A 27-year-old female presents to the Emergency Department after a collapse at work that was followed by a brief tonic-clonic seizure. She is 30 weeks pregnant with no previous pregnancies or other significant medical history. She currently localises bilaterally to painful stimulus but does not open her eyes or vocalise.
Her blood pressure is 170/50 mmHg, her urine analysis is unremarkable, and the cardiotocogram (CTG) is ‘reassuring’. A CT brain scan shows a sigmoid and transverse venous sinus thrombosis, with some temporal lobe parenchymal haemorrhage.
a) List the major risk factors, other than pregnancy, for this condition. (30% marks)
b) Briefly outline the management priorities for this patient? (70% marks)
a)
Prothrombotic conditions – genetic or acquired Oral contraceptive
Malignancy
Parameningeal Infection e.g. ear, sinus
Head trauma
Surgery
Mechanical precipitant
Autoimmune disease e.g. SLE, antiphospholipid
Other drugs e.g. androgens
b)
Resuscitation:
o Consider intubation
o Check gas exchange (expect slight respiratory alkalosis)
o BP currently a bit on the high side, maybe careful hydralazine to SBP 140-160?
Specific therapy for cerebral venous sinus thrombosis
o Therapeutic anticoagulation
o Can use LMWH or UFH
o Intracranial haemorrhage with CVT is not a contraindication to anticoagulation
o Continued for remainder of pregnancy and usually for further 6-12 weeks postpartum
o Aspirin – no evidence of benefit. Occasionally used as alternative if firm CI to therapeutic anticoagulation
o Potential therapies include thrombolysis (systemic or catheter-directed), mechanical clot extraction, decompressive craniectomy
o Assess for underlying cause that may require specific therapy e.g.,
o May need an anticonvulsant; consider neurology input
Pregnancy related:
o Involvement of obstetric service, regular CTG, ultrasound
o ? steroids to allow for early delivery if needed
o Shielding for X-ray and CT limit as able
o Blood conservation given physiological anaemia of pregnancy
o Need to keep family up to date
a)
The following lisk of risk factors was compiled using UpToDate and Ferro et al (2004). The latter was a multinational multicentre observational study which identified 624 patients with confirmed CVT. Of this group, the following risk factors were observed:
b)
The major approaches to fixing this problem are anticoagulation, thrombolysis, endovascular thrombectomy and open clot retrieval.
Roberts, Jonathan C., and Christopher M. Fischer. "Cerebral venous sinus thrombosis." Vascular Emergencies: Expert Management for the Emergency Physician (2013): 1.
Rothwell, P. M., et al. "Risk factors for cerebral venous thrombosis." Oxford Textbook of Stroke and Cerebrovascular Disease (2014): 14.
Bhogal, P., et al. "Cerebral Venous Sinus Thrombosis." Clinical Neuroradiology (2016): 1-6.
Ferro, José M., et al. "Prognosis of cerebral vein and dural sinus thrombosis results of the international study on cerebral vein and dural sinus thrombosis (ISCVT)." Stroke 35.3 (2004): 664-670.
Lee, Emil JY. "The Empty Delta Sign 1." Radiology 224.3 (2002): 788-789.Virapongse, Chat, et al. "The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis." Radiology 162.3 (1987): 779-785.
Virapongse, Chat, et al. "The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis." Radiology 162.3 (1987): 779-785.
Saposnik, Gustavo, et al. "Diagnosis and management of cerebral venous thrombosis a statement for healthcare professionals from the American Heart Association/American Stroke Association." Stroke 42.4 (2011): 1158-1192.
Coutinho, Jonathan M., Sebastiaan FTM de Bruijn, and Jan Stam. "Anticoagulation for cerebral venous sinus thrombosis." Stroke 43.4 (2012): e41-e42.
Coutinho, Jonathan M., et al. "Thrombolysis or anticoagulation for cerebral venous thrombosis: rationale and design of the TO‐ACT trial." International Journal of Stroke 8.2 (2013): 135-140.
Canhão, Patricia, Filipa Falcão, and José M. Ferro. "Thrombolytics for cerebral sinus thrombosis." Cerebrovascular diseases 15.3 (2003): 159-166.
Ciccone, Alfonso, et al. "Thrombolysis for cerebral vein and dural sinus thrombosis." The Cochrane Library (2004).
Mokin, Maxim, et al. "Endovascular treatment of cerebral venous thrombosis: Contemporary multicenter experience." Interventional Neuroradiology (2015): 1591019915583015.
Siddiqui, Fazeel M., et al. "Mechanical Thrombectomy in Cerebral Venous Thrombosis Systematic Review of 185 Cases." Stroke 46.5 (2015): 1263-1268.
Persson, Lennart, and Anders Lilja. "Extensive dural sinus thrombosis treated by surgical removal and local streptokinase infusion." Neurosurgery 26.1 (1990): 117-121.
Ekseth, Kåre, Sverre Boström, and Magnus Vegfors. "Reversibility of severe sagittal sinus thrombosis with open surgical thrombectomy combined with local infusion of tissue plasminogen activator: technical case report." Neurosurgery 43.4 (1998): 960-964.