Diagnostics of cerebral venous thrombosis associated with COVID-19 in young adults: clinical characteristics and imaging patterns

Introduction. Cerebral venous thrombosis (CVT) is relatively rare, but leads to the development of cerebral venous infarction, intracranial hemorrhage, followed by severe disability and death. Due to the epidemiological situation caused by COVID-19, the incidence of CVT is increasing.Aims and objectives: to analyze clinical, laboratory instrumental and neuroimaging (multislice computed tomography (MSCT), MSCT — with intravenous contrast, magnetic resonance imaging of the brain (MRI) and MRI venography) data that confirmed the development of CVT in patients with COVID-19.Methods. Data of 5 young adults with cerebral venous thrombosis (CVT) associated with COVID-19 are presented.Results. Аmong 5 reported cases of COVID-19, two patients presented with venous infarcts (hemorrhagic and ischemic), 3 patients developed encephalopathy syndrome without acute cerebral infarction.Conclusion. Possibilities of modern imaging technologies permitted to timely diagnosis cerebral venous thrombosis associated with COVID-19, that can lead to immediate initiation of therapy and to prevent the development of cerebrovascular complications during the COVID-19 pandemic.

A Case-Based Review of Cerebral Venous Infarcts With Perfusion Imaging and Comparison to Arterial Ischemic Stroke

Cerebral venous thrombosis (CVT) and cerebral venous infarcts (CVI) are diagnostic dilemmas secondary to their rarity, non-specific symptomatology at presentation, and variable imaging features. Despite its relatively infrequence, CVT is particularly prevalent in the younger adult population and is a potentially life-threatening disease with devastating neurological complications if not addressed in a timely manner. However, when treated promptly, CVT has the potential for a more reversible course and favorable prognosis than arterial ischemic strokes (AIS). The pathophysiology of CVI is distinct from that of AIS and is closely related to its potentially reversible nature. Familiarity with the conventional and variant venous anatomy, as well as the temporal evolution of imaging findings, is crucial in establishing diagnostic confidence. The use of MR perfusion imaging (MRP) and arterial spin-labeling (ASL) can potentially aid in the diagnosis of CVT/CVI via characterization of cerebral blood flow. The presence and extent of a cerebral perfusion deficit on either CT or MRI may play a role in clinical outcomes for patients with CVT, although future larger studies must be performed. This review presents a case-based overview focusing on the classic imaging characteristics of CVT and CVI in conjunction with bolus MRP and ASL findings in the adult population.

Venous Anatomy Influence on the Approach Selection of a Petroclival Clear Cell Meningioma With Associated Multiple Spinal Meningiomas: 2-Dimensional Operative Video

Preoperative careful evaluation of the sigmoid transverse sinus and its tributary veins is paramount for the safe surgical planning of petroclival lesions.1,2 When the vein of Labbé is running within the tentorium, classic petrosal approach involving transection of the tentorium is modified to avoid the risk of postoperative morbid temporal lobe venous infarcts.1-3 Thus, the surgical plan should be tailored to the specific patient anatomy as demonstrated in the presented case during which a transmastoid approach was followed, in the same surgical setting, by a middle fossa approach to resect a large petroclival clear cell meningioma with extension into Meckel cave. These meningiomas are WHO grade II tumors with a propensity to local recurrence and cerebrospinal fluid seeding.4 SMARCE1 mutations define this subtype of meningioma, with frequent familial inheritance, and predispose patients to both skull base and spinal clear cell meningiomas.5,6 Maximal surgical resection is the best initial treatment option allowing to withhold or delay the use of radiation in tumors frequently encountered in young patients.7 In this report, we demonstrate the microsurgical techniques deployed to achieve maximal resection of a petroclival clear cell meningioma and associated lumbar and sacral spinal meningiomas in a 20-yr-old patient with a familial SMARCE1 mutation. The patient agreed to the surgical intervention and to the use of her image.

Cerebral Venous Thrombosis in a Patient with Immune Thrombocytopenia, an Apparent Paradox

We present a paradoxical case of immune thrombocytopenia (ITP) that presented with cerebral venous thrombosis. A 39-year-old female patient diagnosed with chronic ITP, who failed treatment on multiple-line agents, was started on eltrombopag (thrombopoietin receptor agonist), which she was not compliant to. The patient later developed extensive cerebral venous thrombosis, along with venous infarcts, and intracranial and subarachnoid hemorrhage. She was treated with intravenous immunoglobulins as well as steroid therapy and was simultaneously started on anticoagulation. The patient improved clinically and radiologically. This case is among few reported cases which signify that patients with ITP are inherently prone to thrombosis despite low platelet count and treating these patients can be a dilemma. Judicious use of anticoagulation and immunosuppressive therapy is recommended based on available evidence pending further recommendations and guidelines about treatment of thrombosis in ITP.

Bilateral Decompressive Craniectomy in Malignant Cerebral Venous Thrombosis

Introduction: Despite the extremely favourable prognosis of patients with cerebral venous thrombosis (CVT), death occurs in 10–15% of patients. In severe cases of malignant CVT with supratentorial haemorrhagic lesions, cerebral oedema and brain herniation, decompressive surgery may be the only life-saving treatment. Patient and methods: We present the case of a puerperal young woman with progressive headache, seizures and decreased alertness. Thrombosis of the entire superior sagittal sinus with bifrontal venous infarcts and midline shift was confirmed by magnetic resonance imaging with venography sequencing. Despite medical treatment with anticoagulation, progressive neurological deterioration was observed, so bilateral, frontal decompressive craniectomy was performed. Results: At the 6-month follow-up, we observed partial functional recovery with a modified Rankin score of 3. Discussion: Bilateral decompressive craniectomy may be a life-saving therapeutic option when medical therapy fails and there are clinical and radiological features of progression in both cerebral hemispheres.

Prevalence of subarachnoid haemorrhage among patients with cranial venous sinus thrombosis in the presence and absence of venous infarcts

Introduction In patients with cranial venous sinus thrombosis, the occurrence of subarachnoid haemorrhage in association with haemorrhagic venous infarcts is a well described phenomenon. However, the presence of subarachnoid haemorrhage in patients with cranial venous sinus thrombosis in the absence of a haemorrhagic venous infarct is exceedingly rare. Methods We retrospectively reviewed charts and scans of all patients who had cranial venous sinus thrombosis confirmed by magnetic resonance venography at our hospital between September 2004 and May 2015. The presence of subarachnoid haemorrhage was ascertained on fluid-attenuated inversion recovery, susceptibility-weighted imaging and/or unenhanced computed tomography scans by a single experienced neuroradiologist. Statistical analysis was performed using the Statistical Package for Social Sciences version 20. Differences in the proportion of haemorrhagic venous infarcts among patients with subarachnoid haemorrhage versus those without subarachnoid haemorrhage were compared using the chi-square test. A P value of less than 0.05 was considered significant. Results A total of 138 patients who had cranial venous sinus thrombosis were included in the study. Seventy-three (52.9%) were women and the median age of subjects was 35 (interquartile range 22–47) years. Venous infarcts and haemorrhagic venous infarcts were noted in 20/138 (14.5%) and 62/138 (44.9%) cases, respectively. Subarachnoid haemorrhage was present in 15/138 (10.9%) cases and, in three cases, subarachnoid haemorrhage occurred in the absence of a venous infarct. Haemorrhagic venous infarcts were more prevalent ( P = 0.021) among patients with subarachnoid haemorrhage (11/15) than in those without subarachnoid haemorrhage (51/123). Conclusion In patients with cranial venous sinus thrombosis, subarachnoid haemorrhage can occur even in the absence of a haemorrhagic venous infarct. The recognition of cranial venous sinus thrombosis as the underlying cause of subarachnoid haemorrhage is important to avoid misdiagnosis and inappropriate management.

Endovascular management of cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is characterized by formation of widespread thrombus within the cerebral venous sinus system. CVST can cause venous hypertension, venous infarcts, hemorrhage and seizures. It is managed in most cases with systemic anticoagulation through the use of heparin to resolve the thrombus. Patients that demonstrate clinical deterioration while on heparin are often treated with endovascular strategies to recanalize the sinuses. We present the case of a patient with widespread CVST, involving his superior sagittal sinuses and bilateral transverse sigmoid sinuses, who was treated with a combination of endovascular therapies.The video can be found here: http://youtu.be/w3wAGlT7h8c.