Venous and arterial cerebral thrombosis: a COVID-19 dual pathology and single possible etiology—a case report

Background Corona virus disease of the year 2019 (COVID-19) is still devastating the world for more than 19 months since its declaration as a pandemic by world health organization. Its manifestations does not stand at respiratory system but involves other body systems including central nervous system and its vasculature. In the following case report, cerebral venous and arterial thrombosis is detected in a case just in convalescence from COVID-19 with still detected positive IgM. Case presentation A 68-year-old female presenting with disturbed conscious level, bilateral convergent squint, single attack of generalized seizures, left sided dense weakness within a short time from catching COVID-19 and while still in quarantine hospital in recovery phase from infection. Magnetic resonance studies revealed bilateral cortical border zone infarcts as well as left lateral dural sinus and deep venous thrombosis. Conclusion Along the forth wave, COVID-19 is still hitting hardly the central nervous system vasculature.

Torcular dural sinus malformation

The dural sinus malformation (DSM) are rare congenital vascular anomalies with variable anatomic features, clinical conditions, and outcomes. There are two forms of disease: a lateral subtype, affecting the jugular bulb with associated high flow arteriovenous fistula; and a midline subtype, called torcular DSM. The torcular subtype is more common and characterized by a giant dural sinus lake involving the confluens sinuum (torcular Herophili). We present a case of a 28-year-old woman with an ultrasound at 32 weeks’ gestation showing a fetal intracranial thrombosed lesion, measuring 6x4 cm. An elective c-section was performed at 38 weeks’ gestation, and a male neonate was born. He remained asymptomatic, and a brain MRI performed 9 days later showed a thrombosed midline mass due to a torcular DSM. The outcome with conservative treatment was favorable, and further development was unremarkable. The 2-year follow-up imaging demonstrated spontaneous involution of the clot. The torcular DSM is frequently diagnosed prenatally as an intraluminar lake thrombosis, and differential diagnosis include tumors, subdural collections, vein of Galen aneurysmal malformations, pial malformations, arachnoid and dermoid cysts. A literature review involving 126 patients with torcular DSM found an overall mortality of 22.1%. Torcular DSM seems to have better prognosis than those having dural arteriovenous shunts, and the worst outcomes were associated to brain damage and patent feeders. In addition, antenatal diagnosis and thrombosis of pouch have good prognosis, possibly because the clot may spontaneously obliterate the fistulas. Treatment options must be individualized, and include conservative, embolization, ventriculoperitoneal shunt and endoscopic third ventriculostomy. Although systemic anticoagulation is controverse in infants, it should be considered for patients with sinovenous thrombosis affecting outflow pathways, especially those aggravated by venous congestion. Intervention is recommended for grade III patients because they progress to grade IV, and endovascular treatment is the gold standard therapy due to the risk of fatal intraoperative exsanguination. Whenever possible, embolization should be prioritized over hydrocephalus treatment because it may avoid ventriculoperitoneal shunt. Close follow-up imaging is recommended to detect any changes, with lesion reduction indicating favorable outcome.

Evidence-Based Minireview: Should warfarin or a direct oral anticoagulant be used in patients presenting with thrombosis in the splanchnic or cerebral veins?

Case 1: A 23-year-old female third-year medical student who has no medical history seeks treatment for abdominal distention. She takes an estrogen-containing birth control pill and does not smoke or consume alcohol. Family history is unremarkable. Physical examination is significant for abdominal distention, and an abdominal fluid wave is detected. Complete blood count is normal. Imaging confirms occlusive thrombosis of the main portal vein. On endoscopy, grade 1 to 2 esophageal varices are noted and banded. Unfractionated heparin is begun. Subsequent workup reveals a homozygous factor V Leiden mutation. Long-term anticoagulation is planned, and she asks if warfarin can be avoided given her hectic ward rotations, erratic diet, and need for monitoring. Case 2: A 35-year-old woman who has no medical history seeks treatment for progressively worsening posterior headaches for 1 week. Magnetic resonance imaging of the brain shows dural sinus thrombosis with associated small areas of petechial cerebral hemorrhage. She is started on a continuous unfractionated heparin infusion and admitted to the hospital for further observation. Her grandmother is on warfarin for atrial fibrillation, and the patient would prefer to avoid warfarin because she does not think she can comply with the frequent monitoring that will be required. She inquires about other oral anticoagulant options for her condition.

Diagnostic Accuracy of 3D Contrast-Enhanced T1 High Resolution Isotropic Volume Excitation MRI for Non-Cavernous Intracranial Dural Arteriovenous Fistula

Objective: To determine the accuracy of 3D contrast-enhanced THRIVE MRI in diagnosis of non-cavernous intracranial dural AVF compared with DSA. Materials and Methods: Thirty-three patients including fourteen dural AVF cases and nineteen control subjects, were included in the present study. They underwent 3D contrast-enhanced THRIVE MRI by 3T, contrast-enhanced MRA, and DSA. Two independent readers reviewed 3D contrast-enhanced THRIVE images for the presence of transosseous arterial feeders, low signal intensity curvilinear structures in the dural venous sinus, shaggy dural sinus, and cortical venous dilatation. Diagnostic performance values were calculated for 3D contrast-enhanced THRIVE MRI. Results: The 3D contrast-enhanced THRIVE MRI identified 23 from 29 locations of dural AVFs. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 91.4%, 79.3%, 93.5%, 67.6% and 96.3%, respectively. Shaggy dural sinus and dilated cortical veins were found in 78.6% and 85.7%, respectively. Conclusion: The 3D contrast-enhanced THRIVE MRI is a valuable tool for diagnosis of dural AVF as well as exclusion of dural AVF due to high sensitivity and specificity. Keywords: Dural arteriovenous fistula; Dural AVF; 3D contrast-enhanced THRIVE MRI

Endovascular treatment for vaccine-induced cerebral venous sinus thrombosis and thrombocytopenia following ChAdOx1 nCoV-19 vaccination: a report of three cases

BackgroundVaccine-induced thrombosis and thrombocytopenia (VITT) is a rare complication following ChAdOx1 nCoV-19 vaccination. Cerebral venous sinus thrombosis (CVST) is overrepresented in VITT and is often associated with multifocal venous thromboses, concomitant hemorrhage and poor outcomes. Hitherto, endovascular treatments have not been reviewed in VITT-related CVST.MethodsPatient records from a tertiary neurosciences center were reviewed to identify patients who had endovascular treatment for CVST in VITT.ResultsPatient records from 1 January 2021 to 20 July 2021 identified three patients who underwent endovascular treatment for CVST in the context of VITT. All were female and the median age was 52 years. The location of the CVST was highly variable. Two-thirds of the patients had multifocal dural sinus thromboses (sigmoid, transverse, straight and superior sagittal) as well as internal jugular vein thromboses. Intracerebral hemorrhage occurred in all patients; subarachnoid blood was noted in two of them, and intraparenchymal hemorrhage occurred in all. There was one periprocedural parenchymal extravasation which abated on temporary cessation of anticoagulation. Outcome data revealed a 90-day modified Rankin Scale (mRS) score of 2 in all cases.ConclusionsWe demonstrate that endovascular treatment for VITT-associated CVST is feasible and can be safe in cases that deteriorate despite medical therapy. Extensive clot burden, concomitant hemorrhage, rapid clinical progression and persistent rises in intracranial pressure should initiate multidisciplinary team discussion for endovascular treatment in appropriate cases.

P.148 Children and teenagers with hydrocephalus: Are narrowed dural sinuses better predictors of shunt-failure than ventriculomegaly?

Background: Intracranial hypertension secondary to shunt-failure is a feared complication requiring cross-sectional imaging for diagnosis. We compared dural sinus narrowing and ventriculomegaly as predictors of shunt-failure. Methods: 60 head MRIs and 60 MR venographies of hydrocephalus patients age 0-18 years (n=25) were analyzed. MRI studies were included when f/u clinical data combined with intra-operative findings proved shunt-failure (positive Gold standard) or when MRI was available when the child was well (negative Gold standard). The absence or presence of concerning hydrocephalus was diagnosed. On MRV, the major dural sinuses were independently analyzed with respect to >50% narrowing, suggesting compression by increased CSF pressure. Ventriculomegaly and significant dural sinus narrowing was correlated to the presence/absence of shunt failure as per Gold standard. Results: Sinus narrowing substantially correlated with proven shunt-failure (Cohen’s kappa test 0.635/p<=0.00001 as per Fisher exact test) while ventriculomegaly correlated poorly (0.258/p=0.0751). Sensitivity/specificity was 0.69/0.92 for sinus narrowing and 0.43/0.81 for ventriculomegaly. Conclusions: In this patient cohort, dural sinus narrowing more reliably predicted shunt-failure compared to ventriculomegaly.

Staged embolisation of a giant torcular dural sinus malformation in a neonate

Torcular dural sinus malformations (tDSMs) represent a rare subset of paediatric cerebrovascular malformations and are often diagnosed antenatally via ultrasound. The management of these in utero lesions remains controversial as previous studies suggested elective termination of the pregnancy because of their presumably high mortality and severe long-term morbidity. However, more recent evaluations have suggested that the overall prognosis for infants harbouring these lesions may be much better than previously believed. As such, we present the case of a neonate with a giant tDSM, diagnosed in utero, who was treated postnatally via staged transarterial and transvenous embolisation to alleviate worsening obstructive hydrocephalus and brainstem compression. We provide details regarding the surgical approach and long-term neurological outcomes for this patient. To the best of our knowledge, this is one of the largest reported tDSM presented in the literature.

Dural Sinus Thrombosis after Resection of Vestibular Schwannoma using Suboccipital Retrosigmoid Approach - Thrombosis Classification and Management Proposal.

ObjectiveDural sinus thrombosis is one of the complications after posterior fossa surgery. However, that topic is not described well with regard to vestibular schwannoma surgery using the unique suboccipital retrosigmoid approach.MethodsWe analyzed retrospectively medical records and radiological investigations of 116 patients. The including criteria were: histopathologically confirmed vestibular schwannoma operated on using the retrosigmoid approach, preoperative and postoperative contrast enhanced MRI, at least 1-year follow-up. ResultsThe patient group included 36% males, 64% females. The average age was 47.3±13.9 years. 60% of tumors were classified as T4b according to the Hannover scale and their mean volume was 13.73±10.28 cm3. There were no signs of thrombosis preoperatively. In 26 (22%) cases, postoperative changes in the dural sinuses were found. In 7 (27%) cases there was an external compression by the hemostatic agent, in 19 (73%) cases a thrombus was visualized in the sinus lumen. The size of the sinus, age, tumor size were not risk factors for thrombosis, whereas an intraoperative sinus injury was a statistically significant risk factor (p=0.0012). All of the patients diagnosed with thrombosis were in good clinical condition in distant follow-up (mRankin=0). Complete recanalization was observed in 58% of cases after 1-year follow-up.ConclusionsPostoperative changes in the dural venous sinuses are a frequent finding after vestibular schwannoma surgery using the suboccipital retrosigmoid approach. Intraoperative dural injury is a risk factor for thrombosis. Thrombosis in that group of patients is usually asymptomatic and does not influence the prognosis.