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VIEWS & REVIEWS: Walter M. van den Bergh, Irene van der Schaaf, and Jan van Gijn The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis Neurology 2005; 65: 192-196 [Abstract] [Full text] [PDF]

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The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis

Zeyad Morcos   (15 November 2005)

Reply to Morcos

Walter M van den Bergh, MD, Irene van der Schaaf, and Jan van Gijn   (15 November 2005)

The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis 15 November 2005
Zeyad Morcos, SF Francis Medical Center 705 Orleans Drive, Granad island, NE 68803 Send Correspondence to journal: Re: The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis zmorcos{at}sfmc-gi.org Zeyad Morcos	Van den Bergh et al [1] illustrated important features related to Cerebral Venous Thrombosis (CVT) and specifically Deep Cerebral Venous Thrombosis (DCVT). Their four cases occured in women. CVT is more common in women, and DCVT has a female to male ratio of 8.3:1. All women were taking oral contraceptives (OCP). It has been shown that OCP, even at low doses, increases the risk of CVT. In the presence of congenital thrombophilia, this risk is 100 times higher. [1] Diagnosis is difficult in DCVT because there are many clinical and radiological presentations. DCVT should be considered in a patient presenting with: headache, altered mental status, neurological symptoms not easily localized to an arterial supply, and imaging abnormalities seen bilaterally in thalamus and basal ganglia. These areas are well perfused via small branches from both anterior and posterior circulations, so an arterial stroke is not the culprit. [3,4,5]. References 1. Van den Bergh WM, Van der Schaaf I, and Van Gijn J. The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis Neurology 2005 65: 192-196. 2. Bousser M, Kittner S. Oral contraceptive and Stroke. Cephalegia 2000;20:183-189. 3. Baumgartner R, Landis T. Venous Thalamic Infarction. Cerebrovasc. Dis. 1992;2:353-358. 4. Ur Rahman N, Al Tahan A. Computed tomographic evidence of an extensive thrombosis and infarction of the deep venous system. Stroke 1993;24:744-746. 5. Zeyad Morcos, Sophia Sundararajan, Contributor, Cerebral Venous Thrombosis, In Critical Care Neurology and Neurosurgery Page 379- 393. Editor Jose I. Suarez. The Humana Press, Totowa, NJ. January 2004. Disclosure: The author reports no conflicts of interest.
Reply to Morcos 15 November 2005
Walter M van den Bergh, MD, UMC Utrecht Department of Neurology Room G03.228 PO BOX 85500 3508 GA Utrecht The Netherlands, Irene van der Schaaf, and Jan van Gijn Send Correspondence to journal: Re: Reply to Morcos w.m.vandenbergh{at}umcutrecht.nl Walter M van den Bergh, MD, et al.	We thank Dr. Morcos for his interest in our article. We agree that DCVT is a diagnostic challenge, especially in the case of partial thrombosis or sufficient collaterals.[1] The recommendations made by Dr. Morcos are appropriate - to consider DCVT in case of headache, altered mental status, neurological symptoms not easily localized to an arterial supply accompanied by thalamus and basal ganglia abnormalities, especially if bilateral. It is unclear whether known risk factors for CVT in general can be directly applied to DCVT, but it seems to be more common in women. However, it is difficult to establish the role of OAC usage as an additional risk factor since its use is extremely common among women in the reproductive age. [6-8] The change in the sex ratio of cases of sinus thrombosis over time provides indirect evidence. Until the mid-1970s, men and women were affected in equal proportions. More recently, there has been a significant female predominance among young adults with sinus thrombosis (70 to 80 percent of cases are in women of childbearing age) but not among children or elderly persons.[9] This might be caused by the increased use of OAC, in particular third-generation contraceptives that contain gestodene or desogestrel.[8] References 6. Martinelli I, Sacchi E, Landi G, Taioli E, Duca F, Mannucci PM. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med 1998;338:1793- 1797 7. de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in carriers of hereditary prothrombotic conditions. BMJ 1998;316:589-592. 8. de Bruijn SF, Stam J, Vandenbroucke JP. Increased risk of cerebral venous sinus thrombosis with third-generation oral contraceptives. Lancet 1998;351:1404-1404. 9. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005 28;352:1791-8. Disclosure: The authors report no conflicts of interest.