Management of Dural Venous Sinus Thrombosis in Pregnancy

Management of Dural Venous Sinus Thrombosis in Pregnancy

SHORT REPORT Management of Dural Venous Sinus Thrombosis in Pregnancy M. Shah a, N. Agarwal a, N.B. Gala a, C.J. Prestigiacomo a b a,b , C.D. Gandh...

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SHORT REPORT

Management of Dural Venous Sinus Thrombosis in Pregnancy M. Shah a, N. Agarwal a, N.B. Gala a, C.J. Prestigiacomo a b

a,b

, C.D. Gandhi

a,b,*

Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, USA

Introduction: Dural venous sinus thrombosis (DVST) is a rare but potentially fatal cerebrovascular condition. Pregnant women are at greater risk of DVST because of their hypercoagulable state. Report: A 20-year-old post-partum woman presented to the emergency department after an episode of seizure and complained only of a headache and chest pain. A T1-weighted magnetic resonance (MR) image of her brain with contrast revealed an empty delta sign in her super sagittal sinus. Discussion: Management of dural venous sinus thrombosis during or after pregnancy is a difficult issue that requires an approach based on the individual patient profile. Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 4 February 2014, Accepted 1 May 2014, Keywords: Cerebral, Dural venous sinus thrombosis, Pregnancy, Management

INTRODUCTION Dural venous sinus thrombosis (DVST) is a relatively rare cerebrovascular complication but has the propensity to cause substantial damage, including potentially fatal conditions, such as hemorrhagic stroke. It affects about five people per million and accounts for about 0.5e1% of all strokes.1,2 There are many predisposing factors that may contribute to the development of DVST. These include cancer, hyperhomocysteinemia, iron deficiency anemia, folic acid deficiency, systemic inflammatory diseases, antithrombin III deficiency, C and S protein deficiency, mutation of factor V Leiden, surgery, head trauma, and pregnancy and puerperium.2,3 Pregnant women are at a greater risk because of their hypercoagulable state, which persists several weeks postpartum.4,5 The typical clinical presentations are headaches, seizures, focal neurological deficits, increased intracranial pressure, and possible hemorrhage.1e4 The authors present a clinical case of DVST during pregnancy and describe an effective management strategy.

postoperative period, she also had elevated blood pressure and was discharged on hydrochlorothiazide. On the day of presentation, she was normotensive with a pulse of 108 beats per minute. Physical examination was within normal limits except for bilateral brisk triceps reflexes. A noncontrast computed tomography (CT) scan of her head was normal (Fig. 1). However, a T1-weighted magnetic resonance (MR) image of her brain with contrast revealed an empty delta sign in her superior sagittal sinus (Fig. 2). This is a classic radiologic sign, in which a central hypointensity due to very slow or absent flow within the sinus is surrounded by contrast enhancement in the surrounding triangular shape in the posterior aspect of the superior sagittal sinus. It can be seen as an upside down triangle in the MR image. The central hypointensity represents the clotted blood in the superior sagittal sinus.6 Additional laboratory work to determine the cause of hypercoagulability revealed a deficiency of protein S (50) and vitamin B12 (164). The patient was treated with anticoagulation therapy and did not require further intervention.

REPORT

DISCUSSION

A 20-year-old G5P1041 woman, with a recent Caesarean delivery for a category 2 tracing, presented to the emergency department with a headache and chest pain on postoperative day 11 after one episode of a witnessed, tonic-clonic seizure. Her postoperative course was complicated by endometritis, which was treated with triple antibiotics. She then developed a Clostridium difficile infection and was discharged home on metronidazole. During her

Pregnant women have a greater risk for developing a dural venous sinus thrombosis because of their hypercoagulable state and other alterations in cardiovascular physiology.4,5 Fibrinogen, platelets, and factor levels (VII, VIII, IX, X, and XII) are elevated, and fibrinolytic activity is reduced.4 The changes in maternal cardiovascular physiology during pregnancy include increases in blood volume and cardiac output. Pregnancy-related cerebral venous thrombosis has also been reported in that the risk of peripartum central venous thrombosis increased with increasing maternal age, Cesarean delivery, as well as in the presence of hypertension, infections, and excessive vomiting in pregnancy.6,7 Several other lab tests were done in this patient to determine the cause of hypercoagulability, and it was found that the patient was deficient in protein S and vitamin B12.

DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2014.05.006 * Corresponding author. C.D. Gandhi, New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07101-1709, USA. E-mail address: [email protected] (C.D. Gandhi). 1533-3167/$ e see front matter Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvsextra.2014.05.004

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Figure 1. Normal non-contrast head computed tomography (CT) scan.

M. Shah et al.

These can be low during pregnancy so this should be investigated during the diagnostic process.8 In terms of the treatments for a DVST, the first therapeutic strategy involves administration of anticoagulants such as heparin and warfarin.1e6 It is imperative, however, to use low-molecular-weight heparin over continuous infusion heparin or oral warfarin when treating a pregnant patient. Low-molecular-weight heparin does not cross the placenta and may avoid teratogenic side-effects, which is critical for the well-being of the fetus.2,8 Another important factor to consider with anticoagulation therapy is the potential consequence of intracranial hemorrhaging, especially in pregnant women.4 If the patient is not responding to anticoagulation therapy and is experiencing neurological deficits, the next step involves fibrinolytic drug therapy.2e4 This involves infusing clot-dissolving agents, such as tissue plasminogen activator (tPA), streptokinase (SK) or urokinase (UK), in the dural sinus via a microcatheter. Long-term medical therapy for these patients includes systemic anticoagulation with warfarin for an average of 6 months. Fortunately, the risk of DVST recurrence during subsequent pregnancies is low.4 These strategies must involve taking the necessary precautions because pregnant women are at greater risk for hemorrhaging. Overall, several precautions must be taken, and a multimodal therapeutic strategy tailored to the individual patient is the best plan of action. FUNDING None. CONFLICT OF INTEREST None. REFERENCES

Figure 2. Abnormal T1-weighted magnetic resonance (MR) image of brain with contrast, showing empty delta sign in superior sagittal sinus.

1 Bushnell C, Saposnik G. Evaluation and management of cerebral venous thrombosis. Continuum (Minneap Minn) 2014;20(2 Cerebrovascular Disease):335e51. 2 Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007;6(2):162e70. 3 Guenther G, Arauz A. Cerebral venous thrombosis: a diagnostic and treatment update. Neurologia (Barc Spain) 2011;26(8): 488e98. 4 Cole B, Criddle LM. A case of postpartum cerebral venous thrombosis. J Neurosci Nurs 2006;38(5):350e3. 5 Nazziola E, Elkind MS. Dural sinus thrombosis presenting three months postpartum. Ann Emerg Med 2003;42(4):592e5. 6 Saposnik G, Barinagarrementeria F, Brown Jr RD, Bushnell CD, Cucchiara B, Cushman M, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42(4):1158e92. 7 Treadwell SD, Thanvi B, Robinson TG. Stroke in pregnancy and the puerperium. Postgrad Med J 2008;84(991):238e45. 8 Burneo JG, Elias SB, Barkley GL. Cerebral venous thrombosis due to protein S deficiency in pregnancy. Lancet 2002;359(9309): 892.