Study of predisposing factors responsible for CVST in Indian population

Transcription

1 Original article: Study of predisposing factors responsible for CVST in Indian population 1 Dr Jagadish B Wable, 2 Dr Piyush Ostwal, 3 Dr Govind S. Shiddapur, 4 Dr Satish Nirhale 1 Resident, Department of Medicine, Dr D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune 2 Assistant Professor, Department of Neurology, Dr D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune 3 Professor, Department of Medicine, Dr D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune 4 Professor, Department of Neurology, Dr D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune Corresponding author : Dr Satish Nirhale Abstract: Introduction: The incidence of CVST is unknown and is reported to be more common in developing countries. 4 There are four main clinical patterns of CVST: (1) Focal deficits associated with headache, seizures, or altered consciousness. (2) Isolated intracranial hypertension with headache, nausea, vomiting, papilloedema, transient visual obscuration, and eventually sixth nerve palsy. Methodology: The study was carried out at a Padmashree Dr.D.Y.Patil Medical College Pimpri Pune. The study spanned over a period from June 2009 to September A total of 62 cases of CVST confirmed by radio imaging were included in the study. All patients admitted to the hospital with a CT scan /MRI/MRV finding diagnostic of CVST were included in the study. Those with confirm diagnosis of CVST were taken up for analysis. Results: In the present study pregnancy and puerperium resulted in 34.87% (95% CI ) of cases followed by secondary factors and id iopathic factors 20.96% (95% CI ). In our study we found that the commonest etiological factor for thrombosis was pregnancy and puerperium (table 20) which accounted for 33.87% of cases. Conclusion: Genetic or acquired prothrombotic factors (such as deficiencies in anticoagulation- promoting proteins, usage of oral contraceptives, pregnancy, and/or malignancy) are the main causes in the western world, while infection remains the most common underlying cause in developing countries. Introduction: The incidence of CVST is unknown and is reported to be more common in developing countries. 1 There are four main clinical patterns of CVST: (1) Focal deficits associated with headache, seizures, or altered consciousness. Isolated intracranial hypertension with headache, nausea, vomiting, papilloedema, transient visual obscuration, and eventually sixth nerve palsy.sub acute diffuse encephalopathy, characterized by a decreased level of consciousness and sometimes seizures without clearly localizing signs or recognizable features of intracranial hemorrhage (ICH). Painful ophthalmoplegia caused by lesions of the third, fourth, or sixth cranial nerves, chemosis, and proptosis. 2 Methodology: The study was carried out at a Padmashree Dr.D.Y.Patil Medical College Pimpri Pune. The study spanned over a period from June 2009 to September A total of 62 cases of CVST confirmed by radio imaging were included in the study. 410

2 All patients admitted to the hospital with a CT scan /MRI/MRV finding diagnostic of CVST were included in the study. Those with confirm diagnosis of CVST were taken up for analysis. Exclusion criteria: All patients less than 18 yrs of age. Patients of stroke due to arterial cause. A detailed history from patient and relatives was obtained. Detailed clinical examination was recorded in each case as per proforma. All patient were subjected to CT scan and MRI/MRV as per feasibility to confirm diagnosis and localization of CVST. Observations: TABLE 1.CLINICAL CONSTELLATION OF FINDINGS OF TOTAL CASES STUDIED (n=62) CLINICAL CONSTELLATION ISOLATED INTRACRANIAL HYPERTENSION(ICT) NO OF CASES PERCENTAGE % 5% Conf Interval AL CEREBRAL SIGNS(FCS) SUBACUTE ENCEPHALOPATHY(S E) CAVERNOUS SINUS THROMBOSIS(CST) PSYCHOSIS I VISION LOSS I ln the present study isolated intracranial hypertension was the most common clinical syndrome % (95% CI ) followed by focal cerebral signs %( 95% CI ) TABLE 2. PREDISPOSING FACTORS (n=62) FACTORS REGNANCY AND NO OF PERCENTAGE% CASES Interval % Conf PUERPERIUM 2) SECONDARY TBM CSOM INFECTION OF FACE MALARIA

3 ENTERIC FEVER SEPSIS OCP DEHYDRATION TRAUMA HYPER-HOMOCYSTEINE* APLA* DIABETIC KETOSIS DIC NEPHROTIC SYNDROME ) IDIOPATIDC APLA, SERUM HOMOCYSTEINE, PROTEIN C, S, FACTOR V LEIDEN, ANTITHROMBIN III WAS DONE IN 17 CASES ONLY. Discussion: In the present study pregnancy and puerperium resulted in 34.87% (95% CI ) of cases followed by secondary factors and id iopathic factors 20.96% (95% CI ). In our study we found that the commonest etiological factor for thrombosis was pregnancy and puerperium (table 20) which accounted for 33.87% of cases. The risk of thrombosis increase in pregnancy and puerperium due to hypercoagulable state (as a result of increase in fibrinogen level, platelet count and platelet adhesiveness), venous stasis. (due to loss of venous tone) and other factors(pelvis infection, anemia, septicemia of pregnancy, dehydration) Nagaraj et ai2.in his study in 1987 reported that this group was responsible for 81% of cases while Wadia et ai found pregnancy and puerperium responsible for 30% of cases.3 The portion of this group, which was very high initially, has been dropping down with availability of better imaging facilities and knowledge of newer factors responsible for thrombosis. Second largest group was secondary group. Third largest group was idiopathic group (20%).Even after subjecting these patients to coagulation studies; a cause could not be ascertained. It is same as Wadia et ai2 2 that the etiological factor could not be ascertained in 28% cases in his study. The portion of this group which was high as 50% in earlier studies (Pa1ikh et al 4 ) has dropped down and is expected to fall further due to increasing use of tests to diagnose conditions like tlu ombophilias which was not possible earlier. Infections (regional and systemic) together accounted for 18% of cases in our study. Ear infection was commonest among these responsible for 5% of cases followed by tuberculous meningitis and malaria (3%each)and sepsis,infection in dangerous area of face and enteric fever being responsible for 2% of cases each. With judicious use of antibiotics proportion of cases due to ENT infections has considerably fallen(5%in our study as compared to 30% in a study from Thialand by Kangsanarak et al ). Hyperhomocystenemia and APLA syndrome was responsible for 4% and 6% in our study.it was same as found by Ferro et al With the elucidation of various thrombophilic disorders like hyperhomocystenemia,apla syndrome,factorv leiden,g20210.a protlu ombin gene 412

4 mutation and others which are reported as very common disorders in western literature and availability and accuracy of tests to detect these disorders,there proportion is likely to go up in the future. Diabetic ketosis,dic,and OCP use accounted for 3% cases each in our study.use of OCP is an important cause for CYST in the west.iscyt reported an incidence of 46% with the use of OCP. It was implicated as an etiological factor in 18% of cases in the study by Schell51 et al.and 12% of cases by Biousse et al 7.The higher portion of cases seen in the west is because of the widespread use of OCP in west as compared to India where its use is still restricted to very small portion of the reproductive age group.cyst is uncommon complication in patients with diabetic ketosis.persistence of altered sensorium and headache after correction of all metabolic abnonnalities in patients with diabetes ketosis should raise suspicion of venous thrombosis and should be investigated accordingly. Daniels et al 8 Dehydration,trauma,nephrotic syndrome accounted for 3%,1% and 1.6% m our study.patients of nephritic syndrome are at high risk for venous thrombosis as it is a hypercoagulable state.it is due to loss of anticoagulant factor like anti thrombi III and antiplasmin activity through leaky glomernlus.a Bums et al 9 Dural sinus thrombosis in 2 cases of falciparnm malaria who had fever, altered consciousness and focal neurological deficits Inghilleri et al 10 report case of CYST after typhoid infection.our study also reports a case of cerebral venous sinus thrombosis. Conclusion: Genetic or acquired prothrombotic factors (such as deficiencies in anticoagulation- promoting proteins, usage of oral contraceptives, pregnancy, and/or malignancy) are the main causes in the western world, while infection remains the most common underlying cause in developing countries. Results: 1. Ehtisham A, Stem BJ. Cerebral venous thrombosis: a review. Neurologist 2006; 12: Allroggen H, Abbott RJ. Cerebral venous sinus thrombosis. Postgrad Med J 2000; 76: Sajjad Z. MRI and MRV in cerebral venous thrombosis. J Pak Med Assoc 2006; 56: McLean B.Dural sinus thrombosis Br.J Hosp Med 1991; 45: de Brnijn SF, de Haan RJ, Stam J. Clinical features and prognostic factors of cerebral venous sinus thrombosis in a prospective series of 59 patients. For The Cerebral Venous Sinus Thrombosis Study Group. J Neurol Neurosurg Psychiatry 2001; 70: Siddiqui FM, Kamal AK. Complications associated with cerebral venous thrombosis. J Pak Med Assoc 2006; 56: de Brnijn SF, Stam J. Randomized, placebo-controlled trial of anticoagulant treatment with low-molecular-weight heparin for cerebral sinus thrombosis. Stroke 1999; 30: Canhao P, Ferro JM, Lindgren AG, et al. Causes and predictors of death in cerebral 413

5 venous tln ombosis. Stroke 2005; 36: Ribes MF. Des recherches faites sur la phlebite. Revue Medicale Fran9aise et Etrangere et Journal de Clinique de l'hotel-dieu et de lacharite de Par;s 1825; 3: Symonds, C. P._Cerebral thrombophlebitis. Br Med J 1940; 2 (4158):