CEREBRAL VENOUS THROMBOSIS IN PREGNANCY-AN EMERGING CATASTROPHY

1. CEREBRAL VENOUS THROMBOSIS IN PREGNANCY-AN EMERGING CATASTROPHY ?? Dr. SUKANYA .M. K BANGALORE BAPTIST HOSPITAL UNDER GUIDANCE OF DR. PADMAJA HOD, DEPARTMENT OF OBG BANGALORE BAPTIST HOSPITAL

2. REVIEW OF CASES In a 1yr retrospective study in our hospital( Jan2009 – Dec 2009), out of 7 cases of stroke in pregnancy 5 cases of cerebral venous thrombosis were reported i.e 71% of stokes in pregnancy. 2 of the patients were antenatal (40%) and 3 of them were postnatal (60%). 80% of patients presented with seizures , 80%with headache . 80% recovered completely with early diagnosis and rapid management and 20% was the mortality. Here we are presenting a review of these cases.

3. primigravida, 26yrs,17wks Chronic hypertension since 7wks h/o headache,blurring of vision -1 week Fundoscopy-papilledema ECHO- normal MRI- normal MRV – hypoplastic old thrombosed and recanalised left transverse sinus- focal thrombosis Rx – Anticoagulants , referred to NIMHANS for second opinion G3P2L2 ,28yrs,33wks h/o OCP use h/o of headache , blurring of vision – 1day, h/o convulsions (GTCS) >10 episodes with loss of consciousness, h/o weakness of rt side of body with deviation of mouth to left Fundoscopy -normal MRI- recent small infarct of left posterior lobe venous infarct MRV- thrombosis of rt transverse sinus. Had normal vaginal delivery after 2days

4. 3 postnatal cases were reported. Age of the patients ranged 21-27 yr Presented after 13-15 days of delivery All the 3 patients presented with headache, vomiting and seizures. 1 patient was unconscious and was declared brain dead.MRI & MRV showed thrombosis of straight sinus with infarct in the thalamic and basal ganglia region. Other 2 patients had thrombosis of transverse and superior sagittal sinus 2 patients had h/o PIH . 1 patient had h/o post partum hemorrhage . RX – anticoagulants – heparin and later warfarin , anticonvulsants, antihypertensives in 2 cases with PIH .

5. CEREBRAL VENOUS THROMBOSIS RIBES- 1825-Known as cortical venous , cerebral sinus , venous sinus, or dural sinus thrombosis Infrequent condition accounts for 15-20% of stroke in pregnancy Commonest cause of stroke in young women in India 50% related to pregnancy and puerperium 95.5% - CVT INCIDENCE : 1 in 1666-10,000 pregnancies Variable clinical manifestation and mode of onset Reported mortality- 5-30% High suspicion required for diagnosis Early diagnosis and rapid mangement – complete recovery , saves life.

6. PATHOGENESIS Thrombosis of cerebral veins obstruction of venous return– intracranial hypertension Localised cytotoxic cerebral edema, venous infarctions Ischemic neuronal damage , petechiae ?large hematoma

7. CAUSES Endocrinological causes- use of OCP, pregnancy, puerperium, Hematological –APLA, anemia, coagulation disorders, thrombophilias Connective tissue disorder- SLE, IBD Neoplastic – metastasis, glomus tumour Infective – abscess, meningitis,endocarditis Miscellaneous- high altitude, cardiac failure Idiopathic- 25%

8. RISK FACTORS IN PREGNANCY Pregnancy and peurperium- hypercoagulability, venous stasis, endothelial injury. Advanced maternal age Multigravida Use of OCPS-third generation –gestodone,desogestrel (54.3%) Hypertension Cesarean delivery Associated infections Excess vomiting during pregnancy Dehydration and increased blood loss Thrombophilias – (34.1%)

9. Clinical Presentation High index of suspicion is required 1.Headache – 90% of adultS- mimic a subarachnoid haemorrhage rarely 2.Focal presentation Cerebral lesions and neurological signs – 50% Unilateral hemispheric symptoms (ie: hemiparesis or aphasia) (cortical lesions on both sides of the superior sagittal sinus) Seizures – 40% Delirium, amnesia, mutism- (straight sinus and branches) Coma , Death- cerebral herniation 3. Cavernous sinus thrombosis- chemosis, proptosis,ophthalmoplagia . 4.Pseudotumour cerebri headache (can mimick migraine or chronic daily headache), progressive with no other neurological symptoms – exception of diplopia due to involvement of 6th cranial nerve, papilloedemaheadache (can mimick migraine or chronic daily headache), progressive with no other neurological symptoms – exception of diplopia due to involvement of 6th cranial nerve, papilloedema

10. INVESTIGATIONS CT- filling defect in posterior portion of sinus- ‘Empty Delta Sign’, small ventricle, decreased sulcal pattern, hemorrhagic infarct MRI- evolves over time, acute phase- absence of normal venous flow void on T1 &T2 weighted images, thrombus appears isotense or hypotense next 10 days- hyperintense MRV- filling defects in the principal dural sinus MRI + MRV – investigation of choice HELICAL CT VENOGRAPHY CONVENTIONAL ARTERIOGRAPHY LUMBAR PUNCTURE

12. Treatment recommended General: supportive, symptomatic Treatment of underlying cause Anticonvulsants Anticoagulation –HEPARIN is first drug of choice Arrest the thrombotic process and prevent Pulmonary embolus. Tendency of venous infarcts to become hemorrhagic. But anticoagulation is safe , even in the setting of ICH , decreases risk of death and dependency. LMWH for 5-7 days followed by 3months or more of warfarin therapy in presence of risk factors. In pregnancy – heparin till 12 weeks, then warfarin till 34 weeks and heparin till term. Endovascular thrombolysis- Urokinase is used Intracranial hypertension alone – lumabar puncture, oral acetazolamide. Surgical evacuation of clot , decompressive craniectomy Mannitol, surgical evacuation of clot or decompressive craniectomyMannitol, surgical evacuation of clot or decompressive craniectomy

13. Prognostic factors- ISCVT Important prognostic factors for death or dependence Coma (GCS < 9) Cerebral Haemorrhage Malignancy Causes of death- secondary intracranial hemorrhage , transtentorial herniation. Prognosis unpredictable- permanent visual loss, residual epilepsy, disability, coma, death. Good prognosis if treated early . Recurrence – h/o CVST does not preclude subsequent pregnancy

14. Pregnancy related VTE and CVST occurs most frequently during the Puerperium - recommend post partum anticoagulation Mehraein study: Unable to draw conclusion regarding need for prophylactic low dose anticoagulation antepartum Evidence of a very low risk of recurrent VTE for women with previous extracerebral venous thrombotic events if no thrombophila present or if the previous VTE was associated with a temporary RF Risk of recurrence increased if thrombophilia present or prior event was idiopathic Decision for prophylactic anticoagulation may be based on Interval b/w previous CVST and subsequent pregnancy- 80% relapses occur within first 2 yrs. Pregnancy and Risk of recurrence- recommendations 0/44 patients without thrombophilia or idiopathic clot 3/51 with thrombophilia or idiopathic had a clot0/44 patients without thrombophilia or idiopathic clot 3/51 with thrombophilia or idiopathic had a clot

15. BEWARE!!! INJUDICIOUS USE OF OCPS CHANGING LIFE STYLE VAGUE NEUROLOGICAL SYMPTOMS IN PREGNANCY ALL CONVULSIONS NEED NOT BE ECLAMPSIA

16. REFERENCES Cerebral venous thrombosis- Isabelle Crassard; J Neuro-Ophthalmol, Vol 24, No.2 2004 Cerebral venous thrombosis – Brig S Kumarvelu; MJAFI 2008;64 A case of postpartum cerebral venous thrombosis Bette Cole; Journal of Neuroscience Nursing 2006 Stroke in pregnancy and peurperium ; Treadwell & Thanvi; Postgrad Med J 2008 Stroke complicating pregnancy and puerperium; C.-C. Liang & S.-D.Chang ; European Journal of Neurology,2006 Venous thromboembolism , Williams Ostetretics