A Clinical and Neuroimaging study of Cerebral Venous Thrombosis

Valarmathi, Anandhan (2006) A Clinical and Neuroimaging study of Cerebral Venous Thrombosis. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Thrombosis of cerebral veins and sinus is a distinct cerebrovascular disorder, unlike arterial stroke, most often affects young adults and children. CVT may be difficult to diagnose clinically because of its various and non-specific manifestations and multiple associated conditions and etiologies. During the past decade, increased awareness of the diagnosis, improved neuroimaging like 3D - MR imaging techniques, and more effective treatment has improved the prognosis. Blood from the brain drains, through small cerebral veins into larger veins such as the vein of Galen. These bigger veins empty into dural sinuses which themselves are drained mostly by the internal jugular veins. The venous territories are less well defined than are arterial territories due the presence of extensive anastomoses between cortical veins. These allow the development of collateral circulation in the event of an occlusion. The main cerebral venous sinuses affected by CVT are the superior sagittal sinus and lateral sinus. Pathophysiologically, there are important differences between arterial and venous thrombosis. CVT has been described as a continuing process in which the balance of prothrombotic and thrombolytic process is disturbed leading to progression of the venous thrombus with time. This slow growth of the thrombus and the good collateralisation of the venous vessels probably explain the usually gradual onset of symptoms, frequently over weeks and months. Sudden onset, however has been described especially in post partum patients. AIM OF THE STUDY: The aim of the present study are; 1. To study the clinical profile of patients with cerebral venous thrombosis. 2. To study the neuro imaging findings, risk factors and possible etiology, clinical course and outcome in patients with cerebral venous thrombosis. MATERIALS AND METHODS: Patients and Methods: The subjects for the present study comprised of patients admitted in Government General Hospital in Medical and Neurology Wards, Chennai, during the period of September 2003 and January 2006. (About 47 patients of age between 15 - 70 years were studied). Inclusion Criteria: The subjects were diagnosed to have CVT and included in the study when an appropriate clinical picture of the patient was supported by one or more of the following. 1. CT Scan - showing unequivocal direct or indirect evidence of cerebral venous thrombosis. 2. MRI showing evidence of cerebral venous thrombosis. a. Partial can complete absence of filling of one or more dural sinus. b. Visualisation of thrombus + c. Parenchymal lesions suggestion of CVT. 3. Age of the patient >14 years. A total of 47 patients (24 men and 23 women) fulfilling the above criteria were studied. * A detailed clinical history was taken with special emphasis on the suspected precipitating or predisposing factors dehydration, fever, sepsis, anemia, parity, underlying medical illness, obstetric history, joint pains, oral / genital ulcers, abortions, oral contraception. * Detailed examination of the patients was carried out including : a. General physical examination - any evidence of anemia, dehydration, sepsis, deep vein thrombosis of leg or arthritis was noted. b. Cardiovascular, respiratory and per abdominal examination was carried out to look for any evidence of systemic involvement. c. A detailed neurological examination was done which included (i) assessment of level of sensorium (ii) any evidence of raised intracranial tension and iii) any focal deficits or bilateral neurological signs and iv) any evidence of meningeal limitation. * All the patients were investigated with hemogram, ESR, Total and differenital leucocyte counts, platelet count, blood sugar, Blood urea, serum creatinine, lipid profile, bleeding time, clotting time, prothrombin time, urine analysis, chest x-ray. CONCLUSION: 1. CVT is far more common neurologic problem than previously assumed. 2. The mode of onset is variable and spectrum of clinical presentation is wide. 3. Diagnosis of CVT requires high index of suspicion. 4. MRI with MRA is the most sensitive neuro-imaging modality in diagnosis of CVT. 5. All patients with isolated ICT should undergo MRI with MRA to rule out CVT. 6. Demonstration of underlying etiology may be difficult of when the cause is not clinically evident. 7. Multiple risk factors can be present in a single patient. 8. Systematic workup for hereditary thrombophilic conditions should be undertaken in every patient ,even when they have one obvious risk/etiologic factor of CVT. SUMMARY: The study involved 47 patients of proven cases of CVT. The clinical profile, neuroimaging findings, predisposing / etiologic factors, treatment and outcome at 4 weeks were studied. Mean age of study cohorts was 28.5 years. 51% were males, 49% females. Most of them (70.2%) had subacute onset, 23% had acute, 6.7% chronic onset of symptoms. 29.7% were puerperal CVTs and 60.8% were non puerperal. Puerperal CVT had earlier mean age of onset. (25.1 years) compared to non - puerperal CVT (31.7 years). Also most of puerperal CVT patients (57%) had acute onset where as most of non - puerperal CVT patients (81.8%) had subacute onset symptoms. Headache is the most common clinical presentation in 85% of cases. Other clinical features were seizures (40.4%), alteration in consiousness (46.8%), focal deficits (55.3%), bilateral papilledema (78.7%). (27.6%) of patients presented with isolated ICT. Of the seizures, GTCS was most common (68.4%). Others were focal (10.5%), focal with secondary generalisation (5.2%) and status epilepticus (15.7%). CT was normal in 21% of study patients. Indirect signs (27.6%) were common than direct signs (14.8%). MRI with MRA was reliable as sole investigation in the diagnosis of CVT. (38.2%) had isolated sinus involvement (61.7%) had multiple sinus involvement. SSS was the most commonly involved sinus. Other commonly involved sinuses are sigmoid (36.1%) and lateral sinus (34%). (10.6%) had cortical vein involvement deep vein system was involved in (6%) and cavernous sinus in 4.2% and IJV in (4.2%). Predisposing / etiologic factors identified (66%) of our patients. Varied risk factors were identified in our patients. (14.5%) were related to infectious causes. Among the non infectious etiology puerperuim (29.7%) was the common risk factor. Others include OCP use (8.5%), SLE (4.2%), APLA (4.2%). All our patients improved with heparin treatment despite hemorrhagic and SAH. Mortality was (4.2%) in out study. Most of our patients had a good neurological outcome. (72%) had complete recovery and (23%) had residual sequelae like focal deficits, recurrent seizures and visual loss.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Cerebral Venous Thrombosis ; Clinical and Neuroimaging study.
Subjects: MEDICAL > General Medicine
Depositing User: Subramani R
Date Deposited: 25 Mar 2018 05:14
Last Modified: 25 Mar 2018 05:14
URI: http://repository-tnmgrmu.ac.in/id/eprint/6558

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