Scientific Letter
Cerebral venous thrombosis: A single disease with different approaches
Trombosis venosa cerebral: una misma enfermedad con diferentes abordajes
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Sevilla Martinez, M.C. Lorente Conesa, S. Silvente Fernandez, E. García Bautisita, F. Guerrero López" "autores" => array:5 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Sevilla Martinez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "M.C." "apellidos" => "Lorente Conesa" "email" => array:1 [ 0 => "mclorente86@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Silvente Fernandez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "E." 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"apellidos" => "Guerrero López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital José María Morales Meseguer, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología Intervencionista, Complejo Hospitalario Universitario de Granada, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombosis venosa cerebral: una misma enfermedad con diferentes abordajes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1488 "Ancho" => 1300 "Tamanyo" => 237895 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Phlebography showing a filling defect in the superior longitudinal sinus. (B) Phlebography with the absence of filling defects and adequate drainage through the left transverse sinus. (C) Brain CT scan showing evidence of intracranial hypertension (bilateral erasure of the convexity sulci, diminished basal cistern size, increased mesencephalic anteroposterior axis). (D) Brain CT scan at discharge, showing improvement of the indirect signs of intracranial hypertension.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cerebral venous thrombosis (CVT) is an infrequent condition that poses a diagnostic and therapeutic challenge due to its highly variable presentation and the lack of clear consensus regarding patient management. The underlying etiology, clinical condition of the patient and resources available in the hospital require an individualized treatment strategy. We present two clinical cases in which CVT, being one same disease, resulted in two different management approaches.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first case corresponded to a hypertensive 35-year-old male who reported to the emergency service due to headache and vomiting. Brain computed tomography (CT) and angioCT revealed a right frontal intraparenchymal hematoma, right subarachnoid hemorrhage, and thrombosis of the sigmoid sinus, right transverse sinus and middle third of the superior longitudinal sinus.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient presented a Glasgow Coma Score (GCS) of 14/15 points, with left hemiparesis and disorientation. Admission to the Intensive Care Unit (ICU) was decided, with the start of heparin sodium infusion. Over the following hours, and in view of the neurological deterioration, a brain CT scan was performed, revealing an increase in size of the hematoma, while phlebography showed the absence of opacification of the superior longitudinal and right transverse sinuses, suggestive of thrombosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Mechanical thrombectomy proved ineffective. Local fibrinolysis was therefore decided (urokinase 60,000<span class="elsevierStyleHsp" style=""></span>IU/h), following placement of a catheter in the longitudinal sinus.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In the course of the following hours the patient presented right-side mydriasis. Measures for the control of intracranial pressure (ICP) were therefore adopted–the CT scan revealing intracranial hypertension without drainable lesions. An intraparenchymal ICP sensor was placed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Despite the measures adopted, the ICP values remained >25<span class="elsevierStyleHsp" style=""></span>mmHg; urgent decompressive craniotomy (DC) was therefore performed and local fibrinolysis was continued. Repeat surgery was decided after 72<span class="elsevierStyleHsp" style=""></span>h, expanding the DC due to intracranial hypertension secondary to extracranial hematoma overlying the initial craniectomy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Local fibrinolysis was subsequently maintained, and control phlebography revealed effective drainage through the left transverse sinus, with partial repermeabilization of the right transverse sinus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). In view of the above, local fibrinolysis was suspended and systemic anticoagulation was started, with no bleeding complications.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical and radiological stabilization was subsequently observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D), and the patient was moved to the hospital ward after 26 days in the ICU, with a GCS of 14/15 points and left hemiplegia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The second case corresponded to a 56-year-old male with a history of arterial hypertension and peripheral vertigo who suffered a fall from a height of one meter, with occipital traumatic brain injury (TBI). The patient reported to the emergency service with agitation, disorientation and a GCS of 14/15 points. The brain CT scan revealed skull base fracture with involvement of the left petrous part of the temporal bone and left occipital fracture, as well as laceration and thrombosis of the left transverse and sigmoid sinuses, with the extension of thrombosis toward the ipsilateral internal jugular zone (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Admission to the ICU for monitoring and pressure control was decided, adopting an expectant approach with regard to anticoagulation. The patient remained 12 days in the ICU, with imaging controls, and a GCS of 14/15 points at all times. Discharge from intensive care was therefore decided, without residual neurological defects.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Cerebral venous thrombosis is an infrequent condition that poses diagnostic and management problems. The annual incidence is 1.3 cases per 100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Cerebral venous thrombosis secondary to traumatic brain injury is even less frequent–accounting for approximately 4% of all cases of CVT.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Cerebral venous thrombosis is particularly frequent in women between 20 and 35 years of age, being associated to pregnancy or puerperium and the use of oral contraceptives. The disorder accounts for 0.5% of all cerebrovascular events.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The manifestations at onset usually comprise headache, seizures, and focal neurological defects.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to diagnosis, magnetic resonance imaging combined with venous resonance imaging is the technique of choice, though CT venography is an adequate alternative and is more widely available.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients with spontaneous thrombosis of the sinuses and with no contraindications to anticoagulation should receive low molecular weight heparin or unfractionated heparin via the intravenous route in order to double the activate partial thromboplastin time and arrest the thrombotic process.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> At present, anticoagulation with low molecular weight heparin is advised, since it is more stable and no adjustment of the coagulation times is required. General antiedema measures should be added to anticoagulation: raising of the patient headrest, recording of mean arterial pressures in order to maintain a cerebral perfusion pressure of >70<span class="elsevierStyleHsp" style=""></span>mmHg, normothermia, and the avoidance of solutions containing dextrose.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The prescription of antiepileptic drugs for the prevention or management of seizures is subject to controversy, and no studies supporting their use are available.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In those cases where neurological worsening is observed despite anticoagulant therapy,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> with no associated intracranial hypertension, endovascular procedures are recommended in centers with experience in the use of such techniques.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The efficacy of endovascular mechanical extraction or local fibrinolysis is not supported by clinical trials but by case series; the level of evidence supporting the benefits of such measures is therefore limited.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Decompressive craniectomy could offer benefit in patients that develop malignant intracranial hypertension, and in cases where initial medical treatment has moreover failed.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our first case, mechanical thrombectomy proved ineffective. We subsequently administered local fibrinolysis through the longitudinal sinus catheter, since the restoration of flow is faster and more efficient than with heparin, assuming the bleeding risk.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">However, in the case of traumatic CVT, anticoagulant use is controversial and should be indicated on an individualized basis, since favorable outcomes have been reported in patients without neurological impairment or complications, in which an expectant approach has been decided.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sevilla Martinez M, Lorente Conesa MC, Silvente Fernandez S, García Bautisita E, Guerrero López F. Trombosis venosa cerebral: una misma enfermedad con diferentes abordajes. Med Intensiva. 2017;41:377–379.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1488 "Ancho" => 1300 "Tamanyo" => 237895 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Phlebography showing a filling defect in the superior longitudinal sinus. (B) Phlebography with the absence of filling defects and adequate drainage through the left transverse sinus. (C) Brain CT scan showing evidence of intracranial hypertension (bilateral erasure of the convexity sulci, diminished basal cistern size, increased mesencephalic anteroposterior axis). (D) Brain CT scan at discharge, showing improvement of the indirect signs of intracranial hypertension.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 949 "Ancho" => 950 "Tamanyo" => 102646 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT reconstruction: posttraumatic thrombosis in the left transverse sinus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The incidence of cerebral venous thrombosis: a cross-sectional study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Octubre | 61 | 56 | 117 |
| 2024 Septiembre | 66 | 40 | 106 |
| 2024 Agosto | 87 | 47 | 134 |
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| 2024 Abril | 91 | 46 | 137 |
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| 2024 Febrero | 82 | 43 | 125 |
| 2024 Enero | 80 | 42 | 122 |
| 2023 Diciembre | 98 | 43 | 141 |
| 2023 Noviembre | 68 | 37 | 105 |
| 2023 Octubre | 85 | 37 | 122 |
| 2023 Septiembre | 56 | 41 | 97 |
| 2023 Agosto | 27 | 18 | 45 |
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| 2023 Junio | 44 | 21 | 65 |
| 2023 Mayo | 55 | 40 | 95 |
| 2023 Abril | 83 | 29 | 112 |
| 2023 Marzo | 107 | 34 | 141 |
| 2023 Febrero | 85 | 37 | 122 |
| 2023 Enero | 83 | 29 | 112 |
| 2022 Diciembre | 89 | 46 | 135 |
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| 2022 Octubre | 96 | 43 | 139 |
| 2022 Septiembre | 63 | 42 | 105 |
| 2022 Agosto | 104 | 49 | 153 |
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| 2022 Junio | 62 | 26 | 88 |
| 2022 Mayo | 69 | 41 | 110 |
| 2022 Abril | 64 | 48 | 112 |
| 2022 Marzo | 81 | 53 | 134 |
| 2022 Febrero | 45 | 39 | 84 |
| 2022 Enero | 37 | 37 | 74 |
| 2021 Diciembre | 64 | 56 | 120 |
| 2021 Noviembre | 57 | 54 | 111 |
| 2021 Octubre | 78 | 80 | 158 |
| 2021 Septiembre | 40 | 38 | 78 |
| 2021 Agosto | 50 | 42 | 92 |
| 2021 Julio | 70 | 35 | 105 |
| 2021 Junio | 42 | 35 | 77 |
| 2021 Mayo | 51 | 53 | 104 |
| 2021 Abril | 93 | 46 | 139 |
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| 2020 Octubre | 45 | 34 | 79 |
| 2020 Septiembre | 37 | 29 | 66 |
| 2020 Agosto | 41 | 18 | 59 |
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| 2019 Noviembre | 46 | 18 | 64 |
| 2019 Octubre | 61 | 16 | 77 |
| 2019 Septiembre | 21 | 23 | 44 |
| 2019 Agosto | 36 | 21 | 57 |
| 2019 Julio | 29 | 21 | 50 |
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| 2019 Mayo | 40 | 26 | 66 |
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| 2018 Noviembre | 98 | 25 | 123 |
| 2018 Octubre | 173 | 30 | 203 |
| 2018 Septiembre | 65 | 14 | 79 |
| 2018 Agosto | 40 | 10 | 50 |
| 2018 Julio | 41 | 19 | 60 |
| 2018 Junio | 46 | 14 | 60 |
| 2018 Mayo | 22 | 11 | 33 |
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| 2018 Marzo | 42 | 10 | 52 |
| 2018 Febrero | 36 | 13 | 49 |
| 2018 Enero | 60 | 30 | 90 |
| 2017 Diciembre | 40 | 15 | 55 |
| 2017 Noviembre | 8 | 2 | 10 |
| 2017 Octubre | 1 | 0 | 1 |
| 2017 Septiembre | 0 | 1 | 1 |
| 2017 Agosto | 1 | 3 | 4 |
| 2017 Julio | 3 | 2 | 5 |
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