European Journal of Cardiovascular Medicine

Cerebral venous thrombosis is a rare condition with varied clinical presentation and often affects young to middle-aged patients. Although known for more than 100years,1 it has been diagnosed frequently ante-mortem in recent years because of greater awareness among physicians and neurologists and improved noninvasive imaging techniques. More than 100 causes of cerebral venous thrombosis have been recorded in the literature.1 However, even with extensive investigation no cause is identified in 20–25% of the cases.2

Cerebral venous thrombosis have wide spectrum of symptoms and signs with headache is the most common presenting symptom, in 70–90% of cases.2,3,4 In one-third to three-quarters of cases focal deficits such as hemiparesis and hemisensory disturbance, seizures, impairment of level of consciousness and papilledema occur.2,4 Superior sagittal sinus (72%) most commonly involved followed by lateral sinus (70%). More than one sinus is involved in 30 to 40% of cases.5

High index of suspicion required for the diagnosis because of its varied clinical presentations. Neuroimaging is the corner stone in the diagnosis of cerebral venous thrombosis. Imaging modalities of choice are CT scan and MRI with MR venogram. CT scan may be normal in 15-30% cases but MRI with MRV is almost 100% diagnostic.6,7,8 In the present study we are going to investigate the clinical profile, radiological findings and risk factors of cerebral venous thrombosis.

Present study was single-center, prospective, observational study, conducted in department of General Medicine, at J. J.  Hospital, Mumbai, Maharashtra, India. Study duration was of 2 years (August 2020 to December 2022). Study was approved by institutional ethical committee.

Inclusion criteria

• All patients age group 18 years and above irrespective of genders admitted to the hospital with a radiological evidence of cerebral venous thrombosis, willing to participate in present study

Exclusion criteria

1. Patients of age group below 18 yrs
2. Patients not willing to participate in the study

Study was explained to participants in local language & written informed consent was taken. In patients not able to give consent, consent will be taken from relatives.

Detailed information of the patient was collected which includes–demographic data, onset & duration of illness, risk factors, history of past illness, personal history, symptoms and signs on presentation in hospital and during stay in hospital, detailed general physical & systemic examination including detailed neurological examinations, Glasgow coma scale at the time of admission. Radiological imaging, Haematological and biochemical investigations, which are available in tertiary care center were done in all cases. The data was documented in attached case proforma.

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Statistical analysis was done using descriptive statistics.

A total of 60 cases of cerebral venous thrombosis were recorded in our study. Majority of the patients, 22 (36.67%) were in 18- 30-year age group. The mean age of the patients in the present study was 36.23 years. In our study more than half, 33 (55%) of the patients were female & male patients were 27 (45%).

Table 1: General characteristics

In 60 patients, 10 (6.67%) had obesity, 12 (20%) had hypertension and 5 (8.33%) had diabetes. Obesity, Hypertension and diabetes were more predominant in female patients 8 (80%), 7 (58.33%) and 4 (80%) respectively, as compared to male patients. Chi square test was applied to test the association between hypertension and sex but was found to be statistically not significant as p- value is more than 0.05 (p- value= 0.79). Also, no statistically significant association was observed between obesity (p- value= 0.08), diabetes (p- value= 0.24) and sex as p- value was found to be more than 0.05 when Fischer exact test was applied as the test of association. Therefore, we can say that there is no statistically significant association between existing co-morbid conditions i.e. obesity, hypertension, diabetes and sex of cerebral venous thrombosis patients.

Table 2: Distribution of Co-morbidity with respect to sex

Majority of the patients 43 (71.67%) had no addictions, of which 31 (51.67%) were female and 12 (20%) were male. Alcohol and smoking was present in 7 (11.67%).

Table 3: Distribution of addiction with respect to sex

Past history of acute gastroenteritis 2 (3.33%), COVID- 19 in 3 (5%), Polycythemia vera in 1 (1.67%), Road traffic accident in 1 (1.67%) and retroviral disease in 2 (3.33%) patients in male patients. In female patients 2 (3.33%) had history of CVST and SLE. 1 (1.67%) had history of seizure, TTP and CVA. Past history of Pulmonary tuberculosis was in 3 (5%) patients, of which 2 (3.33%) were female and 1 (1.67%) was male.

Table 4: Distribution of past history with respect to sex

Mastoiditis was seen 1 (1.67%) male patient. Tubercular meningitis was seen in 3 (5%) female patients and 1 (1.67%) male patient. Lumbar puncture was performed in 2 (3.33%) female patients. Craniotomy was performed in 1 (1.67%) male patient. And 1 (1.62%) had RTA as traumatic etiology.

Table 5: Distribution of etiology with respect to sex

Of 27 (45%) male patients in our study, 7 (25.93%) had alcohol and smoking addiction, smoking addiction was seen in 6 (22.22%) and infectious etiology was seen in 2 patients. 1 (3.70%) had mastoiditis and 1 (3.70%) had Tubercular Meningitis. 1 (3.70%) had undergone Craniotomy and 1 (3.70%) was admitted due to a Road Traffic Accident (RTA).

Table 6: Etiology in male patients

In 33 (55%) female patients, majority of the patients 23 (69.70%) had history of no drug consumption. 6 (18.18%) were on HRT and 4 (12.12%) were on OC pills. In 33 (55%) female patients, Cerebral Venous Thrombosis was seen more in PNC patients, 7 (21.21%). And in 6 (18.18%) patients who were on Hormone Replacement Therapy (HRT). 4 (12.90%) were on Oral Contraceptive (OC) pills, 3 (9.78%) were ANC, 3 (9.68%) had Tubercular Meningitis and 2 (6.45%) patients had undergone Lumbar Puncture.

Table 7: Etiology in female patients

More than half, 15 (55.56%) male patients had addiction and only 2 (6.06%) female patients had addiction. A very highly statistically significant association was observed between addiction and sex as p- value was found to be less than 0.001. Therefore, we can say that the association between addiction (alcohol, smoking or both) and sex of cerebral venous thrombosis patients is very highly significant statistically.  10 (37.03%) of male and 9 (27.28%) of female patients had past history. Chi-square test was applied to test for association between past history in cerebral venous thrombosis patients and sex wise distribution of patients. P- value was found to be 0.41 which is greater than 0.05. Therefore, we can say that there is no statistically significant relationship between past history of patients and sex of the patients.

Table 8: Correlation between gender, addiction & past history

Fischer’s exact test was applied to test the association between infectious etiology in patients and sex of the patient. At 1 degree of freedom, p- value was found to be 1 which is greater than 0.05. Therefore, we can say that there is no statistically significant association between sex of the patient and infectious etiology.

Fischer’s exact test was applied to test the association between traumatic etiology in patients and sex of the patient. At 2 degree of freedom, p- value was found to be 1 which is greater than 0.05. Therefore, we can say that there is no statistically significant association between sex of the patient and traumatic etiology.

Table 9: Correlation between gender & etiology

In this study, out of this 53 (88.33%) belong to non-puerperal group and 7 (11.67%) belong to the puerperal group. Out of the 53 non-puerperal cases, 27 were males and 26 females. Those who presented within 48 hours were considered to have acute onset, with onset longer than 48 hours but less than 1 month were considered subacute, and with onset more than 1 month as chronic. In this study, 70% of CVST had subacute presentation, followed by 20 % with acute presentation.

In this study, 32 patients (83.34%) were conscious and 8 cases (13.33%) had altered sensorium at the time of presentation. Most common symptom was headache in 60 % followed by convulsions in 41.67 % and papilledema in 23.33%. Out of 60 patients only 6 (10%) patients had cranial nerve involvement. In them 2^nd cranial nerve was involved in 2 (33.34%) patients.

Table 10: Clinical feature

Majority 17 (28.33%) had cerebral edema followed by VHI in 5 (8.33%) and HI and IPH was seen in 3 (5%).

Table 11: CT and MRI findings (n- 60)

In this study, superior sagittal sinus was most commonly involved in 33 (55%) patients, followed by right transverse sinus 28 (46.67%) and left transverse sinus in 23 (38.33%).

Table 12: Involvement of veins and sinuses

The mean age of the patients in the present study was 36.23 years. Previous studies done by Goyal et al.,9 shows 34.76 year, Nagaraja et al.,10 shows 24.2 year, Desai et al.,11 shows 31.94 years, Kotireddy CV et al.,12 shows 35.65 years, Stolz et al.,13 42.8 years. This leads us to believe that CVST primarily affects younger people, especially those in their 30s and 40s. In many research, the age range that is most frequently affected is 20 to 40 (Ameri et al.2, 61%). Similar results were also found in the current study, which included 65 % of the same age group (20-40).

In our study more than half, 33 (55%) of the patients were female. And male patients were 27 (45%) were male. The ratio of the male to female population in this study is 1:1.2. which is similar to study carried out by Raina AF et al.,14 shows 1:2.5, Kalita J et al.,15 shows 1:1.8, Goyal et al.,9 Shows 1:2, Patil VC et al.,16 shows 1:1.3, Kotireddy CV et al.,12 shows 1:1.3, study done by Kalita J et al.,17 shows 1.12:1 (male predominance). Most of the study shows similar findings to this study that CVST is most common in females than in males.

Predisposing underlying factors can be identified in up to 80% of patients of CVST.4 In the present study no risk factor could be identified in only 6.67%. no cause identified in other studies like Anadure RK et al.,18 shows 13%, Narayan et al.,19 shows 16% patients had no cause for CVST.  Most common risk factor in females is the patients was on HRT or OC pills (30% of total females) followed by females in ANC and PNC (puerperium). In this study, 7 (11.67%) belong to the puerperal group. These findings are similar to Previous studies carried out by Bano S et al.,20 Gazioglu S et.al.,21 & Kashkoush Al et al.,22

In males alcohol and smoking addiction is the most common risk factor accounting of 55% (15 out of 27) of total male patients. similar finding found in previous studied carried out by, Narayan et al.,19 Bajko Z et al.,23 & Green M et al.,24

According to the duration of time between the development of the first symptom and the date of admission to the hospital, Bousser et al.4 classified modes of onset as acute (less than 48 hours), subacute (more than 48 hours but less than one month), and chronic (more than one month). In the current study, the most frequent presentation was subacute in 48 instances (70%) before acute presentation was seen in 12 cases (20%) and chronic presentation was seen in 6 cases (10%).  Similar findings were noted in the study of Kotireddy CV et al.,12 which shows 53% (sub-acute), 36.7% (acute) & 10% (chronic), Anadure RK et al.,18 shows 53% (subacute) 29% (acute) & 18% (chronic).

In this study the most common presenting symptom was headache which wasobservedin60% of the study group. This was compared with the previous studies showing headache as most common symptoms like 68% in Sébire G et al.,25 79 % Raina AF et al.,14 47% in Goyal G et al.,11 80% in Desai I et al.,9 & 74 % in Bousser et al.,4  8.33% patients shows vomiting as initial symptom in this study. some previous studied like Narayan D et al.,19 Raina AF et al.,14 & Anadure RK et al.,18 shows vomiting as one of the most common manifestation 69%,54%, 62% respectively. But some studies like Koti Reddy CV.,12 shows vomiting as initial symptom in 10% patients which is similar to this study.

In this study 6.67% of the patient has presented with fever as one of the initial symptom. some of the previous studies also shows fever in a CVST patient like 10% in KotiReddy CV.,12 15% in Anadure RK et al.,18,19.5% in Raina AF et al.,14 & 38 % in Patil VC et al.,17

In this study 23.33% of total patients has papilledema, which is comparable to previous studied carried out by Narayan D et al.,19 & Patil VC et al.,17 Wasay M et al.92 which shows presence of papilledema in 18%, 26% and 32% respectively. Convulsion is the second most common symptom in this study seen in 41.67% patients. which is comparable to previous studies like Narayan D et al.,19 Anadure RK et al.,18 KotiReddy CV.,12 shows convulsion as one of the initial symptom in 39%, 42%, 43%, 51% respectively.

In this study Focal neurological deficit and cranial nerve involvement seen in 15% and 10 % respectively. Hemiparesis is most common in all. in cranial nerves 2nd nerve involvement is most common seen in 7.5% of patients followed by 6th nerve, 3rd nerve and 7th nerve. Finding in this study comparable to previous studies like in study conducted by Narayan D et al.,19 shows incidence of focal neurological deficit in 28 %, Patil VC et al.,17 reported focal neurological deficit (hemiparesis most common) in 24% and 2% has cranial nerve involvement. Raina AF et al.,14 shows FND in 29% patients and 15.8% patients shows cranial nerve involvement, KotiReddy CV.,12 reported 23% patients has focal neurological deficit whereas 2% patient had diplopia(cranial nerve involvement)  Altered sensorium was found in 13.33 % of the patients in our study which is comparable to incidence of altered sensorium in the study of Goyal G et al.,9 (14 %) and Bousser et al.,4 (26%). But some studies like KotiReddy CV.,12 & Hassan M26 showed altered sensorium as one of the most common symptom in 43% & 47% patients respectively.

The most common radiological finding in the present study is cerebral edema 28.33% secondary to brain parenchymal injury. 2nd most common presentation in this study is hemorrhagic infarction (23.34 %) followed by Sub arachnoid hemorrhage found in 3.33% cases. In previous study carried out by Raina AF et al.,14 shows 23% patient had hemorrhagic infarct with intra cranial bleed and 10% patient had SAH. Study of Goyal G et al.,9 shows 37.5% cases had hemorrhagic infarct and 6.17% patient had intraparenchymal hemorrhage and 55% patient had SAH in a cases of CVST.

In this study multiple(more than one) sinus involvement with superficial and Deep cortical veins with IJV present in some case of which commonest sinus involved was transverse sinus (84%) followed by sigmoid sinus (56.67%) and superior sagittal sinus (55%). Straight sinus involvement found in 26.67% of cases. Similar findings were reported in the studies conducted by Bousser et al.,4 demonstrated the presence of transverse sinus (74%) and superior sagittal sinus (64%); Study carried out by Goyal G et al.,9 suggestive that 74% involvement of transverse sinus, 44% of superior sagittal sinus 65% of straight sinus and 11% involvement of superficial and deep cortical veins.

Present therapeutic options for treatment include anti-thrombotic therapy with unfractionated heparin, low-molecular-weight heparins (LMWH), oral anticoagulants, intravenous thrombolysis local thrombolysis by selective sinus catheterization and a combination of thrombolysis and anticoagulation in addition to symptomatic therapy.7 Almost 80% of patients recover without sequelae and acute case fatality recorded in less than 5%.8

Early diagnosis and treatment of cerebral venous thrombosis may prevent morbidity and may even be lifesaving. In the present study we are going to investigate the clinical profile, radiological findings and risk factors of cerebral venous thrombosis.

The present study emphasizes that CVST is not an uncommon condition. All age groups can be presented with CVST but its mostly seen in third decade. Addiction, drugs, underlying procoagulant state like pregnancy, puerperium, coagulation disorders, infections are major risk factors for CVST. Evaluation for an underlying procoagulant state may be helpful for further prevention and treatment with long term anticoagulation. Clinical presentation is extremely varied and symptoms may evolve over hours to few weeks. Important clinical features to suggest this disorder are presentation with recent headache, seizures, papilledema and focal deficits in the appropriate clinical settings. Neuroimaging plays a pivotal role in diagnosis. Contrary to ischemic arterial stroke, CVST could be described as an “allor nothing” disease with good short and long term outcomes when the acute phase of illness has been survived.

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