Trombosis venosa cerebral recurrente en el embarazo / Recurrent cerebral venous thrombosis in pregnancy

La trombosis venosa cerebral es una enfermedad poco frecuente, pero de pronóstico potencialmente grave. Debido a los cambios hemostáticos durante la gestación, es una patología que puede asociarse al embarazo. Presenta un amplio rango de signos y síntomas. El diagnóstico y tratamiento precoz mejoran el pronóstico. Presentamos el caso de una mujer de 30 años, que en la semana 8 de gestación acude a Urgencias por cefalea intensa y cuya resonancia magnética reveló una trombosis venosa cerebral. La paciente presentó un segundo episodio en la semana 33, a pesar del correcto tratamiento anticoagulante recibido.

Cerebral venous thrombosis is a rare disease, but with a potentially serious prognosis. It is a condition that can be associated with pregnancy because of the hemostatic changes during gestation. It has a wide range of signs and symptoms. Early diagnosis and treatment improve prognosis. We report the case of a 30-year-old woman, at week 8 of pregnancy, who came to the emergency department for severe headache and whose magnetic resonance imaging revealed a cerebral venous thrombosis. The patient had a second episode at week 33, despite correct anticoagulation received.

Trombosis venosa cerebral / Cerebral venous thrombosis

La trombosis venosa cerebral (TvC) es una rara enfermedad que se incluye dentro del grupo de trombosis en sitios infrecuentes. El correcto estudio y manejo terapéutico de la misma es de capital importancia por la alta morbimortalidad que conlleva de no diagnosticarse y tratarse correctamente. El desarrollo en el conocimiento de los factores de riesgo como las trombofilias entre otros, ha sido de gran importancia diagnóstica. Aún faltan estudios randomizados y controlados de gran número de pacientes para definir la duración óptima del tratamiento según cada caso particular. Por el momento las recomendaciones terapéuticas en este tipo de trombosis se basan en estudios observacionales y opinión de expertos, los cuales recomiendan anticoagulación a largo plazo para pacientes con trombosis inexplicadas, trombosis recurrentes, o asociadas a trombofilias de alto riesgo o combinadas. El objetivo de esta publicación es presentar una serie de casos clínicos, revisar el tema de TvC dado la importancia por las posibles complicaciones evolutivas; conocer los factores de riesgo y discutir las posibilidades terapéuticas.

Diagnóstico por imagem e aspectos clínicos da trombose venosa cerebral em recém-natos a termo sem dano cerebral: revisão em 10 anos / Imaging diagnosis and clinical findings of cerebral venous thrombosis in full-term neonateswithout brain damage: a ten-year review

OBJETIVO: Descrever e comparar os métodos de imagem e os aspectos clínicos em quatro recém-natos a termo diagnosticados como trombose venosa cerebral, sem dano encefálico, adscritos a uma unidade de terapia intensiva neonatal. MATERIAIS E MÉTODOS: Revisão em 10 anos com quatro casos diagnosticados como trombose venosa cerebral por meio de ultrassonografia transfontanela com Doppler e confirmados por ressonância magnética/angiorressonância, correlacionados aos aspectos clínicos e evolução neurológica. RESULTADOS: A ultrassonografia foi normal em 75 por cento dos casos e a ressonância magnética, em 100 por cento. No caso alterado, a dilatação venosa foi identificada. O Doppler e a angiorressonância estavam alterados em 100 por cento dos casos. Dos aspectos clínicos, a hipóxia (100 por cento) e a convulsão precoce (100 por cento) predominaram, com potencial evocado alterado em 50 por cento dos casos. Na avaliação do neurodesenvolvimento, todas as áreas estiveram dentro da normalidade até a última avaliação. CONCLUSÃO: A ultrassonografia associada ao Doppler é capaz de identificar as alterações da trombose venosa cerebral, devendo ser complementada com a ressonância magnética, que é o padrão ouro de diagnóstico.

OBJECTIVE: To describe and compare imaging methods and clinical findings of cerebral venous thrombosis in four full-term neonates without brain damage, admitted to a neonatal intensive care unit. MATERIALS AND METHODS: Ten-year review of four cases diagnosed with cerebral venous thrombosis by transfontanellar ultrasonography associated with Doppler fluxometry and confirmed by magnetic resonance imaging/magnetic resonance angiography in correlation with clinical findings and neurological progression. RESULTS: Ultrasonography presented normal results in 75 percent of cases and magnetic resonance imaging in 100 percent. Doppler fluxometry and magnetic resonance angiography were abnormal in 100 percent of cases. Hypoxia (100 percent) and early seizures (100 percent) were predominant among clinical findings with evoked potential changes in 50 percent of cases. In the assessment of the neurodevelopment all the areas remained within normality parameters up to the conclusion of the present study. CONCLUSION: Ultrasonography in association with Doppler can identify changes related to cerebral venous thrombosis and should be complemented with magnetic resonance imaging that is the gold standard for diagnosis in these cases.

Trombosis venosa intracraneal: signos imaginológicos y errores frecuentes / Intracranial venous thrombosis: imaging signs and common errors

Although intracranial venous thrombosis is a relatively rare disease, it constitutes an entity that must be timely and accurately diagnosed in emergency services, given the need for prompt treatment to avoid serious complications, including neurological deficits or even death. There are several imaging signs provided by both CT and magnetic resonance imaging scans that allow this early diagnosis. On the other hand, some differential diagnoses need to be performed to prevent the error of mistaking intracranial venous thrombosis for any other entity.

Si bien la trombosis venosa intracraneal es una patología relativamente poco frecuente, es una entidad que debe ser diagnosticada a tiempo y con certeza en los servicios de urgencia, dada la necesidad de pronto tratamiento para evitar complicaciones graves que incluyen déficit neurológicos e incluso muerte. Existen varios signos imaginológicos que nos permiten hacer este diagnóstico, tanto en tomografía computarizada como en resonancia magnética. Por otra parte, es necesario considerar algunos diagnósticos diferenciales para no cometer errores, confundiendo esta patología con otras entidades.

[Incidence rate of cerebral venous thrombosis and its related factors in Kermanshah city in 2009-2010]

Cerebral venous thrombosis [CVT] is a rare disorder. Incidence of CVT in developing countries is not clear. This study was conducted to determine the incidence rate of cerebral venous thrombosis, its symptoms and some of its predisposing factors in Kermanshah city. This was a descriptive study. The sample size included 21 cases. Diagnosis of cases of CVT was based on MRI sequences T1, T2, FLAIR and approved by the gold standard MR venography over 12 months. The data were introduced into SPSS software and analyzed by means of descriptive statistics and the frequency of data was calculated. This study included 21 patients; three males [14.3%] and 18 females [85.7%] with a mean age of 36.00 +/- 10.13 years who had a total number of 55 thromboses. The most prevalent clinical symptoms, predisposing factor, associated disorder, and sinus involved, included headache [95.2%], OCP consumption [52.4%], infarction [47.6%] and superior sagital sinus [71.4%] respectively. This study showed that the incidence of cerebral venous thrombosis in Kermanshah is relatively higher in comparison to the statistics mentioned in other studies, so further studies for more evaluation of contributing factors in this disease are recommended

Cortical venous thrombosis due to acquired hyperhomocysteinaemia.

A 20-year-old student presented with generalized tonic– clonic seizures and was diagnosed to have cortical venous thrombosis. Her dietary history and the clinical signs of vitamin deficiency prompted further investigations, which detected hyperhomocysteinaemia secondary to vitamin B12 deficiency as a factor contributing to the hypercoagulable state. This case highlights the importance of a balanced diet, as well as the necessity for primordial prevention.

Peripartum neurological emergencies in a critical care unit

To assess the proportion of eclampsia among patients admitted to the critical care unit [CCU] with an acute neurological emergency in the peripartum period, and careful clinical, laboratory, and radiological evaluation of non-eclampsia cases responsible for such presentation. A case series study that included women with acute deterioration of consciousness, with or without convulsions or neurological deficits, during pregnancy or puerperium, received in the CCU of Ibn Sina Teaching Hospital in Mosul, Iraq, from September 1st 2005 to August 31st 2006. A total of 30 women were included. They received careful clinical, radiological, and laboratory evaluation in an attempt to identify the cause of their presentation. Eclampsia was found to be responsible for two thirds of cases [20 patients]. The remaining one third was diagnosed as cerebral venous thrombosis [CVT] [7 patients], peripartum cerebral infarction [one patient], intracerebral hemorrhage [one patient], and acute fatty liver of pregnancy [one patient]. Four of the women with CVT had preeclampsia during pregnancy. Imaging studies, particularly MRI and MR venography, provided the final diagnosis in most cases. Eclampsia was found more common in women presenting during their first pregnancy, while CVT was more common in multiparous women [p=0.0001]. Cortical blindness was significantly associated with eclampsia instead of CVT [p=0.01]. Acute neurological symptoms in the peripartum period represent a diverse group of conditions, requiring careful clinical evaluation and early access to imaging studies

Trombosis venosa cortical aislada: Comunicación de dos pacientes / Isolated cortical vein thrombosis: Report of two cases

Isolated cortical vein thrombosis is an uncommon presentation of central venous thrombosis. We report two females, aged 29 and 40 years, with isolated cortical vein thrombosis. Both presented with a focal neurological deficit and focal seizures that became generalized. The diagnosis was made with magnetic resonance imaging. Both had a history of oral contraceptive use. Both had a rapid response to unfractionated heparin. One patient had an antiphospholipid syndrome as a possible etiology. The most common manifestations of this disease are a transient or recurrent neurological deficit, visual disturbances and focal or generalized seizures, usually without intracanial hypertension. Neuroimages show ischemic abnormalities that do not follow an arterial vascular territory, often with an early hemorrhagic component. There is a good clinical response to heparin.

Trombosis venosa cerebral / Cerebral venous thrombosis

La trombosis venosa cerebral representa el 0,5 por ciento de los ictus y afecta con mayor frecuencia a sujetos jóvenes con factores de riesgo congénitos o adquiridos. Tiene manifestaciones clínicas variables que unidas a un estudio de neuroimagen adecuado permiten realizar el diagnóstico. La venografía, por resonancia magnética o tomografía computarizada, constituye la principal prueba de confirmación diagnóstica. En esta revisión se hace énfasis en los aspectos clínicos básicos para su diagnóstico y tratamiento que consiste en el control de los factores causales siempre que sea posible, el tratamiento sintomático, especialmente de la hipertensión endocraneana y el empleo de anticoagulantes.

Cerebral venous thrombosis accounts for 0.5 percent of the stroke and affects more frequently young persons with congenital or acquired risk factors. It has variable clinical manifestations that together with an adequate neuroimaging study allow to make the diagnosis. The venography by magnetic resonance or computerized tomography is the main test of diagnostic confirmation. In this review, emphasis is made on the basic clinical aspects for its diagnosis and treatment, consisting in the control of the causing factors if possible, the symptomatic treatment, especially of endocranial hypertension, and the use of anticoagulants.

Trombosis venosa cerebral puerperal: presentación de un caso / Puerperal cerebral venous trombosis: a case presentation

Presentamos el caso de una puérpera de 8 d que presenta cefalea de 4 d de evolución, asociada a cambios posicionales e hipertensión arterial. Es ingresada con diagnóstico presuntivo de trombosis venosa cerebral puerperal vs. hipertensión puerperal complicada y en menos de 12 h de su ingreso desarrolla un estado convulsivo tónico-clónico generalizado, con necesidad de ventilación mecánica y tratamiento anticonvulsivante, el diagnóstico fue sospechado por estudios de tomografía axial computadorizada y confirmada por angiorresonancia. Se inició tratamiento anticoagulante en dosis terapéutica desde el primer estudio imagenològico y egresó sin secuelas neurológicas. Se revisa el tema y se comentan los elementos que nos llevaron al planteamiento clínico de la entidad.

The article presented the case of a puerpera who, after 8 days of giving birth, suffered headache for 4 days associated to positional changes and blood hypertension. She was admitted to the hospital with a presumptive diagnosis of puerperal cerebral venous thrombosis vs complicated puerperal hypertension. Within 12 hours of admission, she developed a generalized tonic-clonic convulsive state and needed to be mechanically ventilated and treated with anticonvulsive drugs. CAT studies provided the suspected diagnosis whereas magnetic angioresonance confirmed it. Anti-coagulant treatment at therapeutic dose was provided since the first imaging study. She was discharged from hospital without any neurological sequelae. This topic was reviewed and the elements leading us to the clinical statement of the disease were commented on.

Cerebral thrombosis in systemic lupus erythematosus with the antibody antiphospholipid syndrome.

Systemic lupus erythematosus (SLE) has numerous manifestations. Haematology is the common system influenced by the disease. The antibody antiphospholipid syndrome, secondary hematology disorder in SLE, is related to high incidence of thrombosis. The thrombosis events like myocardial infarction and stroke are high in mortality. We reported a-36-year old woman treated for lung tuberculosis (TB) with secondary infection, nephritis lupus, and pancytopenia. The general condition has improved and the patient was planned to discharge while she suddenly fell down, unconscious and had seizure. The CT-scan showed an area of hypodensity on the left thalamus. Haematology results showed high level of fibrinogen and D-dimer as the signs of thrombosis. The anticardiolipin antibody was intermediately positive for IgG and IgM, but lupus anticoagulan was weakly positive. The serial test within 2 months still showed positive IgG. The patient received supportive treatment, heparinization, neurotropic drugs and anticonvulsant. She was discharged in good condition while continuing oral anticoagulant to prevent recurrent seizure.

Alterações parenquimatosas na trombose venosa cerebral: aspectos da ressonância magnética e da angiorressonância / Parenchymal abnormalities in cerebral venous thrombosis: findings of magnetic resonance imaging and magnetic resonance angiography

OBJETIVO: Determinar a freqüência e localização das alterações parenquimatosas da trombose venosa cerebral nos exames de ressonância magnética e de angiorressonância, bem como a correlação com o território e a drenagem venosa comprometida. MATERIAIS E MÉTODOS: Foram analisados exames de 21 pacientes realizados entre 1996 e 2004, com diagnóstico clínico e radiológico de trombose venosa cerebral em exames de ressonância magnética e de angiorressonância nas seqüências 2D PC, 3D PC e 3D TOF com contraste paramagnético. Análise estatística foi realizada com o teste do qui quadrado. Quatro pacientes tinham exames de controle e três realizaram angiografia por subtração digital. RESULTADOS: Dos 21 pacientes, 18 eram mulheres, todos com idade entre três e 82 anos (média de 40 anos e mediana de 36 anos). Os principais fatores etiológicos foram infecção, uso de contraceptivos orais, reposição hormonal e colagenoses. Predominaram os sintomas de déficit focal, cefaléia, alteração do nível de consciência e convulsões. Por freqüência, as manifestações parenquimatosas foram: edema/infarto de distribuição cortical e/ou subcortical, congestão venosa e circulação colateral, realce meníngeo e infarto ou edema dos tálamos e núcleos da base. Os principais seios comprometidos foram o sagital superior, o transverso esquerdo, o sigmóide esquerdo e o seio reto, sendo incomum o acometimento dos seios cavernosos e de veias corticais. CONCLUSÃO: A trombose venosa cerebral é causa incomum de acidente vascular encefálico, com prognóstico favorável pelo caráter reversível das lesões. Seu diagnóstico depende fundamentalmente da capacidade do radiologista reconhecer suas formas de apresentação, principalmente nos casos em que ele é sugerido pelas alterações parenquimatosas e não necessariamente pela visualização do trombo. A precisão e a rapidez no diagnóstico permitem o pronto tratamento, reduzindo a morbi-mortalidade da doença.

OBJECTIVE: To determine the frequency and localization of parenchymal abnormalities in cerebral venous thrombosis on magnetic resonance imaging and magnetic resonance angiography as well as their correlation with the territory and affected venous drainage. MATERIALS AND METHODS: Retrospective analysis (1996 to 2004) of 21 patients (3 male and 18 female) age range between 3 and 82 years (mean 40 years, median 36 years) with clinical and radiological diagnosis of cerebral venous thrombosis on magnetic resonance imaging and magnetic resonance angiography in 2D PC, 3D PC and contrast-enhanced 3D TOF sequences. The statistical analysis was performed with the qui-square test. Four patients had follow-up exams and three patients underwent digital subtraction angiography. RESULTS: Main predisposing factors were: infection, use of oral contraceptives, hormone replacement therapy and collagenosis. Predominant symptoms included: focal deficit, headache, alteration of consciousness level and seizures. Most frequent parenchymal manifestations were: cortical/subcortical edema or infarct, venous congestion and collateral circulation, meningeal enhancement and thalamic and basal ganglia edema or infarct. Occlusion occurred mainly in superior sagittal, left transverse, left sigmoid and straight sinuses. Cavernous sinus and cortical veins thrombosis are uncommon events. CONCLUSION: Cerebral venous thrombosis is an uncommon cause of stroke, with favorable prognosis because of its reversibility. Diagnosis is highly dependent on the radiologist capacity to recognize the presentations of this disease, principally in cases where the diagnosis is suggested by parenchymal abnormalities rather than necessarily by visualization of the thrombus itself. An accurate and rapid diagnosis allows an immediate treatment, reducing the morbidity and mortality rates.

Vein of Galen aneurysm in an adult: case report / Aneurisma da veia de Galeno em adulto: relato de caso

Vein of Galen aneurysm is a rare pathology, representing less than 1 percent of intracranial vascular malformations. We report on a 65 years-old man who experienced a generalized tonic-clonic seizure. Brain imaging showed a large calcified expanding mass in the pineal region, confirming the diagnosis of a vein of Galen aneurysm. Because of the spontaneous thrombosis of the malformation, there was no need for microsurgical or endovascular treatment and he is been regularly followed since that.

Aneurisma da veia de Galeno é patologia rara, representando menos de 1 por cento das malformações vasculares intracranianas. Apresentamos o caso de um homem de 65 anos que teve episódio de crise convulsiva tônico-clônica generalizada. Exames de imagem evidenciaram grande processo expansivo calcificado na região pineal, confirmando o diagnóstico de aneurisma trombosado de veia de Galeno. Devido à trombose espontânea da malformação, foi excluída a possibilidade de tratamento endovascular bem como microcirúrgico, mantendo-se o acompanhamento clínico.

Alteraciones venosas intracraneanas: hallazgos por RM / Intracranial venous disorders: MRI findings

Propósito: describir las características imagenológicas por Resonancia Magnética de distintas alteraciones venosas a nivel intracraneano. Material y Métodos: Entre enero de 2002 y marzo de 2004 se estudiaron 18 pacientes portadores de alteraciones venosas intracraniales. Diez de ellos fueron de sexo masculino y 8 femenino con edad comprendida entre 6 y 63 años. En todos los casos se realizó RM de encéfalo con gadolinio en un equipo CVI1.5T(GE Mdical System), realizandose secuencias convencionales de RM y angio-RM en tiempos venosos. Resultados: Sobre 18 casos, 10 correspondieron a trombosis venosas; 6 fueron angiomas venosos, uno de ellos en asociación con cavernoma; y 2 presentaron várices secundarias a fístula arteriovenosa dural. Conclusión: Las diferentes entidades de origen venoso que hemos descripto varían en sus formas de presentación clínica, pronóstico y tratamiento; pero en todas ellas la Resonancia Magnética debería ocupar el primer lugar en el algoritmo diagnóstico. El conocimiento de las alteraciones morfológicas que las caracterizan, y el uso de las secuencias más apropiadas a cada caso, allanarán eventuales dificultades diagnósticas evitando la multiplicación de exámenes complementarios y/o procedimientos invesivos no indicados.