. In this patient, heparin for 6 weeks was
sufficient for the recanalisation of the
sinus.
Low molecular weight heparin remains the
most frequently used anticoagulant,
although there is increasing experience
with low-molecular weight heparin in this
age group.

22. ??
Any side effects
with LMWH?
Practical difficulties
in administering
LMWH?

23. ???
• How will the
management differ
if there is associated
haemorrhage?

24. Learning points
• Incidence .6/100000 [30 to 40 percent in neonate]
• Neonates and infants, less than 1 year of age,
account for the largest proportion of thrombotic
events during the paediatric age.
• The diagnosis of cerebral venous thrombosis needs
a high index of clinical suspicion in severe neonatal
hypernatremia presenting diffuse neurological
signs. Other location of the thrombus must be
looked for.

25. Thank you