10.4081/btvb.2023.85
Cerebral vein thrombosis (CVT) is a rare type of stroke that can present with a wide range of symptoms and signs, making it challenging to differentiate from other neurological conditions. Therefore, this study aimed to evaluate the clinical characteristics and risk factors of cerebral vein thrombosis patients. This descriptive analysis included 103 CVT patients registered in two centers, one in Saudi Arabia and one in Oman. The study covered all patients who presented to these centers from 2006 to 2020 with a confirmed diagnosis. Out of the 103 CVT patients included in the study, 32% were male, and 68% were female, with a mean age of 39 years. Headache was the commonest presenting symptom, followed by seizures. Identifiable risk factors were observed in most patients, with oral contraceptive pills and pregnancy being the most prevalent risk factors. The transverse sinus was the most commonly involved sinus, followed by the sagittal sinus, while intracerebral bleeding was present in 22% of patients. CVT is an uncommon type of stroke that affects individuals in the middle age group, particularly child-bearing age females. The clinical characteristics of CVT vary, with headache being the most prevalent clinical presentation, and its diagnosis requires a high degree of clinical suspicion.
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Mosaad Almegren
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Bleeding, Thrombosis and Vascular Biology
sinuses.
Clinical and radiological characteristics of cerebral vein thrombosis: a retrospective study
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2023-10-12
2023-05-25
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Bleed Thromb Vascul Biol
Mosaad Almegren
2023/10/12
10.4081/btvb.2023.85
College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh
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sinuses.
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Al Hashmi K, Al Wahaibi K, Al-Khabori M, Al Lamki S. Characteristics and outcomes of patients with cerebral venous sinus thrombosis. Oman Med J 2019;34:434-7.
Clinical and radiological characteristics of cerebral vein thrombosis: a retrospective study
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                                                                                                            ORIGINAL ARTICLE

Clinical and radiological characteristics of cerebral vein thrombosis:
a retrospective study
Mosaad Almegren

College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Kingdom of Saudi Arabia



ABSTRACT
    Cerebral vein thrombosis (CVT) is a rare type of stroke that can present with a wide range of symptoms and signs, making it chal-
lenging to differentiate from other neurological conditions. Therefore, this study aimed to evaluate the clinical characteristics and risk
factors of cerebral vein thrombosis patients. This descriptive analysis included 103 CVT patients registered in two centers, one in Saudi
                                                                          Arabia and one in Oman. The study covered all patients who
                                                                          presented to these centers from 2006 to 2020 with a confirmed
                                                                          diagnosis. Out of the 103 CVT patients included in the study,
  Correspondence: Mosaad Almegren, College of Medicine, Imam              32% were male, and 68% were female, with a mean age of 39
  Mohammad Ibn Saud Islamic University. P.O. Box 7544, Othman             years. Headache was the commonest presenting symptom, fol-
  Bin Affan road, Al Nada, Riyadh, Kingdom of Saudi Arabia.               lowed by seizures. Identifiable risk factors were observed in
  Tel.: +966.112037100.
                                                                          most patients, with oral contraceptive pills and pregnancy being
  E-mail: moalmegren@imamu.edu.sa
                                                                          the most prevalent risk factors. The transverse sinus was the
  Citation: Almegren M. Clinical and radiological characteristics of      most commonly involved sinus, followed by the sagittal sinus,
  cerebral vein thrombosis: a retrospective study. Bleeding, Throm-       while intracerebral bleeding was present in 22% of patients.
  bosis, and Vascular Biology 2023;2:85.                                  CVT is an uncommon type of stroke that affects individuals in
                                                                          the middle age group, particularly child-bearing age females.
  Key words: cerebral vein thrombosis, symptoms, risk factors, si-        The clinical characteristics of CVT vary, with headache being
  nuses.                                                                  the most prevalent clinical presentation, and its diagnosis re-
                                                                          quires a high degree of clinical suspicion.
  Acknowledgment: the author thanks Dr. Bader AlRawahi and Dr.
  Turki AlShuaibi for providing the data and I thank American man-
  uscript editors for the English language editing service.

  Conflict of interest: the author declares no potential conflict of in-    Introduction
  terest.
                                                                                Cerebral vein thrombosis (CVT) occurs due to a decrease
  Funding: none.                                                            in blood flow in the cerebral veins, resulting from partial or
                                                                            complete occlusion of the dural sinuses that drain blood from
  Ethical approval and consent to participate: the study protocol was       the brain. CVT is a relatively rare, potentially fatal neurological
  reviewed and approved by the ethical committee of both partici-           disorder that can be challenging to diagnose because of wide
  pating hospitals.                                                         variability in clinical and radiological presentation.1 CVT is less
                                                                            common than ischemic stroke and intracerebral hemorrhage,
  Availability of data and material: data and materials are available
                                                                            with an estimated incidence range of 3-4 cases/million/year, ac-
  by the authors.
                                                                            counting for less than 1% of all stroke types, and is three times
  Informed consent: the manuscript does not contain any individual          folds increase in females than in males.2 However, a retrospec-
  person’s data in any form.                                                tive Australian study reported a higher incidence rate of 15.5
                                                                            cases per million per year,3 while another retrospective study re-
  Received: 25 May 2023.                                                    ported an even higher rate of 1.32 per 100,000 person-years.4
  Accepted: 22 September 2023.                                                  CVT is a multifactorial disorder with sex-specific causes
                                                                            and varied clinical characteristics. The clinical characteristics
  Publisher’s note: all claims expressed in this article are solely those
                                                                            of CVT are diverse and can manifest in various symptoms, from
  of the authors and do not necessarily represent those of their affili-
  ated organizations, or those of the publisher, the editors and the re-    headache to coma, resembling other disorders, and presenting
  viewers. Any product that may be evaluated in this article or claim       diagnostic challenges.5 Headache is the most common present-
  that may be made by its manufacturer is not guaranteed or endorsed        ing feature in CVT, with other frequently observed symptoms
  by the publisher.                                                         and signs including seizures, impaired level of consciousness,
                                                                            motor/sensory deficits, and vomiting.6
  ©
   Copyright: the Author(s), 2023                                               CVT typically has a favorable prognosis if diagnosed and
  Licensee PAGEPress, Italy                                                 treated promptly, while delayed diagnosis and treatment can re-
  Bleeding, Thrombosis and Vascular Biology 2023; 2:85                      sult in poor outcomes including death or disability.5 However,
  doi:10.4081/btvb.2023.85
                                                                            data on CVT in the Arabian Gulf population are limited. In a
  This work is licensed under a Creative Commons Attribution-               small case series of 26 patients from Saudi Arabia, headache
  NonCommercial 4.0 International License (CC BY-NC 4.0).                   was the most common symptom, and the transverse sinus was
                                                                            the most commonly affected sinus.7 In another study involving


                                              Bleeding, Thrombosis and Vascular Biology 2023; 2:85
30                                                              M. Almegren




the pediatric age group, identifiable risk factors for CVT were         43 patients (41.7%), vomiting in 39 patients (37.8%),
found in 80% of the study population.8 Therefore, we evaluated          sensory/motor deficits in 39 patients (37.8%), impaired level of
the clinical characteristics and risk factors of CVT patients from      consciousness in 32 patients (31%), and visual loss in 23 patients
Saudi Arabia and Oman.                                                  (22.3%). The median time from the onset of symptoms to con-
                                                                        firmed radiological diagnosis was 5 days (range 0-700 days).

Materials and Methods
     We conducted a retrospective cohort analysis of 103 CVT            Table 1. Demographics and risk factors in 103 patients with
patients registered in two centers from Saudi Arabia and Oman           cerebral vein thrombosis.
from January 2006 to December 2020. Patients were included
                                                                         Variable                                                      N (%)
if they were adults aged 18 years or older, and CVT was con-
firmed radiologically using magnetic resonance imaging (MRI),            Mean age                                                    39±13 years
computed tomography (CT), or cerebral angiography. CVT is                Female                                                       70 (68%)
defined as complete or partial occlusion of the dural sinuses or         Chronic disease
veins, or both, by a blood clot that is confirmed radiologically.         Diabetes mellitus                                           17 (16.5)
     Data were collected by reviewing the medical records of in-          Hypertension                                                16 (15.5)
cluded patients. The following were collected: age, gender,               History of VTE                                               10 (9.7)
chronic diseases (diabetes mellitus, hypertension, history of ve-         Coronary artery disease                                      8 (7.8)
nous thromboembolism, malignancy), clinical presentation, risk            Chronic kidney disease                                       8 (7.8)
factors, sinuses involved, time from symptoms onset to con-               COPD                                                          4 (3.9)
firmed diagnosis, and length of hospital stay. Follow-up data            Risk factors
were collected from the time of CVT diagnosis to the last fol-            OCP                                                         26/70 (37)
low-up date, death, or end of the study period (December 2021).           Hormonal replacement therapy                                2/70 (2.8)
Patients who did not attend at least one follow-up visit after hos-         Pregnancy                                                11/70 (15.7)
                                                                            First trimester                                              1/11
pital discharge were excluded.
                                                                            Second trimester                                             3/11
     Clinical data were collected from the patient's medical
                                                                            Third trimester                                              7/11
records and distributed in a pre-designed spreadsheet, which was          Puerperium                                                  8/70 (11.4)
used for further analysis. The median, mean, and standard devi-           Infection                                                    10 (9.7)
ation were calculated, and frequency and proportion were used             Neurosurgery                                                  4 (3.9)
to calculate binary and categorical data variables. All analyses          Head trauma                                                   4 (3.9)
were performed using IBM SPSS Statistics (version 21).                    Cancer                                                        3 (2.9)
     The study protocol was reviewed and approved by the ethi-            Thrombophilia                                                11 (10.6)
cal committee of both participating hospitals.                            Prothrombin gene mutation                                        2
                                                                          Antiphospholipid antibody syndrome                               5
                                                                          Antithrombin III deficiency                                      2
                                                                          Protein C deficiency                                             1
Results                                                                   Protein S deficiency                                             1
                                                                          More than one risk factor                                    16 (15.5)
     We identified 103 CVT patients from 2006 to 2020, of
                                                                          No identifiable risk factor                                  23 (22.3)
whom 33 (32%) were males, and 70 (68%) were females, with
                                                                         VTE, venous thromboembolism; COPD, chronic obstructive pulmonary dis-
a mean age of 39 (±13) years. The median follow-up time was              ease; OCP, oral contraceptive pills.
23 months (0-101 months), and the median length of hospital
stay was 11 days (0-90 days). Diabetes mellitus and hyperten-
sion were found to be the most common chronic diseases (16.5%           Table 2. Radiological features.
and 15.5%, respectively). A history of venous thromboembolism
(VTE), coronary artery disease, chronic renal impairment, and            Radiological feature                                          N (%)
chronic obstructive pulmonary disease were also observed.                CT                                                           47 (45.6)
Table 1 shows the results. Risk factors were identified in most
                                                                         MRI                                                          27 (26.2)
patients (77.6%), with 16 patients carrying more than one risk
factor. Gynecological causes were found to be the main risk fac-         CT and MRI                                                   29 (28.2)
tor for CVT (45.6%), with 47 out of 70 females (67%) being af-           Sinus/vein involved
fected. Oral contraceptive pills (OCP) and hormonal                       Transverse                                                  71 (68.9)
replacement therapy accounted for 28 females (40%), pregnancy             Sagittal                                                     69 (67)
                                                                          Sigmoid                                                     59 (57.3)
for 11 females (15.7%), and puerperium for eight females
                                                                          Straight                                                    19 (18.4)
(11.4%). However, infections, including central nervous system            Deep cerebral veins                                         18 (17.5)
(CNS), head, and neck infections, were the major risk factors in          Cortical veins                                              16 (15.5)
males (18%). Other risk factors, such as thrombophilia, neuro-            Single sinus/vein involvement                               20 (19.4)
surgery, and head trauma, were also observed.                             Multiple sinuses/veins involvement                          83 (80.6)
     Headache was the most frequently observed clinical pres-             Cerebral hemorrhage                                         23 (22.3)
entation, observed in 86 patients (83%), followed by seizures in         CT, computed tomography; MRI, magnetic resonance imaging.



                                         Bleeding, Thrombosis and Vascular Biology 2023; 2:85
                       Clinical and radiological characteristics of cerebral vein thrombosis: a retrospective study                       31



     CT was the primary radiological imaging for CVT diagnosis                Similar to our study, multiple sinus involvement was observed
in 47 patients (45.6%), while MRI was used in 27 patients                in most patients from Saudi Arabia and Oman.7-14 The transverse
(26.2%), with one-third of patients undergoing both CT and MRI           sinus was the most frequently involved, followed by the sagittal
at the time of diagnosis. The transverse sinus was the major sinus       and sigmoid sinuses. In contrast to our study, deep cerebral vein
involved in 71 patients (69%), followed by the sagittal sinus in         thrombosis accounted for 2-9% of the two retrospective stud-
69 patients (67%). Multiple sinus involvement was the main ra-           ies.11,13 A higher rate of cerebral hemorrhage (42%) was observed
diological feature in 83 patients (80.6%), while single sinus in-        in a retrospective study that included 119 patients, while a lower
volvement was documented in 20 patients (19.4%). Deep                    rate of hemorrhage was observed in other studies.8,11-13
cerebral vein involvement was found in 18 patients (17.4%),                   Retrospective type and a relatively small sample size were
cortical vein involvement in 16 patients (15.5%), and cerebral           the limitations of this study. However, it provides valuable in-
bleeding at the time of CVT diagnosis in 23 patients (22.3%)             sight into the clinical presentations, risk factors, and radiological
(Table 2).                                                               features of CVT in Arabian Gulf countries, including Saudi Ara-
                                                                         bia and Oman.

Discussion
                                                                         Conclusions
    This study presented the demographics, clinical presenta-
tions, risk factors, and radiological characteristics of 103 adult           Our study revealed that headache is the major presenting
patients diagnosed with CVT from Saudi Arabia and Oman.                  symptom in patients with CVT. Risk factors are identifiable in
Two-thirds of the study population were females, with a mean             most patients, with obstetric factors being the predominant ones.
age of 39 years (±13). Diabetes mellitus and hypertension were           The transverse sinus is the most frequently involved sinus, and
the patients most commonly observed chronic diseases. OCP                multiple sinus involvement is the most observed pattern of sinus
and pregnancy were the major risk factors in females, while              thrombosis.
CNS and head and neck infections were the major risks in males.
Headache was the main presenting symptom, followed by
seizures and sensory/motor deficits. Multiple sinus involvement          References
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