Case Reports of Pregnancy-Related Cerebral Venous Thrombosis in the Neurology Department of the Emergency Clinical Hospital in Constanta

Cerebral venous thrombosis accounts for 0.5–1% of all cerebrovascular events and is one type of stroke that affects the veins and cerebral sinuses. Females are more affected than males, as they may have risk factors, such as pregnancy, first period after pregnancy, treatment with oral contraceptives treatment with hormonal replacement, or hereditary thrombophilia. This neurological pathology may endanger a patient’s life. However, it must be suspected in its acute phase, when it presents with variable clinical characteristics, so that special treatment can be initiated to achieve a favorable outcome with partial or complete functional recovery. The case study describes the data and the treatment of two patients with confirmed cerebral venous thrombosis with various localizations and associated risk factors, who were admitted to the neurology department of the Sf. Apostol Andrei Emergency Hospital in Constanta. The first patient was 40 years old and affected by sigmoid sinus and right lateral sinus thrombosis, inferior sagittal sinus, and right sinus thrombosis, associated with right temporal subacute cortical and subcortical hemorrhage, which appeared following a voluntary abortion. The second case was a patient aged 25 who was affected by left parietal cortical vein thrombosis, associated with ipsilateral superior parietal subcortical venous infarction, which appeared following labor. The data are strictly observational and offer a perspective on clinical manifestations and clinical and paraclinical investigations, including the treatment of young patients who had been diagnosed with cerebral venous thrombosis and admitted to the neurology department.

Venous outflow profiles are associated with early edema progression in ischemic stroke

Background: In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes. Methods: Multicenter, retrospective analysis to investigate AIS–LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0–2 points on the modified Rankin scale). Results: A total of 728 patients were included. Primary outcome analysis showed VO+ (β: –0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: –0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839–9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals. Conclusions: Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.

Cerebral venous outflow profiles are associated with the first pass effect in endovascular thrombectomy

BackgroundRecent studies found that favorable venous outflow (VO) profiles are associated with higher reperfusion rates after mechanical thrombectomy (MT) in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Fewer retrieval attempts and first-pass revascularization during MT lead to better functional outcomes.ObjectiveTo examine the hypothesis that favorable VO profiles assessed on baseline CT angiography (CTA) images correlate with successful vessel reperfusion after the first retrieval attempt and fewer retrieval attempts.MethodsA multicenter retrospective cohort study of patients with AIS-LVO treated by MT. Baseline CTA was used to determine the cortical vein opacification score (COVES). Favorable VO was defined as COVES ≥3. Primary outcomes were successful with excellent vessel reperfusion status, defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 and 2c/3 after first retrieval attempt.Results617 patients were included in this study, of whom 205 (33.2%) had first pass reperfusion. In univariate analysis, ordinal COVES (p=0.011) values were significantly higher in patients with first pass than in those with non-first pass reperfusion, while the number of patients exhibiting favorable pial arterial collaterals using the Maas scale on CTA did not differ (p=0.243). In multivariable logistic regression analysis, higher COVES were independently associated with TICI 2b/3 (OR=1.25, 95% CI 1.1 to 1.42; p=0.001) and TICI 2c/3 (OR=1.2, 95% CI 1.04 to 1.36; p=0.011) reperfusion after one retrieval attempt, controlling for penumbra volume and time from symptom onset to vessel reperfusion.ConclusionsFavorable VO, classified as higher COVES, is independently associated with successful and excellent first pass reperfusion in patients with AIS-LVO treated by endovascular thrombectomy.

Abstract 1122‐000181: Collateral Circulation in Ischemic Stroke is Not Determined by Anatomical Variants of the Cerebral Arteries

Introduction : In acute ischemic stroke, collateral circulation determines tissue fate and treatment results. The aim of this study was to evaluate the role of anatomical variations of the Circle of Willis (CoW) in formation of cerebral collateral blood flow in patients with acute M1 occlusion. Methods : This study was a retrospective assessment of radiological examinations of patients with stroke due to middle cerebral artery M1 segment occlusion. All patients underwent mechanical thrombectomy from January 2015 until March 2021. The anatomy of the CoW was assessed on initial CT‐angiography and DSA. CTA was utilized to grade cranial collateral vasculature status and cortical vein opacification score (COVES). Non‐contrast CT scans and ASPECTS scores (using RAPID software) were used to determine the ischemic area. Results : A total of 100 patients were included in the analysis (58 females and 42 males, mean age: 71.6 +/‐ 13.9). We classified the anatomy of the CoW according to its continuity as a full circle. Patients with fully continuous CoW (n = 19) had worse COVES scores than those with CoW incomplete at both anterior and posterior portion (n = 9) (89% vs 68% with COVES 0–2, p = 0.179). No statistically significant results were found when comparing the enhancement of collaterals between these two groups (p = 0.390). The COVES scores were similar for patients with complete and incomplete anterior portions of CoW (77% vs 80% with COVES 0–2, p = 0.812). Patients with incomplete posterior portions of CoW had lower COVES scores than those with complete (80% vs 67% with COVES 0–2, p = 0.206). No statistically significant differences were discovered when comparing different types of the posterior communicating artery (adult, transitional and fetal). Analysis of ischemic areas determined as ASPECTS scores pre‐ and post‐thrombectomy yielded no significant differences between any of the groups. Conclusions : Although certain variants of the CoW have been reported to increase the risk of ischemic stroke, our results show that the anatomy of CoW has no large effect on collateral blood flow during acute M1 occlusion. We presume that the greater role is played by pial arterioles than anatomical variants of major cerebral arteries in cerebral collateral circulation formation. Detailed knowledge about the factors that influence collateral blood flow is crucial as it may aid in identification of patients prone to worse outcomes of ischemic stroke. Anatomical variants of CoW do not play a major role in formation of cerebral collaterals.

Abstract 1122‐000160: Transvenous Embolization Technique: A Modern Strategy for Anterior Ethmoidal Dural Arteriovenous Fistulas

Introduction : Ethmoidal dural arteriovenous fistulae (AVF) are rare intracranial lesions and account for 2–3% of all dAVF. They are often supplied by the ethmoidal or falcine branches of the ophthalmic artery and typically drain into a cortical vein then into the superior sagittal sinus (SSS). Current available treatment options include surgical resection and endovascular embolization via transarterial and transvenous routes. Prior studies have solely compared surgical and transarterial endovascular treatment approaches. Reports of the transvenous approach remain scarce in the literature. Methods : We performed a retrospective review for anterior ethmoidal (AE)‐dAVFs treated with transvenous embolization by our practice between August 2018 and August 2021. Four patients with 5 dAVFs were identified. We describe the presentation, treatment, and outcome of these cases. Results : We describe four patients with AE‐dAVF. Case 1 is a 33‐year‐old man with a previously treated basal ganglia arteriovenous malformation achieving cure. He was lost for follow up for three years and returned with symptoms of peri‐orbital headache and blurry vision. Diagnostic angiography revealed a dAVF arising from the cribriform plate with arterial supply derived from bilateral AE arteries and venous drainage via a common cortical frontal interhemispheric vein to the anterior third of the SSS. Transvenous embolization was achieved and liquid embolic was injected into the vein with retrograde penetration to the fistulous point. Follow‐up angiography revealed obliteration of the dAVF. Case 2 is a 23‐year‐old man with chronic headache who was found to have a right sided ethmoidal dAVF arising from the right ophthalmic artery for which he underwent successful embolization through a transarterial approach. Follow‐up angiography demonstrated occlusion of the treated fistula and new left sided ethmoidal AVF arising from the left ophthalmic artery with a single draining cerebral vein which drains into the anterior third of the SSS. Transvenous embolization was achieved via coiling. Follow up angiography also showed complete occlusion of the dAVF. Case 3 was a 67‐year‐old woman who presented with a Cognard type III right ethmoidal dAVF with arterial feeders through surpra‐orbital branches of the right ophthalmic artery, draining into a frontal cortical vein leading to the SSS. The patient underwent transvenous embolization using coils. Case 4 was a 64‐year‐old woman who presented with scalp tenderness. Diagnostic angiography revealed a left AE‐dAVF. Transvenous embolization with complete occlusion was achieved using a combination of liquid embolic and coil embolization. No adverse events were encountered during or after embolization, but long‐term outcome has yet to be collected for cases 3 and 4. There were no neurologic procedural complications. Conclusions : This small case series shows that transvenous embolization is a feasible, effective, and safe alternative to surgery. Larger prospective studies are needed to further validate this treatment approach in patients with ethmoidal dAVF.

Acquired pial arteriovenous fistula secondary to cerebral cortical vein thrombosis: A case report and review of the literature

Pial arteriovenous fistulas (AVFs) are rare neurovascular malformations. They differ from arteriovenous malformations (AVMs) in that they involve single or multiple feeding arteries, draining directly into a dilated cortical vein with no intervening nidus. Pial and dural AVFs differ in blood supply, as the first originate from pial or cortical arteries and the latter from outside the dural leaflets. Unlike dural AVFs, most of the pial AVFs are supratentorial. The vast majority are congenital, manifesting during infancy. Acquired pial AVFs are significantly rarer and occur after vasculopathy, head trauma, brain surgery, or cerebral vein thrombosis. We describe a unique case of an acquired pial AVF in a 50-year-old man secondary to a cortical vein thrombosis manifesting as a focal-onset seizure with secondary generalization. A cerebral digital subtraction angiography revealed a low-flow pial AVF fed by a postcentral branch of the left middle cerebral artery draining to the superior sagittal sinus via a cortical vein. It also showed a collateral venous circulation adjacent to the previously thrombosed left parietal vein. There was no evidence of an associated dural AVF or venous varix. Endovascular treatment was scheduled three months later, but the angiogram preceding the embolization showed spontaneous and complete closure of the malformation. To our knowledge, this is the first case illustrating acquired pure pial AVF unaccompanied by a dural component following cortical vein thrombosis, eventually resulting in an unprompted closure.

Treatment and Prognosis of Postoperative Acute Cerebral Venous Infarctions

IntroductionThe incidence of cerebral venous infarctions is not high, but this condition can cause serious complications. This paper summarizes the cases of serious complications after cerebral venous infarctions and proposes corresponding treatment strategies.MethodsA retrospective analysis was performed on 5 patients that had severe complications secondary to injury or sacrifice of related veins during the resection of different intracranial lesions (cerebellopontine angle, lateral ventricle, frontal lobe, falx parietal lobe, frontal parietal lobe). There were 2 males and 3 females, aged 34-58 years. Routine CT and MRI/MRV examinations were performed before the operation, and the diagnoses were a hemifacial spasm, a meningioma of the lateral ventricle, a hemangioma, a falx meningioma and a glioma. Postoperative CT examinations were performed to understand the intracranial conditions of the patients.ResultsFive cases had injuries to associated veins, which included the cerebellar cortical vein, internal cerebral vein, middle frontal vein, straight sinus, and postfrontal vein, during the operations. There were 2 cases of venous infarctions, 3 cases of hemorrhagic infarctions, 2 cases who had conservative treatment, 3 cases who had surgical treatment, 1 case who died (the hemifacial spasm), 1 case who had a vegetative survival (the lateral ventricular meningioma), and 3 cases with good recoveries (the hemangioma, falx meningioma, and glioma).ConclusionsSurgeons should pay more attention to intracranial vein injuries during procedures. Acute neurological dysfunction or even death may occur after these injuries. Surgeons should closely monitor the condition of the patient and proceed with surgical intervention if necessary. The prognosis is usually good for these surgery cases, but the prognosis can be poor if important veins are injured. The key to avoiding cerebral venous infarctions is to preserve the integrity of the veins to the greatest extent during the operation.

Clinical outcomes of procedures combining endovascular embolization with a direct surgical approach in a hybrid operating room for the treatment of refractory dural arteriovenous fistulas

Background: We reviewed the clinical outcomes of a procedure that combines endovascular embolization and a direct surgical approach in a hybrid operating room (OR) for the treatment of refractory dural arteriovenous fistulas (dAVFs). Methods: All patients with intracranial dAVFs who underwent a procedure combining endovascular embolization and direct surgical approach with biplane angiography or a robotic C-arm system in a hybrid OR between February 2004 and June 2020 were considered. Borden grading, occlusion rate, pre-and post-operative modified Rankin Scale (mRS) scores, and complications were retrospectively investigated. The pre-and postoperative mRS scores were compared using the Wilcoxon signed-ranks test. Results: We evaluated 14 arteriovenous fistulas (AVFs) in consecutive 13 patients. Of these, ten AVFs were previously treated with endovascular embolization, ten were located in the transverse-sigmoid sinus, and four in the cortical vein. The Borden grade was II in two AVFs and III in 12 AVFs. Immediate occlusion of the AVF was achieved in 13 AVFs, and gradual occlusion was observed in one case. The median preoperative mRS was 1 (0–3), whereas the median postoperative mRS was 0 (0–1) which indicated marked improvement (P = 0.006). Complications including postoperative transient visual disturbance and intraprocedural extravasation were observed in only two cases. Conclusion: The combination of endovascular embolization and direct surgical approach in a hybrid OR could achieve sufficient occlusion of refractory AVFs with acceptable complication rates and improved symptoms.

Cerebral venous thrombosis following spontaneous intracranial hypotension diagnosed by craniotomy: A case report and diagnostic pitfalls

Background: Cerebral vein and dural sinus thrombosis (CVT) is a rare but important complication of spontaneous intracranial hypotension (SIH). The diagnosis is difficult in cases lacking typical symptoms and typical imaging findings. Case Description: A 29-year-old male patient with a seizure attack was admitted to our hospital. Based on the head imaging findings, we misdiagnosed the patient with primary cerebral parenchymal lesion and performed an open biopsy. However, during the procedure, the patient was diagnosed with low cerebrospinal fluid pressure and cerebral cortical vein thrombosis. Conclusion: Thus, CVT due to SIH should be considered as a probable cause of secondary parenchymal lesions.

Simultaneous Arterial and Venous Brain Infarctions in a Patient with COVID-19.

Introduction: Stroke is one of the manifestations of COVID-19 associated coagulopathy. Arterial infarcts are the most common presentation, however involvement of both arterial and venous irrigation is possible but rare. We report, what is, to our knowledge, the second case of concomitant arterial and venous brain thrombosis evidenced in magnetic resonance. Case presentation: A 62-year-old man presented with acute weakness of the left hand and lack of coordination in the left arm. Nine days earlier, he was positive for SARS-CoV-2 RT-PCR. The brain images revealed two subacute infarcts, one corresponding to the territory of the right middle cerebral artery, and the other in the right frontal cortical vein. Conclusion: The existence of both venous and arterial brain infarcts due to COVID-19 infection, has been previously reported once. Most of the cases of stroke are due to only arterial thrombosis, therefore this could be the starting point to start collecting data about simultaneous compromise in order to assess and compare outcomes, severity of the disease, among other variables.