QJM Advance Access originally published online on January 18, 2008
QJM 2008 101(3):247-249; doi:10.1093/qjmed/hcm138
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Intracerebral haemorrhage due to cerebral venous sinus thrombosis
Sir,Cerebral venous sinus thrombosis (CVST) is a common cause of stroke in young in India especially during post-partum period.1 It has diverse clinical presentations including headache, seizures and focal neurological deficit in various combinations. In the causes of intracerebral haemorrhage (ICH), CVST is not mentioned in standard text. A Medline search using terms ICH and CVST revealed only four articles comprising of eight patients.2–5 In last 3 years we have managed 33 patients with CVST and three of them had ICH and were initially misdiagnosed as aneurysmal or arteriovenous venous malformation (AVM) bleed. We report these patients and review the contemporary literature.
Case no 1
A 65-year-old female presented with sudden onset of left sided headache for first time in life 2 weeks back associated with vomiting. For 2 days she was unable to recognize her relatives and gradually became comatose. Her blood pressure was 120/86 mm of Hg and Glasgow Coma Scale (GCS) score 7. She had bilateral papilloedema. There was no focal weakness. Tendon reflexes were brisk and plantar bilaterally extensor. Her systemic examination was normal. Haematology, serum chemistry and coagulation profile were normal. CT scan revealed left temporal and right occipital haematoma (Figure 1A). D Dimer was positive, protein C low (57%), protein S normal and MTHFR and Factor V Leiden mutations were absent. Arterial phase on 4-vessel digital subtraction angiogram (DSA) was normal. MR venography revealed superior sagittal venous sinus and straight sinus partial thrombosis (Figure 1B). Patient was treated with subcutaneous low molecular weight heparin (LMWH) and improved by second week. At 3 weeks she had left homonymous haemianopia.
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Case no 2
A 22-year-old unmarried female had sudden onset of severe headache, projectile vomiting and became unconscious a few hours later. After 8–10 h, her consciousness improved and she was able to walk to the hospital. On examination she was conscious, BP 130/80 mmHg, pulse 102/minute and neck was stiff. She had bilateral papilloedema and right subhyaloid haemorrhage. Rest of the neurological examination was normal. She again became unconscious two days later (GCS score 9) and had mild haemiparesis. A day later her consciousness improved but was abulic. Her investigations of blood and urine were normal. CT scan revealed left frontal haematoma with intraventricular extension. DSA revealed left transverse and sigmoid sinus thrombosis (Figure 1C and D). She was treated with LMWH 2500IU twice daily. She improved in 2–3 days, her haemiplegia improved but abulia persisted at 1 month, which also improved at 3 months.
Case no 3
A 42-year-old female developed severe uterine bleeding after a gynaecological procedure and was prescribed oral estrogen preparations. She developed severe headache, vomiting, seizures and altered sensorium two days later. One day later she developed left partial seizures with secondary generalization lasting for 10–15 min. On examination she was drowsy (GCS score 11), had bilateral papilloedema and mild left sided haemiparesis with brisk tendon reflexes. Her CT scan revealed left parietal haematoma and MR venography revealed superior sagittal and straight sinus thrombosis (Figure 1E and F). The patient was treated with LMWH, phenytoin 300 mg and later acitrom 2 mg daily. She improved completely by day 10. Her abdominal ultrasound revealed hydatid cyst in the liver.
In our study 3 out of 33 CVST patients presented with medium size ICH. In the available literature this seems to be rare.2–5 The CT scan of the report of five cases by Singh and Chakera reveals haemorrhagic infarctions rather than primary ICH.2 In another report one of the patients had associated aneurysm and CVST was diagnosed at autopsy only. This patient underwent stenting with high dose heparin therapy, which might have contributed to ICH.4 Lobar haemorrhage in young is often attributed to aneurysm or AVM. All our patients underwent emergency DSA for excluding these possibilities. Presence of bilateral haematoma in CT may be a clue for CVST. Haemorrhagic infarction is common in CVST and is reported in 35–50% of patients, which is attributed to blockade of venous sinuses. There is increase in venous and capillary pressure resulting in diapedesis of RBC and subsequent rupture of small vessels.6 Presence of ICH may be an extension and exaggeration of above-mentioned sequence. Rapidity of venous thrombosis and lack of fibrinolysis may contribute to occurrence of ICH. All our patients had acute CVST for <15 days. We could not find common underlying predisposing or precipitating factors in these patients although one patient each had low protein C and estrogen therapy. Haemorrhagic transformation in CVST is regarded a poor prognostic factor.7 One of the earlier reported patient died and one had poor outcome.2,4 All our patients however improved completely following anticoagulation, which reiterates the safety and efficacy of anticoagulation in CVST.
It can be concluded that ICH may be a rare presentation of CVST and this possibility should be considered in appropriate clinical setting.
Department of Neurology
Sanjay Gandhi Post Graduate Institute of
Medical Sciences
Lucknow
India
email: jayanteek{at}yahoomail.com; jkalita{at}sgpgi.ac.in
Department of Radiology
Sanjay Gandhi Post Graduate Institute of
Medical Sciences
Lucknow
India
References
1. Srinivasan K, Natarajan M. Cerebral venous and sinus thrombosis in pregnancy and puerperium, a study of 135 patients. Angiology (1983) 34:731–46.
2. Singh T, Chakera T. Dural sinus thrombosis presenting as unilateral lobar hematomas with mass effect: an easily misdiagnosed cause of cerebral hemaorrhage. Austalas Radiol (2002) 46:351–65.[CrossRef]
3. Voutsinas L, Gorey MT, Gould R, Black KS, Scuderi DM, Hyman RA. Venous sinus thrombosis as a cause of parenchymal and intraventricular hemorrhage in the full term neonate. Clin Imaging (1991) 15:273–5.[CrossRef][Web of Science][Medline]
4. Carvi y Nievas M, Haas E, Hollerhage HG, Lorey T, Klein PJ. Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding: implications for treatment. Surg Neurol (2004) 61:95–8.[CrossRef][Web of Science][Medline]
5. Chan KH, Cheung RT, Liu WM, Mak W, Ho SL. Cerebral venous thrombosis in a gentleman presenting with fever, convulsion and fronto-temporal hemorrhages. J Clin Neurosci (2005) 12:186–8.[CrossRef][Web of Science][Medline]
6. Villringer A, Mehraein S, Einhäupl KM. Pathophysiological aspects of cerebral sinus venous thrombosis. J Neuroradiol (1994) 21:72–80.[Web of Science][Medline]
7. Mehraein S, Schmidtke K, Villringer A, Valdueza JM, Masuhr F. Heparin treatment in cerebral sinus and venous thrombosis: patients at risk of fatal outcome. Cerebrovasc Dis (2003) 15:17–21.[CrossRef][Web of Science][Medline]
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