Search Results (43)

Background and clinical significance: Tranexamic acid (TXA) is commonly used for menorrhagia. Common side effects include diarrhoea, nausea, and vomiting. However, more serious and rare side effects, including embolism, thrombosis, and seizures, are less commonly considered. Case presentation: We report the case of a 39-year-old woman of Asian origin who presented after a first-time seizure while driving, following starting tranexamic acid for menorrhagia seven days prior. She complained of a headache, nausea, neck stiffness, floaters, and blurred vision. Her lactate was elevated on presentation. On examination there were no neurologic abnormalities. A computed tomography (CT) head scan showed acute haemorrhagic foci along the left temporal lobe. This prompted a CT venography, which showed filling defects in the left transverse and sigmoid sinuses, in keeping with cerebral venous sinus thrombosis. MRI of the head further showed a blooming artefact, indicating secondary thrombosis of the lateral tentorial sinus on the left side extending into the vein of Labbe. Following the diagnosis of cerebral venous sinus thrombosis, the patient was started on regular levetiracetam as well as a therapeutic dose of low molecular weight heparin. Since the initial episode, she has been seizure-free for over three months now. Conclusions: This case highlights the importance of considering less common side effects of tranexamic acid in patients who are taking TXA and are presenting with first-time seizures and headaches. These patients should be monitored for embolic-related intracranial events. A careful diagnostic approach, including cerebrovascular imaging, is essential for an accurate diagnosis and effective treatment. Full article

Background: Fulminant idiopathic intracranial hypertension (IIH) is a rare and vision-threatening variant of IIH, characterized by rapid visual deterioration and a high risk of irreversible blindness. Urgent intervention is required to prevent permanent optic nerve damage. Cerebral transverse venous stenting (CTVS) has emerged as an effective treatment for medically refractory IIH, but data on its use in fulminant cases remain limited. Methods: A retrospective consecutive cohort study was conducted at a tertiary center and included all patients with fulminant IIH diagnosed by modified Dandy criteria, with bilateral transverse sinus stenosis > 50% and a trans-stenotic pressure gradient ≥ 8 mmHg on venography. Before stenting, patients received high-dose acetazolamide (up to 3000 mg/day) and IV methylprednisolone (1000 mg/day × 3). Neuro-ophthalmic assessment included BCVA, Ishihara color vision, pupillary exam, disc edema grading, Humphrey visual fields, and optical coherence tomography (OCT). Follow-up occurred at baseline (admission), 1 week, 1 month, 3 months, and 12 months. Results: Five young female patients underwent successful CTVS without peri- or post-procedural complications. Significant improvement in headache and stabilization or recovery of visual function were observed in all patients. OCT revealed early retinal nerve fiber layer thinning within one week, preceding clinical resolution of papilledema. Conclusions: Emergent CTVS appears to be a safe and effective vision-preserving procedure in fulminant IIH, offering rapid intracranial pressure reduction and early neuro-ophthalmologic improvement. OCT may serve as a useful early predictor of treatment success, supporting its role in post-procedural monitoring. Larger prospective studies are warranted. Full article

The internal jugular vein (IJV) is of utmost importance during various surgical and endovascular approaches, including central access. It descends through the parapharyngeal space, carotid triangle, and sternocleidomastoid region. The anatomical variables of the IJV are mainly related to its calibre and dominance, number of venous channels (i.e., duplications and fenestrations), and compression sites. Specific compressions of the IJV are not exclusively due to the jugular nutcracker between the styloid process (SP) of the temporal bone and the C1 transverse process, which, in turn, should not be granted the eponym of Eagle. The possible morphologies of the SP and ossified stylohyoid chain are discussed here. Additionally, the digastric and sternocleidomastoid muscles, the hyoid, and the distorted carotid arteries may compress the IJV, thereby raising intracranial pressure. Here, a case is documented with a long inferior petrosal sinus adjacent to the IJV, both compressed into the C1–styloid nutcracker, which is an absolute novelty. Multiple compression sites of the IJV are supported here with original evidence. All anatomical variables of the IJV are relevant, as they may lead to stenoses or interfere with IJV cannulation. In rare cases of IJV agenesis, multiple compression sites on the opposite side may significantly alter bilateral cerebral drainage. Different methods may be used to decompress a stenotic IJV, including styloidectomy. In conclusion, the anatomical variables of the IJV should be acknowledged by practitioners and documented on a case-by-case basis. Full article

Background: Venous sinus stenting is a promising treatment for intracranial venous disorders, such as idiopathic intracranial hypertension and pulsatile tinnitus, associated with transverse sinus stenosis. The VIVA Stent System (VSS) is a novel self-expanding braided venous stent designed to navigate tortuous cerebral venous anatomy. This preclinical study assessed the safety, thrombogenicity, and performance of the VSS in a swine model. Methods: Fifteen swine underwent bilateral internal mammary vein stenting with either the VSS (n = 9) or the PRECISE^® PRO RX stent (n = 6, reference). Fluoroscopy and thrombogenicity assessments were conducted on the day of stenting, clinical pathology analysis was carried out throughout the in-life phase, and CT Venography was performed before sacrifice. Animals were sacrificed at 30 ± 3 or 180 ± 11 days post-stenting for necropsy and histological evaluation. Results: Fluoroscopic angiography confirmed the successful VSS deployment with complete venous wall apposition and no vessel damage. The VSS achieved the highest scores on a four-point Likert scale for most performance parameters. No thrombus formation was observed on either delivery system. CT Venography confirmed vessel patency, no stent migration, and complete stent integrity. Histopathology showed a mild, expected foreign body reaction at 30 days, which resolved by 180 days, indicating normal healing progression. Both stents showed increased luminal diameter and decreased wall thickness at 180 days, suggesting vessel recovery. No adverse reactions were observed in non-target organs. Conclusions: The VSS exhibited favorable safety, procedural performance, and thromboresistance in a swine model, supporting its potential clinical use for treating transverse sinus stenosis and related conditions. Full article

Background and Clinical Significance: Herein, we describe the clinical case of a 17-year-old patient with psychotic disorder secondary to cerebral venous thrombosis due to primary thrombophilia, which was related to protein S deficiency and a heterozygous MTHFR gene mutation with the p.Ala222Val variant. Case presentation: A 17-year-old female, with no history of previous illnesses, was admitted to the emergency service department due to a psychotic break. Psychiatric evaluation detected disorganized thought, euphoria, ideas that were fleeting and loosely associated, psychomotor excitement, and deviant judgment. On the fifth day, an inflammatory process in the parotid gland was detected, pointing out a probable viral meningoencephalitis, prompting antiviral and antimicrobial treatment. One week after antiviral and steroidal anti-inflammatory treatments, the symptoms’ improvement was minimal, which led to further neurological workup. MRI venography revealed a filling defect in the transverse sinus, consistent with cerebral venous thrombosis. Consequently, anticoagulation treatment with enoxaparin was initiated. The patient’s behavior improved, revealing that the encephalopathic symptoms were secondary to thrombosis of the venous sinus. Hematological studies indicated the cause of the venous sinus thrombosis was a primary thrombophilia caused by a heterozygous MTHFR mutation variant p.Ala222Val and a 35% decrease in plasmatic protein S. Conclusions: This case highlights the possible relationship between psychiatric and thrombotic disorders, suggesting that both the MTHFR mutation and protein S deficiency could lead to psychotic disorders. Early detection of thrombotic risk factors in early-onset psychiatric disorders is essential for the comprehensive management of patients. Full article

Background and Clinical Significance: The occurrence of cerebral venous sinus thrombosis (CVST), both with or without thrombocytopenia, following COVID-19 vaccination, is well documented and more common in recipients of vector vaccines. Cases of CVST following immunization with the COVID-19 messenger RNA (mRNA) vaccine are rare; most of these cases occur within 28 days of the first dose of the vaccine. Case Presentation: We present the case of a 38-year-old male with a history of two episodes of deep vein thrombosis in the lower limbs, but without a specific thrombophilic condition, who developed CVST 13 days after the second dose of the Pfizer/BioNTech BNT162b2 vaccine. He suffered from diffuse tension-type headache of progressively increasing intensity, and his objective neurological findings were normal. Magnetic resonance venography showed thrombosis of the transverse and right sigmoid sinuses, and magnetic resonance imaging (MRI) of the brain revealed no cerebral infarction. Two months later, a follow-up MR venography showed partial recanalization of the affected sinuses, and a brain MRI showed no infarction. Conclusions: Given the temporal sequence and the absence of other possible causes, we speculate that the second dose of the COVID-19 BNT162b2 vaccine may have triggered the development of CVST. Full article

Background/Objectives: The effect of rapid maxillary expansion (RME) on the nasal and pharyngeal airways in children remains uncertain. This retrospective study utilized computational fluid dynamics (CFD) to assess the changes in ventilation parameters caused by RME in children. Methods: Pre- and post-RME cone beam computed tomography (CBCT) images of 20 patients (4 males, mean age 13 ± 2 years) treated with RME for maxillary transverse insufficiency were evaluated. The RME treatment was conducted using two distinct techniques: tooth-borne and tooth-bone-borne. CFD simulations were used to investigate the airflow conditions (pressure and velocity) in the whole upper airway, nasal airway, and maxillary sinus. Morphological alterations and variations in ventilation parameters before and after RME treatment were statistically compared. The extent of changes in the morphological and ventilatory characteristics of the upper airway, depending on the type of RME, was assessed. Additionally, changes in the ventilation conditions of the upper airway, nasal airway, and maxillary sinus after RME treatment were statistically analyzed. Statistical analyses using IBM SPSS v22 (New York, USA) software included paired t-tests, Mann–Whitney U tests, Wilcoxon matched-pairs signed-rank tests, intraclass correlation coefficients, and coefficients of variation (p < 0.05). Results: The CFD study revealed a notable reduction in both air flow velocity and pressure after the RME treatment (p < 0.05). A statistically significant increase was seen in the parameters used to assess the morphological changes following RME treatment, including nasal width, anterior and posterior nasal cross-sectional area, intermaxillary and intermandibulary molar width, and oropharyngeal airway width (p < 0.05). Regarding the change in airway ventilation, there was no statistically significant difference between tooth-borne and tooth-bone-borne RME treatments (p > 0.05). Conclusions: RME not only treats orthodontic issues in childhood but also increases airflow, which enhances ventilation. CDF is an effective method for the detection of ventilation improvement. Full article

Background: Acute and chronic sinusitis significantly impact patients’ quality of life. Effective drug delivery to paranasal sinuses is crucial for treating these conditions. However, medications from conventional devices like nasal drops, sprays, and nebulized mists often fail to penetrate the small ostia and reach the sinuses. This study aims to assess the effectiveness of e-vape-generated aerosols entering and filling paranasal sinus cavities, particularly the maxillary sinus. Methods: The aerosol droplets were generated using an electronic vaporizer (e-vape) and were composed solely of vegetable glycerin (VG) and propylene glycol (PG). Patient-specific, transparent nose-sinus models, including one with post-uncinectomy surgery, were used to evaluate the effectiveness of these e-vape-generated VG-PG aerosols in entering the sinuses under unidirectional and bidirectional airflow conditions. Visualizations from various nasal model views and lighting conditions were recorded. Particle size distribution measurements of the e-vape aerosol were conducted using a laser diffraction particle size analyzer. Results: E-vape-generated VG-PG droplets effectively enter paranasal sinuses under specific administration conditions. E-vape aerosol droplet size measurements revealed a mean particle size ranging from 2.895 to 3.359 μm, with a median particle size (D50) averaging 2.963 μm. The speed of aerosol entering the paranasal sinuses is directly proportional to the ostia size; larger ostia result in faster sinus entry. A continuous moderate flow is necessary to gradually fill the paranasal sinus cavities. The aerosol entry into sinuses was observed at 2 L/min and decreased with increasing flow rate. The mechanisms of aerosol entry involve maintaining a positive pressure gradient across the ostial canal, a non-equilibrium transverse pressure distribution, and a two-way flow through the ostium. Gravitational forces and recirculation currents further enhance the deposition of e-vape aerosols. Comparative tests showed that traditional delivery devices exhibited limited penetration into paranasal sinuses. Conclusions: This study demonstrated that e-vape-generated aerosols could serve as a vehicle for delivering active pharmaceutical ingredients (APIs) directly to the paranasal sinuses, improving treatment outcomes. Full article

Cerebral venous thrombosis (CVT) is a rare and potentially critical cerebrovascular disease involving intracranial dural sinuses and veins. The diagnosis is a stepwise pathway starting from clinical suspicion and employing several neuroradiological techniques, mainly Computed Tomography (CT)-based and Magnetic Resonance Imaging (MRI)-based modalities. The neuroradiological findings, both in the diagnostic phase and in the follow-up phase, may provide some results at risk for misdiagnosis. Non-thrombotic filling defects of intracranial dural sinuses are among them, and the potential sources are artefactual and or anatomical (venous septa and arachnoid granulations). The misdiagnosis of these findings as CVT is potentially linked to dangerous consequences. A potential strategy to avoid this is to increase the knowledge about technical and anatomical reasons for non-thrombotic filling defects of intracranial dural sinuses and their imaging features. The main aim of this review is to address these issues, including the variability of the intracranial venous pathways, providing the solutions for overcoming the above-cited potential misdiagnosis of non-thrombotic filling defects as CVT. Full article

Objective: Patients with chronic idiopathic intracranial hypertension (IIH) commonly experience a high level of disability and low satisfaction with medical treatment. We aim to evaluate long-term functional improvement and patient satisfaction in IIH patients with similar symptoms by comparing venous sinus stenting (VSS) to standard medical therapy. Methods: We conducted a cross-sectional questionnaire study of 111 IIH patients, comparing 37 adult female patients who underwent venous sinus stenting with 74 patients treated medically. Propensity score matching was used to balance age and presence of papilledema at presentation between groups. Headache-related disability was evaluated using the Migraine Disability Assessment Scale (MIDAS), while general function and treatment satisfaction were assessed using custom questionnaires. Electronic medical records and the results of imaging upon diagnosis were reviewed retrospectively. Results: The stented group reported significantly better outcomes in physical well-being (median 4.0 vs. 1.0, p < 0.001), task completion (4.0 vs. 1.0, p < 0.001), work/school persistence (5.0 vs. 1.0, p < 0.001), and mental well-being (4.0 vs. 1.0, p < 0.001). Additionally, the stented group had a lower proportion of patients with severe MIDAS (MIDAS > 4, 24.3% vs. 47.9%, p = 0.017). Logistic regression suggested venous stenting as a protective factor against severe MIDAS scores (OR = 0.174, p = 0.004). Conclusion: Cerebral venous stenting in patients with IIH is associated with lower disability and higher patient satisfaction from medical treatment compared to those treated with medications only. These findings suggest that venous sinus stenting may be a valuable treatment option for selected IIH patients. However, larger prospective studies are needed to further validate our results. Full article

Background and Purpose: The cerebral circulation is highly regulated to maintain brain perfusion, keeping an equilibrium between the brain tissue, cerebrospinal fluid (CSF) and blood of the arterial and venous systems. Cerebral venous drainage abnormalities have been implicated in multiple cerebrovascular diseases. The purpose of this study is to evaluate the relationship between the arterial inflow (AI) and the cerebral venous outflow (CVO) and their correlation with the cardiac outflow in healthy adults and children to understand the role of the emissary veins in normal venous drainage. Materials and Methods: A total of 31 healthy volunteers (24 adults (39.5 ± 16.0) and seven children (3.4 ± 2.2)) underwent intracranial 4D flow with full circle of Willis coverage and 2D PC-MRI at the level of the transverse sinus for measurement of the AI and CVO, respectively. The AI was calculated as the sum of the flow values in the bilateral internal carotid and basilar arteries. The CVO was calculated as the sum of the flow values in the bilateral transverse sinuses. The cardiac outflow was measured via 2D PC-MRI with retrospective ECG gating with images acquired at the proximal ascending aorta (AAo) and descending (DAo) aorta. The ratios of the AI/AAo flow and CVO/AI were calculated to characterize the fraction of cerebral arterial inflow in relation to cardiac outflow and venous blood draining through the transverse sinuses, respectively. Results: The AI and CVO were significantly correlated (r = 0.81, p < 0.001). The CVO constituted approximately 60–70% of the AI. The CVO/AI ratio was significantly lower in children versus adults (p = 0.025). In adults, the negative correlation of the AI with age remained strong (r = −0.81, p < 0.001). However, the CVO was not significantly associated with age. Conclusion: The CVO/AI ratio suggests an important role of the emissary veins, accounting for approximately 30–40% of venous drainage. The lower CVO/AI ratio in children, although partially related to decreased AI with age, suggests a greater role of the emissary veins in childhood, which strongly decreases with age. Full article

Background: Lemierre syndrome is a rare and life-threatening disease. It is characterized by septic thrombophlebitis of the internal jugular vein, historically associated with Fusobacterium necrophorum infection. However, atypical cases and associations with other organisms have been reported. Methods: Here, we describe a challenging case of Lemierre syndrome in a 71-year-old woman caused by Streptococcus constellatus and review the related literature. Case: The patient experienced multiple hospital admissions due to misdiagnoses and developed thrombosis involving the internal jugular vein and transverse sinus bilaterally, pulmonary complications including the formation of a pseudoaneurysm, and occipital abscess. She presented with headaches, neck pain, and blindness. Prolonged antibiotic therapy was administered, leading to gradual improvement of symptoms, with partial resolution of blindness. Prophylaxis with intramuscular penicillin was prescribed at discharge. Conclusions: Our case underscores the importance of considering Lemierre syndrome in patients who present with multiple thrombotic events affecting the intracranial circulation and/or jugular veins, particularly in those already receiving anticoagulation therapy or with no identifiable cause for thrombosis, even in the absence of sore throat or fever. Full article

Background/Objectives: Endovascular embolization is an effective treatment option for cerebral arteriovenous malformation (AVM) and dural arteriovenous fistulas (DAVFs). The objective of this study was to assess the safety and efficacy of Menox^TM in patients with cranial dural arteriovenous fistulas. Methods: From January 2021 to January 2023, 19 patients with intracranial DAVFs underwent embolization procedures. All patients were treated by embolization with Menox^TM or/and in combination with other embolization products such as Onyx (Covidien, Irvine, California), PHIL (MicroVention, Tustin, California), and Squid (Balt Extrusion, Montmorency, France). Treatment approaches were selected depending on the anatomical location of the fistula. Patients were monitored and followed-up for 12 months. Results: The patients’ mean age was 56.26 ± 16.49 years. Of these 19 patients, 58% (n = 11) were treated with the Menox^TM liquid embolizing agent (LEA) alone or in combination with different LEAs, while n = 7 were treated with other LEAs and 1 patient was treated solely with coils. Complete occlusion of DAVFs with Menox^TM and other agents was evident in 68.4% (n = 13/19) of patients. Complete occlusion (100%) was observed in the sinus rectus, transverse sinus, and diploic veins of the orbital roof, while complete occlusion was observed in 50% of falcotentorial patients and 60% of superior sagittal sinus patients. The lowest rate of complete fistula obliteration was observed in the dural carotid cavernous fistula (CCF) group (25%). An intra-procedural adverse event occurred in one patient. No other post-procedural adverse events were noted. Furthermore, in patients treated with Menox^TM, total occlusion was achieved in 72.7% (n = 8) of patients, whereas the non-Menox^TM group had 62.5% (n = 5) of patients with 100% occlusion and 37.5% (n = 3) of patients with subtotal occlusion. Conclusions: Outcomes using Menox^TM alone and in combination with other agents were effective, and it is safe for the treatment of dural arteriovenous fistulas. Full article

Venous hemangiomas within the central nervous system (CNS) represent a rare pathological entity described by sporadic case reports so far. Comprehensive insights into their histological and imaging features, pathogenesis, natural course, and therapeutic modalities are lacking. This review article presents two patients with contrast-enhancing cerebellar lesions near the tentorium cerebelli lacking edema or diffusion restriction. Despite meticulous preoperative neuroradiological examination, diagnostic classification remained inconclusive. Confronted with both—progressive size and diagnostic uncertainty—surgical intervention was undertaken, resulting in uneventful and complete resection of the lesions. Histopathological analyses subsequently revealed a venous hemangioma in each case. In the literature, the term “hemangioma” is often misapplied and inaccurately used to describe a broad spectrum of vascular anomalies. Therefore, a precise identification is essential since the particular type of vascular anomaly affects its natural course and the treatment options available. We aim to contribute to the understanding of this diagnostically intricate entity by presenting the two cases and by providing a detailed overview of radiological and histopathological features of venous hemangiomas. Full article

Background: Alterations in the cerebral venous system have been increasingly recognized as a significant component of the pathophysiology of multiple sclerosis (MS). This study aimed to explore the relationship between venous sinus diameter and MS to understand potential vascular alterations in MS patients compared with controls. We sought to determine whether these alterations were correlated with disease characteristics such as duration, lesion type, and disability score. Methods: This study included 79 MS patients diagnosed according to the 2017 McDonald criteria and 67 healthy individuals. Magnetic resonance imaging (MRI) scans via a 1.5 Tesla system provided measurements of the superior sagittal sinus, right and left transverse sinus, sinus rectus, and venous structures. Statistical analysis was conducted via SPSS, employing independent sample t tests, ANOVA, chi-square tests, and Pearson correlation analysis, with the significance level set at p < 0.05. Results: This study revealed significant differences in venous sinus diameter between MS patients and controls, with MS patients exhibiting larger diameters. Specifically, patients with brainstem and spinal lesions had larger diameters in certain sinus regions. No significant correlations were found between venous sinus diameter and demographic factors, expanded disability status scale scores, or lesion counts. However, a significant increase in perivenular lesions was noted in patients with longer disease durations. Conclusions: The findings indicate notable vascular alterations in MS patients, particularly in venous sinus diameters, suggesting a potential vascular component in MS pathology. The lack of correlation with conventional clinical and MRI metrics highlights the complexity of MS pathology. These insights underscore the need for further research, particularly longitudinal studies, to elucidate the role of venous changes in MS progression and their potential as therapeutic targets. Full article