Search

Background: Given the evolving application and promising outcomes of direct oral anticoagulants (DOACs) in various thromboembolic conditions, we aimed to compare the efficacy and safety of DOACs with warfarin in the post-acute treatment of cerebral venous sinus thrombosis (CVST) using clinical and radiological parameters., Methods: A total of 140 CVST patients were enrolled, with 95 receiving warfarin and 45 receiving DOACs as post-acute treatment. Clinical and imaging parameters of the patients in follow-up visits were investigated, including the last modified Rankin Scale (mRS), venous thromboembolic events, CVST recurrence, mortality rate, recanalization status, and hemorrhagic events, to compare the efficacy and safety of treatment between the two groups., Results: At baseline, patients' assessments using two prognostic scores, ISCVT-RS and IN-REvASC, revealed that there was no statistically significant difference in the distribution of prognostic risk categories between the warfarin and DOACs groups. Following acute therapy, patients in the warfarin and DOACs groups were followed up for the median of 359 and 325 days, respectively. Analysis to compare the efficacy of warfarin and DOACs revealed no significant difference in last mRS scores, CVST recurrence rate, venous thromboembolic events, and recanalization status between the two groups. Additionally, there was no statistically significant difference in the risk of hemorrhagic events between warfarin and DOACs groups., Conclusion: Our findings show that DOACs have comparable safety and efficacy in the post-acute treatment of CVST patients; however, large-scale randomized controlled trials are required to validate our findings., Competing Interests: Declarations. Conflict of interest: No potential competing interest. Ethical approval and consent to participate.: All procedures were carried out with the approval of the Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1402.240). Consent for publication: Not applicable., (© 2024. The Author(s) under exclusive licence to Belgian Neurological Society.)

Introduction: Cerebral venous sinus thrombosis (CVST) is an uncommon but fatal cause of stroke worldwide. Endovascular treatments could be life-saving in patients who don't treat with anticoagulants as a mainstay of treatment. Currently, there is no consensus considering the safety, efficacy, and also selected approaches of endovascular intervention for these patients. This systematic review evaluates the literature on endovascular thrombolysis (EVT) in CVST patients., Materials and Methods: A comprehensive search was conducted through PubMed and Scopus databases between 2010 and 2021, with additional sources identified through cross-referencing. The primary outcomes were the safety and efficacy of EVT in CVST, including catheter-related and non-catheter-related complications, clinical outcomes, and radiological outcomes., Results: A total of 10 studies comprising 339 patients were included. Most of the patients presented with headaches (86.72%) and/or focal neurologic deficits (45.43%) (modified Rankin Scale of 5 in 55.88%). Acquired coagulopathy and/or consuming estrogen/progesterone medication were the most frequent predisposing factors (45.59%). At presentation, 68.84% had multi-sinus involvement, and 28.90% had venous infarcts and/or intracranial hemorrhage (ICH). The overall complication rate was 10.3%, with a 2.94%, 1.47%, and 1.17% rate of ICH, herniation, and intracranial edema, respectively. The complete and partial postoperative radiographic resolution was reported in 89.97% of patients, increasing to 95.21% during the follow-up. Additionally, 72.22% of patients had no or mild neurologic deficit at discharge, rising to 91.18% at the last follow-up. The overall mortality rate was 7.07%., Conclusions: EVT can be an effective and safe treatment option for patients with refractory CVST or contraindications to systemic anticoagulation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Cerebral venous sinus thrombosis associated with vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is a severe disease with high mortality. There are few data on sex differences in CVST-VITT. The aim of our study was to investigate the differences in presentation, treatment, clinical course, complications, and outcome of CVST-VITT between women and men., Patients and Methods: We used data from an ongoing international registry on CVST-VITT. VITT was diagnosed according to the Pavord criteria. We compared the characteristics of CVST-VITT in women and men., Results: Of 133 patients with possible, probable, or definite CVST-VITT, 102 (77%) were women. Women were slightly younger [median age 42 (IQR 28-54) vs 45 (28-56)], presented more often with coma (26% vs 10%) and had a lower platelet count at presentation [median (IQR) 50x10 9 /L (28-79) vs 68 (30-125)] than men. The nadir platelet count was lower in women [median (IQR) 34 (19-62) vs 53 (20-92)]. More women received endovascular treatment than men (15% vs 6%). Rates of treatment with intravenous immunoglobulins were similar (63% vs 66%), as were new venous thromboembolic events (14% vs 14%) and major bleeding complications (30% vs 20%). Rates of good functional outcome (modified Rankin Scale 0-2, 42% vs 45%) and in-hospital death (39% vs 41%) did not differ., Discussion and Conclusions: Three quarters of CVST-VITT patients in this study were women. Women were more severely affected at presentation, but clinical course and outcome did not differ between women and men. VITT-specific treatments were overall similar, but more women received endovascular treatment., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A.S. has received a grant from Swiss Heart Foundation; C.C. has received speaker honoraria from Boehringer Ingelheim, personal fees for advisory board participation from AstraZeneca and Biogen, and personal fees for steering committee participation from Biogen and Bristol Myers Squibb; T.J.K. has received educational meeting cost assistance from Boehringer Ingelheim; T.S.F. receives in-kind study medication from Bayer Canada and advisory board honoraria from HLS Therapeutics; S.P. received research support from BMS/Pfizer, Boehringer-Ingelheim, Daiichi Sankyo, European Union, German Federal Joint Committee Innovation Fund, and German Federal Ministry of Education and Research, Helena Laboratories and Werfen as well as speakers’ honoraria/consulting fees from Alexion, AstraZeneca, Bayer, Boehringer-Ingelheim, BMS/Pfizer, Daiichi Sankyo, Portola, and Werfen (all outside the submitted work); R.L. reports fees paid to his institution for consultancy by Boehringer Ingelheim, Genentech, Ischemaview, Medtronic and Medpass; E.L. has received academic grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF agreement (ALFGBG 942851), Swedish Neurologic Society, Elsa and Gustav Lindh’s Foundation, Wennerströms’ Foundation, P-O Ahl’s Foundation and Rune and Ulla Amlöv’s Foundation for research on CVT; A.C. received speaker grants from Alexion Pharma, Italfarmaco, and Daiichi-Sankyo; M.W. has received consulting fees from Portola/Alexion; C.J. has received speaker honoraria from Alexion, CSL Behring, TEVA and Sanofi Genzyme, personal fees for advisory board participation from Alexion, Roche, Novartis and Merck Serono; H.K. has received personal fees for consulting and data safety monitoring board activities for Octapharma, Grifols, CSL Behring, UCB, Argenx, Takaeda, Alexion and his institution has received clinical trial support from Takaeda; S.N. has received consulting fees from Brainomix and lecture fees from Boehringer Ingelheim and BMS Pfizer; T.G. has received travel grants and speaker honoraria from Boehringer Ingelheim, Bayer, Novartis, BMS / Pfizer and Alexion; A.G. has received personal fees from Bayer Vital, Bristol Myers Squibb, and Daiichi Sankyo; K.J. has received academic grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF agreement (ALFGBG 965417) for research on CVT; T.T. has received personal fees from Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Inventiva, and Portola Pharma; D.A.S. reports travel support from Boehringer Ingelheim, speaker fees from Bayer, and Advisory Board participation for AstraZeneca; J.M.F. has received personal fees from Boehringer Ingelheim, Bayer, and Daiichi Sankyo as well as grants from Bayer; J.M.C. has received grants paid to his institution from Boehringer Ingelheim and Bayer, and payments paid to his institution for data safety monitoring board participation by Bayer; M.A. reports personal fees from AstraZeneca, Bayer, Bristol Myers Squibb, Covidien, Daiichi Sankyo, Medtronic, Novartis, Pfizer, and Amgen; M.R.H. reports grants from the Swiss Heart Foundation and from the Bangerter Foundation, and Advisory Board participation for Amgen. All other authors have nothing to disclose.

Background: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication of adenoviral vector-based vaccines against SARS-CoV-2. This syndrome is caused by antibodies against platelet factor 4 (PF4; CXCL4) that lead to platelet activation and is characterized by thrombocytopenia and thrombosis in unusual locations, including cerebral venous sinus thrombosis (CVST). VITT can be classified based on anti-PF4 antibodies properties in vitro: those that require PF4 to activate platelets (PF4-dependent) and those that can activate platelets without additional PF4 (PF4-independent) in the serotonin release assay., Objectives: We aim to characterize the relationship of VITT platelet-activating profiles with CVST., Methods: We conducted a retrospective cohort study involving patients with confirmed VITT who were tested between March and June 2021. Data were collected with an anonymized form and cases were identified as VITT with high clinical suspicion according to platelet activation assays. Anti-PF4 antibody binding regions on PF4 were further characterized with alanine scanning mutagenesis., Results: Of the patients with confirmed VITT (n = 39), 17 (43.6%) had PF4-dependent antibodies and 22 (56.4%) had PF4-independent antibodies. CVST occurred almost exclusively in PF4-independent patients (11 of 22 vs 1 of 17; P < .05). Additionally, PF4-independent antibodies bound to 2 distinct epitopes on PF4, the heparin-binding region and a site typical for heparin-induced thrombocytopenia antibodies, whereas PF4-dependent antibodies bound to only the heparin-binding region., Conclusion: These findings suggest that VITT antibodies that cause PF4-independent platelet activation represent a unique subset of patients more likely to be associated with CVST, possibly due to the 2 different types of anti-PF4 antibodies., Competing Interests: Declaration Of Competing Interests There are no competing interests to disclose., (Copyright © 2023 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Background: Adenovirus-based COVID-19 vaccines are extensively used in low- and middle-income countries (LMICs). Remarkably, cases of cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) have rarely been reported from LMICs., Aims: We studied the frequency, manifestations, treatment, and outcomes of CVST-VITT in LMICs., Methods: We report data from an international registry on CVST after COVID-19 vaccination. VITT was classified according to the Pavord criteria. We compared CVST-VITT cases from LMICs to cases from high-income countries (HICs)., Results: Until August 2022, 228 CVST cases were reported, of which 63 were from LMICs (all middle-income countries [MICs]: Brazil, China, India, Iran, Mexico, Pakistan, Turkey). Of these 63, 32 (51%) met the VITT criteria, compared to 103 of 165 (62%) from HICs. Only 5 of the 32 (16%) CVST-VITT cases from MICs had definite VITT, mostly because anti-platelet factor 4 antibodies were often not tested. The median age was 26 (interquartile range [IQR] 20-37) versus 47 (IQR 32-58) years, and the proportion of women was 25 of 32 (78%) versus 77 of 103 (75%) in MICs versus HICs, respectively. Patients from MICs were diagnosed later than patients from HICs (1/32 [3%] vs. 65/103 [63%] diagnosed before May 2021). Clinical manifestations, including intracranial hemorrhage, were largely similar as was intravenous immunoglobulin use. In-hospital mortality was lower in MICs (7/31 [23%, 95% confidence interval (CI) 11-40]) than in HICs (44/102 [43%, 95% CI 34-53], p  = 0.039)., Conclusions: The number of CVST-VITT cases reported from LMICs was small despite the widespread use of adenoviral vaccines. Clinical manifestations and treatment of CVST-VITT cases were largely similar in MICs and HICs, while mortality was lower in patients from MICs., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C.C. received honoraria from Boehringer-Ingelheim, AstraZeneca, Biogen, Bristol Myers Squibb; T.J.K. received cost-assistance from Boehringer-Ingelheim; T.S.F. receives study medication from Bayer Canada and honoraria from HLS Therapeutics; S.P. received support from BMS/Pfizer, Daiichi Sankyo, European Union, German Federal Joint Committee Innovation Fund, German Federal Ministry of Education and Research, Helena Laboratories, Werfen, Alexion, AstraZeneca, Bayer, Boehringer-Ingelheim, Portola; R.L. reports fees by Boehringer-Ingelheim, Genentech, Ischemaview, Medtronic, Medpass; A.S. received grants from Swiss Heart Foundation; E.L. received grants from Swedish state, Swedish Neurologic Society, Elsa and Gustav Lindh’s Foundation, Wennerströms’ Foundation, P-O Ahl’s Foundation, Rune and Ulla Amlöv’s Foundation; A.G. received fees from Bayer Vital, Bristol Myers Squibb, Daiichi Sankyo; K.J. received grants from Swedish state; T.T. received fees from Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Inventiva, Portola Pharma; M.R.H. reports grants from Swiss Heart Foundation and Bangerter Foundation and Advisory Board participation for Amgen; M.A. reports fees from AstraZeneca, Bayer, Bristol Myers Squibb, Covidien, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Amgen; D.A.S. reports travel support from Boehringer-Ingelheim, fees from Bayer, and Advisory Board participation for AstraZeneca; J.M.F. received fees from Boehringer-Ingelheim, Bayer, and Daiichi Sankyo and grants from Bayer; J.M.C. received grants from Boehringer-Ingelheim and Bayer and payments for DSMB participation by Bayer; the other authors have no disclosures.

Purpose: Accurate assessment of dural sinus, deep and cortical venous thrombosis on MR imaging is challenging. The aim of this study is to evaluate the accuracy of 3D-T1 turbo spin echo (T1S), sequences in detecting venous thrombosis and comparing it with susceptibility-weighted imaging (SWI), magnetic resonance venography (MRV) and post contrast T1 magnetization-prepared rapid acquisition gradient echo (T1C)., Methods: A blinded retrospective observational analysis of 71 consecutive patients evaluated for cerebral venous thrombosis (CVT) and 30 control patients was performed. Multimodality reference standard adopted included T1C, SWI with MRV. Sub-analyses in superficial, deep and cortical venous segments were performed in addition to correlation of signal intensity of thrombus with the clinical stage., Results: A total of 2222 segments in 101 complete MRI examinations were evaluated. Sensitivity/specificity/positive predictive value/negative predictive value/accuracy and precision of T1S for detection of cortical vein thrombosis was 0.994/1/1/0.967/0.995/1, 1/0.874/0.949/1/0.963/0.950 for detection of superficial venous sinus thrombosis and 1/1/1/1/1/1 for deep venous thrombosis. The AUC yield for T1S was 0.997 for cortical, 1 for deep and 0.988 for superficial venous segments., Conclusion: T1S paralleled the accuracy of conventional sequences in the overall detection of CVT but showed superior accuracy in the detection of cortical venous thrombosis. It makes a fitting addition to the CVT MRI protocol in scenarios demanding negation of gadolinium administration., (© 2023. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Background: Cerebral venous sinus thrombosis (CSVT) is a rare condition, causing 0.5% of all strokes only, several mechanisms might be involved in forming the thrombosis, including closed head injury., Methods: Systematic review was done by using the following databases: PubMed, Google Scholar, Microsoft Academic, Clinical Trials, Cochrane Library, and Web of Science., Results: 25 articles met our criteria out of 152 articles, average and standard deviation of the age was 38.2 ± 16.8 years with an age range of 18-82. The majority of cases presented with loss of consciousness or decreased GCS (41%), followed by headache (26%), scalp abrasions/lacerations (21%), paralysis (18%), visual disturbance (18%), nystagmus (15%), and agitation (15%). The most commonly used diagnostic method was angiography. Thrombosis was the most frequently reported radiological finding among all the cases (26/34, 76%). Comparisons of outcomes between patients who underwent surgical intervention and those who did not undergo surgery revealed a significant difference in outcome favoring non-surgical treatment (p < 0.005, odds ratio (OR) 0.04, (95% CI) 0.003 - 0.30)., Conclusion: Non-surgical outcomes were better than the surgical outcomes. However, no significant difference was seen comparing anti-coagulation versus conservative management (supportive without anticoagulation), single versus multi-sinuses (≥2 sinuses) involvement, and between any of the sinuses involved., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: COVID-19 vaccines became available after being carefully monitored in clinical trials with safety and efficacy on the human body. However, a few recipients developed unusual side effects, including cerebral venous sinus thrombosis (CVST). We aim to systematically review the baseline features, clinical characteristics, treatment, and outcomes in patients developing CVST post-COVID-19 vaccination., Methods: This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) 2020 guideline. Investigators independently searched PubMed, Embase, and Google Scholar for English language articles published from inception up until September 10, 2021, reporting the incidence of CVST post-COVID-19 vaccines. We analyzed CVST patients' baseline data, type of vaccines, clinical findings, treatment, and outcomes. Our systematic review process yielded patient-level data., Result: The final analysis included 25 studies that identified 80 patients who developed CVST after the COVID-19 vaccination. Of the 80 CVST cases, 31 (39.24%) patients died. There was no significant relationship between mortality and age ( P  = .733), sex ( P  = .095), vaccine type ( P  = .798), platelet count ( P  = .93), and comorbidities such as hypertension ( P  = .734) and diabetes mellitus ( P  = .758). However, mortality was associated with the duration of onset of CVST symptoms after vaccination ( P  = .022). Patients with CVST post-COVID-19 vaccination were more likely to survive if treated with an anticoagulant ( P  = .039). Patients who developed intracranial hemorrhage ( P  = .012) or thrombosis in the cortical vein ( P  = .021) were more likely to die., Conclusion: COVID-19 vaccine-associated CVST is associated with high mortality rate. Timely diagnosis and management can be lifesaving for patients.

Introduction: Cerebral venous sinus thrombosis (CVST) is rare; however, it has been observed in patients with vaccine-induced immune thrombotic thrombocytopaenia syndrome (VITT) following the use of adenovirus vector vaccines against COVID-19. Adverse vaccine effects have been heavily addressed in mainstream media, likely contributing to vaccination anxiety. This study aimed to assess how the vaccine rollout and media coverage has influenced the use of computed tomography venography (CTV) in an acute care setting of a tertiary hospital., Method: Single-centre retrospective cohort study from 30 March 2021 to 13 June 2021. Direct comparison to same calendar dates in the preceding 3 years., Results: In 2021, 57 patients received CTV with headache being the reason in 48 (84%) and 40 (70%) had received ChAdOx1 nCov-19 (AstraZeneca COVID-19 vaccination). Only 20 of these patients received CTV after platelets and D-Dimer had returned, and only three patients met existing guidelines for imaging. Zero cases were positive. The number of CTV studies was 5.2 times than in 2020 and 2.7 times the mean number for the 3 preceding years., Conclusion: The use of CTV in patients with headache has markedly increased at our centre since negatively biased vaccination influence of mainstream media. Headache is a common vaccine-related side effect and VITT is exceptionably rare. With the rates of vaccination increasing in the community, these results highlight the importance of strict adherence to established evidence-based guidelines. Otherwise, critical care capacity, and in particular imaging resources already under pressure will be strained further., (© 2021 The Royal Australian and New Zealand College of Radiologists.)

Background and Purpose: Cerebral venous sinus thrombosis (CVST) has been described after vaccination against SARS-CoV-2. The clinical characteristics of 213 post-vaccination CVST cases notified to the European Medicines Agency are reported., Methods: Data on adverse drug reactions after SARS-CoV-2 vaccination notified until 8 April 2021 under the Medical Dictionary for Regulatory Activities Term 'Central nervous system vascular disorders' were obtained from the EudraVigilance database. Post-vaccination CVST was compared with 100 European patients with CVST from before the COVID-19 pandemic derived from the International CVST Consortium., Results: In all, 213 CVST cases were identified: 187 after AstraZeneca/Oxford (ChAdOx1 nCov-19) vaccination and 26 after a messenger RNA (mRNA) vaccination (25 with Pfizer/BioNTech, BNT162b2, and one with Moderna, mRNA-1273). Thrombocytopenia was reported in 107/187 CVST cases (57%, 95% confidence interval [CI] 50%-64%) in the ChAdOx1 nCov-19 group, in none in the mRNA vaccine group (0%, 95% CI 0%-13%) and in 7/100 (7%, 95% CI 3%-14%) in the pre-COVID-19 group. In the ChAdOx1 nCov-19 group, 39 (21%) reported COVID-19 polymerase chain reaction tests were performed within 30 days of CVST symptom onset, and all were negative. Of the 117 patients with a reported outcome in the ChAdOx1 nCov-19 group, 44 (38%, 95% CI 29%-47%) had died, compared to 2/10 (20%, 95% CI 6%-51%) in the mRNA vaccine group and 3/100 (3%, 95% CI 1%-8%) in the pre-COVID-19 group. Mortality amongst patients with thrombocytopenia in the ChAdOx1 nCov-19 group was 49% (95% CI 39%-60%)., Conclusions: Cerebral venous sinus thrombosis occurring after ChAdOx1 nCov-19 vaccination has a clinical profile distinct from CVST unrelated to vaccination. Only CVST after ChAdOx1 nCov-19 vaccination was associated with thrombocytopenia., (© 2021 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Objectives : Several cases of unusual thrombotic events with thrombocytopenia were reported in several countries, in association with AstraZeneca's COVID-19 vaccine. The European medicines agency conducted a detailed review and concluded that there was no evidence to suggest an association of thrombotic events with the use of COVID-19 vaccine AstraZeneca. Methods : King Abdulaziz Medical City is a 1500 bed tertiary care hospital in Riyadh, Saudi Arabia; this study describes spontaneously reported vaccine adverse effects received through the hospital's internal electronic safety reporting system from December 2020 to 13 April 2021.We assessed each report for causality association utilizing the world health organization's (WHO) causality assessment of an adverse event following immunization (AEFI) classification 2nd Edition 2019. Results : The majority of the reported events were mild to moderate, there were five serious events, one reported cardiac arrest, two cerebral venous sinus thrombosis, and two pulmonary embolism. Clinical and laboratory summary of the five patients are presented in detail. Conclusions : Efforts of pharmacovigilance in mediating the rare risk of thrombosis associated with COVID-19 vaccine are crucial in providing awareness on the possible risk factors and signs/symptoms that should raise red flags.

Purpose: This study aims to test the validity of a new quantitative scoring instrument-the Venous Occlusion Image Score (VOIS), and assess the diagnostic and prognostic value of VOIS for cerebral venous sinus thrombosis (CVST)., Methods: The VOIS divided the major cerebral venous sinuses and internal jugular veins into nine parts of interest. CT venography and DSA source images and reconstruction were extracted from the database, then interpreted and scored independently according to VOIS by a panel of three reviewers. Inter-observer and intra-observer reliability were determined using the intraclass correlation coefficient (ICC) and the kappa coefficient (κ). The primary outcome was the 3-month functional outcome and evaluated by modified Rankin Scale (mRS). The sensitivity and specificity of VOIS for the primary outcomes were computed. Logistic regression was applied to evaluate the association between the score on VOIS and the primary outcomes., Results: Fifty-six patients with CVST were included in the study. For 16 patients underwent cerebral CTV and DSA, excellent interobserver agreement was observed for DSA (ICC=0.90, 95%CI = 0.87 - 0.92, P < 0.001), and CTV (ICC = 0.92, 95%CI = 0.84 - 0.93, P < 0.001). The κ coefficient of agreement for the two radiology measures was 0.88 (95%CI = 0.79-0.92), indicating good inter-method agreement. For 56 patients followed up by CTV, baseline VOIS value correlated inversely with the severity of stroke on the National Institutes of Health Stroke Scale (r = -0·53, P < 0·001), and modified Rankin Scale (r = -0·59, P < 0·001). Baseline CTV-VOIS value predicted functional outcome (P < 0·05)., Conclusion: VOIS may serve as a convenient and reliable method in the treatment guidance and outcome prediction of patients with CVST., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: COVID-19 infection has been known to predispose patients to both arterial and venous thromboembolic events such as deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke. A few reports from the literature suggest that Cerebral Venous Sinus Thrombosis (CVSTs) may be a direct complication of COVID-19., Objective: To review the clinical and radiological presentation of COVID-19 positive patients diagnosed with CVST., Methods: This was a multicenter, cross-sectional, retrospective study of patients diagnosed with CVST and COVID-19 reviewed from March 1, 2020 to November 8, 2020. We evaluated their clinical presentations, risk factors, clinical management, and outcome. We reviewed all published cases of CVST in patients with COVID-19 infection from January 1, 2020 to November 13, 2020., Results: There were 8 patients diagnosed with CVST and COVID-19 during the study period at 7 out of 31 participating centers. Patients in our case series were mostly female (7/8, 87.5%). Most patients presented with non-specific symptoms such as headache (50%), fever (50%), and gastrointestinal symptoms (75%). Several patients presented with focal neurologic deficits (2/8, 25%) or decreased consciousness (2/8, 25%). D-dimer and inflammatory biomarkers were significantly elevated relative to reference ranges in patients with available laboratory data. The superior sagittal and transverse sinuses were the most common sites for acute CVST formation (6/8, 75%). Median time to onset of focal neurologic deficit from initial COVID-19 diagnosis was 3 days (interquartile range 0.75-3 days). Median time from onset of COVID-19 symptoms to CVST radiologic diagnosis was 11 days (interquartile range 6-16.75 days). Mortality was low in this cohort (1/8 or 12.5%)., Conclusions: Clinicians should consider the risk of acute CVST in patients positive for COVID-19, especially if neurological symptoms develop., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background : To our knowledge, this is the first report of patient with BHD syndrome caused by a novel mutation in the FLCN gene who developed a cerebral venous sinus thrombosis(CVST). Case presentation : A 62-year-old male patient with a history of hypertension and two case of spontaneous pneumothorax. He had a 1-month history of headache and was admitted to the hospital one day after the headache aggravated. The patient had a family history of BHD syndrome which was confirmed by FLCN gene sequencing. Sequencing analysis revealed a novel nonsense mutation (NM&#95;144997; c.607A > T; p.Lys203Ter) in the FLCN gene exon 6 of the patient, which was proved to be a pathogenetic mutation by pedigree verification. BHD syndrome was finally definitive diagnosis. Low molecular weight heparin (21 days) was given for anticoagulant therapy before and after resection of renal tumor which is confirmed to be clear cell carcinoma in the kidney. After discharge, warfarin was given for anticoagulant therapy (6 months). Conclusions : There was no recurrence of CVST. And no recurrence of tumor and new renal tumor were found in renal MRI examination after 6 months.

There are many uncontrollable factors in the pathogenesis of cerebral venous sinus thrombosis (CVST). In order to further explore the pathophysiology and morphology of CVST, it is necessary to establish a highly compatible CVST animal model that can standardize the site and stage of venous thrombosis. The present study employed the insertion of a self-made thread embolism into the superior sagittal sinus (SSS) to establish a rat model of SSS occlusion that emulates CVST. The thread embolism was removed after 6 h of SSS occlusion in order to achieve recanalization. After successful preparation of the model, the cerebral blood flow (CBF) status and ultrastructural changes of the blood-brain barrier (BBB) were monitored. This CVST model was able to achieve continuously high occlusion of SSS. The parasagittal venous-collateral circulation underwent extensive compensation and recombination, which alleviated blood flow stasis and brain tissue hypoxia caused by restricted reflux. Removing SSS occlusion significantly improved cerebral circulation, reduced brain edema, and accelerated the receding of brain edema. This study established a new model of acute occlusion and recanalization of SSS in rats via a thread-embolism method, which standardized the ischemic site and stage of venous thrombosis. In addition, our study suggests that promoting collateral circulation may be a potential treatment for promoting brain protection., (Copyright © 2019 IBRO. Published by Elsevier Ltd. All rights reserved.)

Most patients with cerebral venous sinus thrombosis (CVST) treated with anticoagulation have good outcomes. We examined which factors were associated with poor outcomes after treatment. We retrospectively reviewed patients ≥18 years old who were diagnosed with CVST between 1997 and 2015. Good (modified Rankin score [mRS] ≤2) and poor outcomes were dichotomized. Demographic, historical, clinical, imaging, and treatment characteristics were compared. Eighty-nine patients received treatment for CVST (52.8% males, 74.2% Caucasian). Sixty-eight (76.4%) had good outcomes and 21 (23.6%) had poor outcomes. Poor outcome was associated with systemic or central nervous system (CNS) infection (p = 0.002), lower use of heparin-only therapy than interventional-only treatments (p = 0.003), and increased use of craniectomy (p = 0.002). Good outcomes were associated with migrainous headache on presentation (p = 0.01) and involvement of superficial cortical vessels only (p = 0.02). No prothrombotic or imaging findings correlated with poor outcome. Multivariable analysis showed that any clinical risk factor (p = 0.02) and headache (p = 0.02) predicted improved outcome whereas systemic or CNS infection (p = 0.02) and craniectomy (p = 0.02) predicted poor outcome. A published risk score showed a moderate ability to predict good outcome but not poor outcome. Overall sensitivity (23.8%), specificity (75.0%), and positive (24.0%) and negative (77.0%) predictive value suggested moderate prediction of good outcome and limited prediction of poor outcome. Rates of poor outcomes in CVST were comparable with previous investigations (23.6%), but prediction of poor outcome remains challenging in patients with CVST. Our results suggested that systemic infection and craniectomy were the most robust predictors of poor outcome., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To report a case of successful use of unfractionated heparin (UFH) infusion to treat cerebral venous sinus thrombosis (CVST)., Case Summary: A 54-year-old female with a history of ovarian cancer addressed through palliative care, presents to the Emergency Department complaining of nausea, vomiting and headache for the last 72h. The patient was on a home regimen of enoxaparin 1.5mg/kg subcutaneously daily for recent pulmonary embolism and deep vein thrombosis that developed while on warfarin therapy previously. CT scan showed superior sagittal sinus thrombosis. UFH infusion was initiated and continued for 48h until the headache dissipated., Discussion: Stable CVST may be treated with UFH infusion; however, there is limited literature that describes UFH dosing for CVST management., Conclusions: UFH may be considered as one of the pharmacological agents to manage CVST. The dosing for UFH bolus and infusion is similar to treatment dose for pulmonary embolism/deep vein thrombosis management with goal anti-Xa between 0.3 and 0.7units/mL., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Cerebral venous sinus thrombosis (CVST) is common in Asians, accounting for 15% of all strokes in the young. CVST causing malignant cerebral oedema with brain herniation and death are referred as malignant CVST. This study was aimed at evaluating the outcome of patients and factors predicting the outcome with malignant CVST after decompressive surgery. It was a retrospective, observational, single centre, hospital-based and cross-sectional study. Records of patients with malignant CVST who had decompressive surgery were analysed. Over 5 years (2010-2015), 30 patients (15 men and 15 women) underwent decompressive surgery. In univariate analysis, age more than 50 years (p = 0.05); presence of midline shift of more than 10 mm (p = 0.03) and total effacement of basal cisterns (p = 0.01) had significant correlation with poor outcome. On multivariate analysis, presence of midline shift of more than 10 mm (p = 0.01) was a significant predictor of poor outcome. Decompressive surgery is a life saving therapeutic intervention in patients with malignant CVST and more than two-thirds of patient shows favourable outcome. Age more than 50 years, midline shift >10 mm and total effacement of basal cisterns determine poor outcome following decompressive surgery.

Purpose: We aimed to define the possible risk factors for acute and remote seizures in patients with cerebral vein and sinus thrombosis (CVST)., Method: Ninety-four patients were recruited prospectively at Al-Zahra Hospital, Isfahan, Iran, between April 2007 and April 2012. To identify seizure predictors, we compared demographic, clinical and imaging factors between patients with or without acute and remote seizures., Results: Of the 94 patients, 32 (34%) experienced at least one seizure after CVST development. Bivariate analysis showed a significant association of remote seizure with loss of consciousness at presentation (P=0.05, OR: 5.11, 95%CI: 1.07-24.30), supratentorial lesions (P=0.02, OR: 9.04, 95%CI: 1.04-78.55), lesions in the occipital lobe (P=0.00, OR: 12.75, 95%CI: 2.28-71.16), lesions in the temporal and parietal lobes, thrombophilia (P=0.03, OR: 5.87, 95%CI: 1.21-28.39), seizure in the acute phase (P=0.00, OR: 13.14, 95%CI: 2.54-201.2) and sigmoid sinus thrombosis (P=0.00, OR: 12.5, 95%CI: 2.23-69.79). Seizures in the acute phase were also more common in patients with paresis (P=0.00, OR: 4.88, 95%CI: 1.91-12.46), hemorrhagic lesions indicated by imaging (P=0.02, OR: 2.77, 95%CI: 1.08-7.10), supratentorial lesions, lesions in the frontal (P=0.01, OR: 3.81, 95%CI: 1.28-11.31) and parietal lobes (P=0.00, OR: 5.16, 95%CI: 2-13.29), thrombophilia and history of miscarriage (P=0.03, OR: 2.91, 95%CI: 1.07-7.91). No factor predicted acute or remote seizure in a multiple logistic regression analysis., Conclusion: Our results demonstrate that seizure development in the acute phase is the most significant factor for development of remote seizure. Parenchymal lesions in the supratentorial area were also found to be associated with both acute and remote seizures. However, no factor was predictive of acute or remote seizures in a multivariate analysis., (Copyright © 2013 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Classical homocystinuria is the most commonly inherited disorder of sulfur metabolism, caused by the genetic alterations in human cystathionine beta-synthase (CBS) gene. In this study, we present comprehensive clinical findings and the genetic basis of homocystinuria in a cohort of Turkish patients. Excluding some CBS mutations, detailed genotype-phenotype correlation for different CBS mutations has not been established in literature. We aimed to make clinical subgroups according to main clinical symptoms and discussed these data together with mutational analysis results from our patients. Totally, 16 different mutations were identified; twelve of which had already been reported, and four are novel (p.N93Y, p.L251P, p.D281V and c.829-2A>T). The probands were classified into three major groups according to the clinical symptoms caused by these mutations. A psychomotor delay was the most common diagnostic symptom (n=12, 46.2% neurological presentation), followed by thromboembolic events (n=6, 23.1% vascular presentation) and lens ectopia, myopia or marfanoid features (n=5, 19.2% connective tissue presentation). Pyridoxine responsiveness was 7.7%; however, with partial responsive probands, the ratio was 53.9%. In addition, five thrombophilic nucleotide changes including MTHFR c.677 C>T and c.1298 A>C, Factor V c.1691 G>A, Factor II c.20210 G>A, and SERPINE1 4G/5G were investigated to assess their contributions to the clinical spectrum. We suggest that the effect of these polymorphisms on clinical phenotype of CBS is not very clear since the distribution of thrombophilic polymorphisms does not differ among specific groups. This study provides molecular findings of 26 Turkish probands with homocystinuria and discusses the clinical presentations and putative effects of the CBS mutations., (Crown Copyright © 2013. Published by Elsevier B.V. All rights reserved.)