INTRODUCTION
Cerebral venous thrombosis refers to blockage of venous channels in the cranial cavity, including cortical vein thrombosis, dural venous thrombosis, and deep cerebral vein thrombosis, CVT is life threatening and rare form of stroke which cause damage to the venous system of the brain, The event of CVT is 3-4 cases per million in a year, but over the past 5 to 10 years it has been diagnosed more frequent due to greater awareness and availability of better non-invasive diagnostic techniques. CVT is slightly more widespread in women, predominantly due to pregnancy, puerperium and oral contraceptive use. Thrombosis of the dural sinus or cerebral veins (CVT) is an unusual form of stroke, usually affecting adolescent individuals. Despite advances in the recognition of CVT in recent years, diagnosis and management can be complicated because of the diversity of underlying risk factors and the absence of a uniform treatment approach.
The elevated rate in adults is in their third decade. Identification is still frequently disregarded or overdue because of the wide scale of clinical symptoms and the often sub acute or enduring onset. Headache is the most common symptom of CVT and occurs in almost 90% of all cases. The headache may be of thunderclap headache (acute onset) and may be clinically indistinguishable from headache in subarachnoid haemorrhage patients. Generalized seizures or focal are far more often seen in CVT than in arterial stroke and occur in 40% of all patients with superior incidence (76%) in peripartum CVT. Focal neurological signs (including focal seizures) are the most common finding in CVT. They include sensory deficits and central motor, haemianopsia or aphasia and happen in 40 to 60% of all cases. In patients with focal deficits together with seizures, headache, or an altered consciousness, CVT should always be considered. The syndrome of inaccessible intracranial hypertension (IIH) with headache, blurred vision and vomiting because of papilloedema is the most identical pattern of clinical presentation accounting for 20–40% of CVT cases. Stupor or coma is usually seen in cases with widespread thrombosis of the deep venous system with bilateral thalamic association. Of all clinical signs reported in CVT, coma at admission is the most dependable and strongest predictor of a poor result
The clinical presentation of CVT is highly variable. It is an infrequent condition with a large variety of causes. Numerous infective or non infective conditions can predispose or cause CVT. They comprise all gyneco-obstetric, surgical, and medical cause of leg vein thrombosis, followed by number of local causes such as head injury, tumors, blend into the internal jugular vein, and intracranial and regional infections, neurosurgical procedures and lumbar puncture. Hematologic disorders are rare but well-established causes; they include red blood cell disorders, thrombocythemias, leukemia’s ,and congenital or acquired coagulation disorders: Antithrombin, Protein C, and Protein S deficiencies or lupus anticoagulant, mutation in the blood coagulation factor V gene called factor V Leiden. Pregnancy related hypertension and caesarean delivery are related with intracranial venous thrombosis in the post partum period and peripartum. A significant minority (12.5%) of cases had no known risk factor. Drugs associated include Androgen, danazol, lithium, vitamin A, IV immunoglobulin, ecstasy, Antineoplastic drugs (tamoxifen, L-asparaginase). Other systemic conditions associated include Iron deficiency anemia, Nephrotic syndrome, Paroxysmal nocturnal hemoglobinuria, Polycythemia, Systemic lupus erythematosus, Inflammatory bowel disease, Thyroid disease, Behçet disease and Sarcoidosis.
A prothrombotic risk factor is identified in 85% of patients with sinus thrombosis and patients with CVT usually have several risk factors. Use of the oral contraceptive pill (OCP) and thrombophilic states both acquired and genetic are the most commonly identified risk factors. A recent Italian study found that OCP use is strongly and autonomously associated with CVT. In addition, the arrangement of a prothrombin gene mutation and contraceptive pills use further increased the risk of sinus thrombosis.
In this project I have observe various symptoms in different patients like headache is common in cerebral venous thrombosis but some of the patient doesn’t had headache. Focal deficit, seizures, limbs weakness, and weakness of face are also common symptoms. According to recent studies CVT is increasing in women but my research doesn’t suggest much difference in the ratio, we have identified the most common risk factors in women that is responsible for cerebral venous thrombosis are OCP, pregnancy and partum infection.
Intra-arterial four-vessel angiography has been the great standard for establishing the diagnosis of CVT but today MRI and magnetic resonance angiography (MRA) is regarded the best apparatus both for the diagnosis and follow-up of CVT . CT scan alone is not sufficient but diagnosis can be conventional in combination with CT angiography even though the use of iodinated distinction fluid and ionizing radiation remains a drawback which makes it inappropriate for follow-up examinations.
RESULT
CVT is diagnosed by CT venography, MRI, CT scan and by the biochemistry tests. In present study we observed all the patients result of examination and analysed the all the report to identify the common or high risk factors.
Most affected gender and age is shown below in the table.
Number of Patients
Percentage of Cases
Total no. of patient 54
Female 25 46.3%
Male 29 53.7%
Age group: 18-70
Most affected age 18-30 24 44.4%
30-50 23 42%
50-70 5 9%
Table no.1: Analysed result of patient Age and Gender
Fifty four patients were included in the study, of which 25 cases were female and most of them are of age group between 20-30, are due to pregnancy & post partum infection cases, half of non pregnant female cases used contraceptive pill. 29 cases were male.
Presenting Symptoms Number of patients Percentage of Patients
Headache 40 74%
Seizures 13 24%
Vomiting 24 44%
Focal Deficit 26 48%
Table 2: Presenting clinical Symptoms
Headache is the most common clinical symptom found in more than half of the patients, followed by focal deficit, vomiting and seizure. Most of the patients show abnormal vision and weakness of the face and limbs.
In this project we have observe various symptoms in different patients like headache is common in cerebral venous thrombosis but some of the patient doesn’t had headache. Focal deficit, seizures, limbs weakness, and weakness of face are also common symptoms. According to recent studies CVT is increasing in women but my research doesn’t suggest much difference in the ratio, we have identified the most common risk factors in women that is responsible for cerebral venous thrombosis are OCP, pregnancy and partum infection
Risk Factors Number of Patients Percentage of Cases
HTN 8 14%
DM 8 14%
Smoking 2 3%
Alcohol 3 5.5%
Homocysteine 25 46%
HB 10 18%
Thrombophilia 37 68.5%
Protein C deficiency 9 16.6%
Protein S deficiency 3 5.5%
Antithrombin essay 4 7.4%
ACL 3 5.5%
MTHFR Mutation 13 24.7%
Factor V Leiden 2 3%
Prothrombin Gene Mutation 2 3%
B2 Glycoprotein 2 3%
Lupus Anticoagulant 2 3%
ANA
C-ANCA
P-ANCA 3 5.5%
Pregnancy & Post partum infection 7 12.6%
Oral Contraceptive Use 9 16.7%
Table 3: Identified Risk Factors for Cerebral Vein Thrombosis
Thrombophilia screening was performed in 75% of the cases out of which 68% cases found positive for thrombophilia. Homocysteine was also found as most common risk factor, followed by post-partum state infection, pregnancy and use of OCP. Some of other risk factors also found like B12 deficiency, 40% of patients had B12 deficiency and some of the patients had hypothyroidism & chron’s disease.
DISCUSSION
This study in Sir Ganga Ram Hospital shows that cerebral venous thrombosis is increasing among the young people, where the mostly patient population (46.3% female and 53.7%) were (20 to 35) young adults. Most of the female of child bearing age were affected due to cerebral venous thrombosis. According to ISCVT, CVT is increasing in female due to the pregnancy, Partum infection and use of contraceptive pill. Our study shows the similar result in the case of risk factors responsible of CVT in female, 3rd generation contraceptive pills are mostly responsible for cvt and is most popular among young female. But in our study the ratio of male and female is a little different, male are still leading as compare to female. The risk factors for CVT are pregnancy, puerperium infection, oral contraceptive pills, antiphospholipid syndrome, thrombophilia mutation, deficiency of protein c & s, ANA, prothrombin mutation, antithrombin deficiency, anticardiolipin protein, factor v leiden, B2 glycoprotein, MTHFR mutation, homocysteine, anti-nuclear antibody etc.
A prothrombotic risk factor is identified in 68% of patients with sinus thrombosis and patients with CVT usually have several risk factors. Use of the oral contraceptive pill (OCP) and thrombophilic states both acquired and genetic are the most regularly identified risk factors. A recent study found that OCP use is strongly and autonomously associated with CVT. In addition, the arrangement of a prothrombin gene mutation and contraceptive pills use further increased the risk of sinus thrombosis.
CVT is potentially lethal but treatable. The symptoms and clinical course are highly variable and because of the manifestations and its ability to imitate other diseases. CVT make it difficult to diagnose. This study shows headache is still most common symptom, followed by seizure, vomiting and focal deficit. There are multiple predisposing causes of CVT.
The elevated rate in adults is in their third decade. Identification is still frequently disregarded or overdue because of the wide scale of clinical symptoms and the often sub acute or enduring onset. Headache is the most common symptom of CVT and occurs in almost 90% of all cases. The headache may be of thunderclap headache (acute onset) and may be clinically indistinguishable from headache in subarachnoid haemorrhage patients. Generalized seizures or focal are far more often seen in CVT than in arterial stroke and occur in 40% of all patients with superior incidence (76%) in peripartum CVT. Focal neurological signs (including focal seizures) are the most common finding in CVT.
We have identified the most common risk factors in male as well female, mutation in thrombophilia factor is an underlying risk factor followed by DM, CAD, HTN, pregnancy, puerperium infection, oral contraceptive pills, antiphospholipid syndrome, c & s protein deficiency, prothrombin mutation, antithrombin deficiency, anticardiolipin protein, factor v leiden, B2 glycoprotein, MTHFR mutation, homocysteine, anti-nuclear antibody etc. There are some other risk factors that are not directly responsible for CVT but somewhere it is leading to cerebral venous thrombosis is B12 deficiency, and bechets disease