Libyan Journal of Medical Sciences

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 1  |  Issue : 2  |  Page : 36--39

Clinical characteristics and outcome of cerebral venous sinus thrombosis: A 4-year Hospital-based study from 2008 to 2011


Mushtak Talib Algherbawe1, Fahmi Yousef Khan1, Salma Suliman Abonof1, Hussien Kamal2, Muhammad Bakhtyar Khan1, Abdel-Naser Elzouki1,  
1 Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
2 Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar

Correspondence Address:
Fahmi Yousef Khan
Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, P. O. Box 3050, Doha
Qatar

Abstract

Background and Objective: Cerebral venous sinus thrombosis (CVST) is associated with serious morbidity and mortality. This study aimed to analyze the characteristics of patients with CVST, clinical features, and predisposing factors of CVST in a series of 43 patients. Subjects and Methods: We conducted a retrospective study including 43 patients with confirmed diagnosis of CVST, admitted at Hamad Hospital, Doha, Qatar, between January 1, 2008, and December 30, 2011. Results: We identified 43 patients with CVST, the mean age of the patients was 34.3 ± 12.3 years (range: 17–82 years). There were 29/43 (67.4%) males and 14/43 (32.6%) females. The most frequent predisposing factor of CVST was local infection in 13/43 (30.2%), the mean duration of symptoms before presentation was 7.7 ± 9.5 days (range: 1–42 days), and the most common presenting symptom was headache found in 41 (95.3%) patients with the superior sagittal sinus being involved most frequently in 36 (83.7%) patients. The case fatality rate was 4.6%. Conclusion: In our hospital, CVST affects males more than females, with infection being the main predisposing factor and a mortality of 4.6%. Further prospective studies are needed to explain the predominance of infection as a predisposing factor.



How to cite this article:
Algherbawe MT, Khan FY, Abonof SS, Kamal H, Khan MB, Elzouki AN. Clinical characteristics and outcome of cerebral venous sinus thrombosis: A 4-year Hospital-based study from 2008 to 2011.Libyan J Med Sci 2017;1:36-39


How to cite this URL:
Algherbawe MT, Khan FY, Abonof SS, Kamal H, Khan MB, Elzouki AN. Clinical characteristics and outcome of cerebral venous sinus thrombosis: A 4-year Hospital-based study from 2008 to 2011. Libyan J Med Sci [serial online] 2017 [cited 2022 Aug 20 ];1:36-39
Available from: https://www.ljmsonline.com/text.asp?2017/1/2/36/217800


Full Text

 Introduction



Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke with extremely varied clinical presentations, predisposing factors, imaging findings, and outcomes.[1] CVST is clinically challenging and mimics all neurological conditions such as meningitis, encephalopathy, benign intracranial hypertension, and stroke.[2] Recent reports indicate that CVT is more common than previously assumed, due to greater awareness and the availability of better noninvasive diagnostic techniques. Although its real incidence is unknown, annual incidence in some regions is estimated to be three to four cases per million, representing 0.5% of all strokes.[3] The majority of published data came from the developed countries. There are few reports about CVST coming from Gulf countries.[4],[5]

In Qatar, there is a lack of information about CVST. The aim of this study was to describe the clinical manifestations, predisposing factors, location of the thrombus, laboratory findings, and the outcome of CVST.

 Subjects and Methods



Design and settings

This hospital-based retrospective study was conducted at Hamad General Hospital; the study includes all adult patients 15 years of age or older who were admitted to Hamad General Hospital with CVST from January 1, 2009, to December 31, 2011.

Case definition

The diagnosis of CVST was confirmed by magnetic resonance imaging and venography (MRI + MRV) or by enhanced computed tomography (CT) scan brain.

Case finding and data collection

all cases were identified from the medical records. The files of the patients were reviewed to retrieve the following data on standardized data sheet: age, sex, clinical manifestations according to history and physical examination, predisposing factors, location of the thrombus, number and location of parenchymal lesions, laboratory findings, and outcome.

Research committee approval

This study obtained ethical approval from the Medical Research Committee at Hamad Medical Corporation. As the study was retrospective in nature, a waiver of informed consent was obtained from the research committee.

Data analysis

The data were analyzed by SPSS 17.0 software (Chicago, SPSS Inc) using simple descriptive statistics.

 Results



During the period of study, we identified 43 patients with CVST, which accounted for 0.14% of the total admissions to the medical ward and 0.9% of the total number of stroke cases. The mean age of the patients was 34.3 ± 12.3 years (range: 17–82 years). There were 29/43 (67.4%) males and 14/43 (32.6%) females (male:female ratio was 2.1). Most of the cases (38/42, 88.4%) occurred in non-Qatari residents, whereas five cases (11.6%) occurred in Qatari residents [Table 1].{Table 1}

The most frequent predisposing factor of CVST was local infection in 13/43 (30.2%) patients. [Table 2] summarizes the predisposing factors associated with CVST in our study. The mean duration of symptoms before presentation was 7.7 ± 9.5 days (range: 1–42 days) and the most common presenting symptom was headache in 41 patients (95.3%) followed by vomiting in 24 (55.8%). [Table 1] summarizes the clinical picture of patients with CVST.{Table 2}

[Table 3] summarizes the sinus sites involved in this study. The main site involved was superior sagittal sinus in 36 patients (83.7%) followed by lateral sinus in 35 (81.3%). Mean duration of stay in the hospital was 6.5 ± 9.3 days (range: 2–45 days). Two patients died in the hospital, resulting in a case fatality rate of 4.6%. The cause of death in the first patient was intracranial hypertension with cerebral herniation, while ventilator-associated pneumonia was the cause of death in the second patient.{Table 3}

All patients received low-molecular-weight heparin 1 mg/kg twice a day and then shifted to warfarin to keep international normalized ratio between 2 and 3. Four patients were lost to follow-up as they returned to their home country, while the rests of the patients were followed up by MRI and MRV up to 1 year, and all of them showed recanalization.

 Discussion



The novelty of our study comes from being the first to study CVST in Qatar. As noted, the mean age of the patients in this study (34.3 years) was lower than those described in other studies,[4],[5],[6] but it is higher than that of Saudi patients (27.8%) as studied by Daif et al.[4] In contrast with many other reports,[5],[6],[7],[8],[9] our study showed predominance of male patients regardless of their nationality. The reason for this is obscured, and further studies are needed to identify the cause.

Similar to other reports,[5],[6],[7],[8] the main cerebral venous sinus affected by CVST in our study was the superior sagittal sinus. Symptoms in CVST are usually secondary to increased intracranial pressure or focal brain injury from venous infarction or hemorrhage. The onset may be acute, subacute, or insidious, most patients presenting with symptoms, which have evolved over days or weeks.[5],[6],[7],[8],[9] CVST presents with a wide spectrum of symptoms and signs, that is, headache, seizures, and various focal neurological deficits, including cranial nerve palsies, hemiparesis, hemisensory disturbances, seizures, impairment of consciousness, and papilledema.[4],[5],[6],[7],[8],[9] Symptoms and signs in our series are similar to those of other studies, with headache being the dominant clinical picture.

Risk factors for CVST vary among different studies, with 20% of cases having unidentified predisposing factors.[10] Numerous conditions can cause or predispose to CVST and often more than one cause will be found in an individual patient.[10],[11],[12] Predisposing factors can be divided into infective (e.g., meningitis, mastoiditis, ear infections, tonsillitis, and sinusitis) and noninfective factors (e.g., connective tissue diseases, other granulomatous or inflammatory disorders, and malignancies).

In Iran, Brazil, and some European countries,[5],[6],[8],[12],[13] oral contraceptives were found to be the main predisposing factors, while in Saudi Arabia, Behcet's disease was found in 25% of cases.[5] In our study, we could not identify the cause in 11% of cases, and infection was the main predisposing factor as it was found in 30.2% of patients. The reasons for this are obscured and necessitate extensive study.

CT of the head is often the first investigation performed. Around 30% of CVT patients present normal cranial CT in the beginning of the clinical picture.[14] The primary sign of acute CVST on noncontrasted CT is hyperdensity of a cortical vein or dural sinus. Thrombosis of the posterior portion of the superior sagittal sinus may appear as a dense triangle (delta sign).[10] CT venography is most useful in subacute or chronic situations because of varied density in a thrombosed sinus.

MRI combined with MRV is the imaging modality of choice for the diagnosis of CVST; it is more sensitive for CVT than CT at every stage of thrombosis.[10],[11] In our study, the diagnosis was confirmed in all patients by MRI combined with MRV and CT venography.

Mortality ranks between 5.5% and 18% in the recent studies,[10] and transtentorial herniation is the major cause of death.[14] In our series, mortality was 4.6%, which is less than other centers. Factors associated with a poorer prognosis include infancy and advanced age, rapid onset with coma and focal deficits, intracerebral hemorrhage, and thrombosis of the deep cerebral venous system.[10],[14],[15],[16],[17],[18] The relatively small number of cases recruited and the retrospective design represented a limitation of the current study, leading to inevitable biases.

 Conclusion



VST is a recognized cause of morbidity and mortality in our hospital. It affects males more than females, and infection was the main predisposing factor and mortality was 4.6%. Further prospective studies are needed to explain the predominance of infection as a predisposing factor to reduce the morbidity and mortality of CVST in our hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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