Dr. Shuu-Jiun Wang at the 2023 Cedars-Sinai Intracranial Hypotension Conference
Dr. Shuu-Jiun Wang (Professor and Director, Brain Research Center, National Yang-Ming University School; and Director of The Neurological Institute, Taipei Veterans General Hospital) presented this talk titled “Cerebral Venous Thrombosis: Incidence and Management” at the 2023 Cedars-Sinai Intracranial Hypotension Conference on July 8, 2023. The conference was hosted by Cedars-Sinai with generous support from the Spinal CSF Leak Foundation in Kohala Coast, Hawaii.
Transcript
[00:00:12] I’m Dr. Wang . My topic is Cerebral Venous Thrombosis, CVT, the incidence and the management. I come from Taiwan. I’m very happy to give the talk. These are my disclosures. and my outline.
[00:00:28] CVT is a very infrequent condition encountered clinically with an annual instance about three to four cases per one million population. Female has a higher ratio than male. And it is found SIH is one of the risk factor for the development of CVT. The instance of CVT is about 1 to 2%, according to several larger studies published earlier. And in our study, we also found 1.8%. And if you see the female to male, the ratio is about the same because the number is too few, so it cannot be judged just from the the total numbers. And we also found in our study female, according to their ratios, is a little lower than males. There is no statistical significance because of the low number.
[00:01:34] We know the cerebral venous related signs are very important in the diagnostic in patients with SIH, like diffuse pachymeningeal enhancement, venous distention sign of lateral sinus, and also the pituitary hyperemia. Therefore, the putative mechanisms of CVT in patients with SIH might be related. It is known that the reduction of cerebrospinal fluid in the brain will be compensated by the engorgement of the venous system by the Monro-Kellie doctrine. So, the venous volume is increased, and because the flow velocity of the venous system decreased, which might increase the stagnation or coagulation of the venous blood and causing venous thrombosis.
[00:02:45] So who should be suspected to have CVT in patients with SIH? The most frequent symptoms are blurred vision due to intracranial hypertension and pulmonary edema, new focal neurological signs, altered consciousness, and I believe seizures are the most important. In our hospital, we collected eight cases with SIH and CVT.
[00:03:18] We found none of them have blurred vision, but one case with new focal signs, and three cases with seizures. This is our first case published earlier, who has CVT and SIH. This is our first case of 33-year-old female patient with SIH, complicated with CVT, and in her MRI, we found the SAH and we also found the Vein of Trolard, the on the left side with the CVT. The patient presented with a neurological deficit and also a seizure.
[00:04:03] How to diagnose CVT in patients with SIH is very similar to, to diagnose CVT generally. I believe the MR venography and the CT venography are the hallmark for the diagnosis. On the left hand side, you can see this patient with superior sagittal sinus thrombosis. Here and here, and you can see the typical empty delta sign in the patient. On the right hand side, you can see the deep cerebral venous thrombosis, including straight sinus and vein of Galen here. And because of the thrombosis of these vessels, you can see the swelling of bilateral thalamus.
[00:04:52] The three major treatments for SIH complicated with CVT, including epidural blood patching for SIH, anticoagulant therapy due to CVT, and also anti-epileptic drugs for seizure. This is our flowchart for treatment of SIH. When we see a patient with SIH, and we try to do the localization as soon as possible. After that, we do targeted epidural blood patch.
[00:05:24] Sometimes we may need two to three times of epidural blood patch if the first trial does not succeed. This is how we did the directed epidural blood patch by anesthesiologists after we localize the leakage by the MR myelography.
[00:05:51] How about anticoagulant therapy in patients with SIH complicated with CVT? First, there’s no RCT studies in these cases because of the case number is very few. The second thing is we don’t know if it is similar for anticoagulant therapy in these cases and the general CVT cases. There is one study just published three years ago about a randomized controlled trial with the probe design to compare dabigatran the, the new anticoagulant, and the traditional warfarin studies.
[00:06:35] The study design with a screening phase on parenteral heparin followed by either dibigatrin 150 mg two times a day or warfarin based on INR for 24 weeks and another one week for follow up. The study showed that the effectiveness was similar between the two groups. That is, there’s no venous thrombotic events in both groups, and the safety is also very similar with one major reading in one case in the dibigatrin group and two cases in warfarin group.
[00:07:17] What is provoked CVT? You have to find out the risk factors. And in fact, I found that lumbar puncture is also one of the risk factors for CVT, which can be considered to interpolate to our condition, the SIH. Based on the AHA and ASA guidelines. CVT may be considered as a provoked CVT, the anticoagulation, the treatment duration is suggested to be three to six months. You can see on the right hand side, “treat underlying cause.” In our situation, this will be the SIH, which is solved by epidural blood patch. And it is suggest to do the three to six months treatments with anticoagulation for provoked CVT.
[00:08:13] In such cases will be the SIH. How about the seizure treatments? Do we need prophylaxis? The data are very limited in the prophylaxis of anti seizure medications in patients with CVT. A multi center prospective observational study: with CVT, they found in patients with supratentorial lesions and also presenting with seizures in patients with CVT, the odds ratio is very low and statistically significant.
[00:08:51] So we can use this study results to consider to use anti-epileptic drugs to prevent early seizures in patients with CVT. For those with supertentorial lesions and those who presents with seizures with CVT. So what is the duration of anti-epileptic treatments? There is no evidence to provide any guidelines.
[00:09:20] But a study showed AED needs to be used for one year when the seizures are associated with brain abnormalities, including brain edema, infarction, or hemorrhage. What’s the prognosis of the patient with CVT? Most patients have very good prognosis. In this case, you can see that even though they use anticoagulants and epidural blood patch, anticoagulation alone, epidural blood patch alone.
[00:09:50] You can see there’s no any differences. We only see one case mortality that’s only use anticoagulations. So in my opinion, probably this is the best, anticoagulation and epidural blood patch at the same time. In our eight cases with SIH and CVT, the prognosis is very good. They receive one to three times of EBP and they showed recanalization in all of them. Four of them received warfarin treatments and two patients received anti-epileptic treatments.
[00:10:33] This is my last slide. CVT is a real complication for SIH. About one to two percent, there’s no sex predominance. MR venography is very important in the diagnosis with CVT. Patients may present with seizure and new neurological symptoms.
[00:10:53] The treatment includes EBP, the best with the directed EBP or targeted EBP. The second one is anticoagulant therapy. You can use Warfarin or NOAC. The effectiveness and safety are similar and can be used for three to six months. Because I consider SIH is also the prevalent cause for CVT, anti-epileptic treatments is suggested to use in patients with supratentorial lesions and presenting seizures. Most importantly, the prognosis is very good. We still need data to have a conclusion to treat these patients. I have to acknowledge my clinical and research group in the research and clinical service for SIH. This concludes my talk, and thank you for your attention.