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Journal of Clinical Neuroscience 39 (2017) 9–15

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Journal of Clinical Neuroscience


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Review article

Cerebral venous sinus thrombosis in pregnancy and puerperium:


A pooled, systematic review
Ahmed I. Kashkoush a, Henry Ma a, Nitin Agarwal a, David Panczykowski a, Daniel Tonetti a,
Gregory M. Weiner a, William Ares a, Cynthia Kenmuir b, Ashutosh Jadhav b, Tudor Jovin b,
Brian T. Jankowitz a, Bradley A. Gross b,⇑
a
Department of Neurological Surgery, UPMC, Suite B-400, 200 Lothrop St., Pittsburgh, PA 15213, USA
b
Department of Neurology, 811 Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA

a r t i c l e i n f o a b s t r a c t

Article history: Pregnancy and puerperium are risk factors for cerebral venous sinus thrombosis (CVST); however studies
Received 2 December 2016 describing diagnosis and management in this population are limited. The objective of this study was to
Accepted 13 February 2017 amalgamate published case reports and series regarding diagnosis and management of CVST in preg-
nancy and puerperium. Searches of PubMed and the Cochrane library were performed using search terms
‘‘pregnancy”/‘‘puerperium” and ‘‘sinus occlusion”/‘‘sinus thrombosis”. Studies were included in our
Keywords: pooled analysis if they included individual patient symptoms, management approach and follow-up con-
Cerebral venous sinus thrombosis
dition. Multivariate regression was utilized to assess the effect of non-modifiable factors on excellent out-
Sinus thrombosis
Stroke
come (mRS 0). Sixty-six patients were included. Mean duration of symptom onset to diagnosis was
Pregnancy 5.9 days (95% CI 4.2–7.6). Clot involvement of the superior sagittal sinus was seen in 67% of cases, the
Endovascular transverse/sigmoid in 64% and of the deep venous system in 15% of cases. Management approaches
Thrombectomy included anticoagulation (91% of patients), IA (intra-arterial) thrombolysis alone (26%), and IA thrombec-
tomy with IA thrombolysis (8%). Fifty-nine percent of patients were mRS 0 at follow-up; 94% were mRS 0-
2. Presentation with headache alone was associated with excellent outcome on multivariate analysis
(p = 0.04); coma/obtundation predicted against excellent outcome (p = 0.03). As compared to IA throm-
bolysis alone, patients undergoing IA thrombolysis with IA thrombectomy demonstrated a trend toward
better outcome (p = 0.10).
Ó 2017 Elsevier Ltd. All rights reserved.

1. Introduction at approximately 10–12 in 1,000,000 people per annum [3,8–10].


Mortality from CVST has improved to a rate of <15%, with an in-
Cerebral venous sinus thrombosis (CVST) is a rare disease with hospital mortality of 6% and a 30-day mortality of 4% or less
an estimated annual incidence of 5 per million, accounting for 0.5– [8,9,11–23].
1.0% of all stroke [1,2]. A conservative estimate of the prevalence of The incidence of CVST increases with sex-specific risk factors
people who have suffered morbidity from CVST in the general US such as oral contraceptive use, hormone replacement therapy,
population alone with respect to cognitive impairments, depen- pregnancy, and puerperium [24]. In a retrospective study of 113
dency, or restrictions in lifestyle currently numbers over 20,000 patients with CVST, Cantú et al. reported that 59% of patients pre-
[3–7]. Within the general population, women experience more sented during pregnancy or puerperium [25]. Roughly 0.004–0.01%
than three times the incidence of CVST when compared to men, of pregnancies are complicated by CVST, which cause about 2% of
pregnancy-associated strokes [26]. The frequency of pregnancy-
associated CVST is highest during the third trimester and puer-
⇑ Corresponding author at: Department of Neurological Surgery, UPMC, Suite perium [27,28]. CVST is estimated to affect 0.012% of deliveries
B-400, 200 Lothrop St., Pittsburgh, PA 15213, USA. Fax: +1 (412) 647 0989. during the puerperal period, and this risk is further modulated
E-mail addresses: aik8@pitt.edu (A.I. Kashkoush), hem53@pitt.edu (H. Ma), by factors such as infection, instrumented delivery, cesarean sec-
agarwaln@upmc.edu (N. Agarwal), panczykowskidm@upmc.edu (D. Panczykowski),
tion, increasing maternal age, increasing hospital size, excessive
tonettida@upmc.edu (D. Tonetti), weinergm@upmc.edu (G.M. Weiner), areswj@
upmc.edu (W. Ares), kenmuircl@upmc.edu (C. Kenmuir), jadhavap@upmc.edu vomiting during pregnancy, and hyperhomocysteinemia [28–30].
(A. Jadhav), jovitg@upmc.edu (T. Jovin), jankbt@upmc.edu (B.T. Jankowitz),
grossb2@upmc.edu (B.A. Gross).

http://dx.doi.org/10.1016/j.jocn.2017.02.046
0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
10 A.I. Kashkoush et al. / Journal of Clinical Neuroscience 39 (2017) 9–15

Although pregnancy and puerperium are known risk factors for 5. Continuous variables were initially tested for normality using a
CVST, studies describing this population are limited to case reports Kolmogorov–Smirnov test. To assess for differences in continuous
and small series. This study amalgamates results from published variables according to outcome, we utilized a two-tailed student’s
cases of CVST in pregnancy and puerperium, evaluating clinical t-test in cases of normality and a Wilcoxon signed-rank test in
presentation, diagnosis, and intervention strategies in order to cases of non-normal data. We subsequently performed a multivari-
delineate non-modifiable and modifiable prognosticators for poor ate logistic regression analysis using the variables identified in the
outcomes. univariate analysis as inputs to assess the odds ratio for excellent
clinical outcome. Chi-squared and Fisher exact tests were utilized
in sub-group analyses to determine differences in outcome across
2. Methods
treatment modalities. mRS 0 and mRS 0-2 outcomes were consid-
ered for sub-group analyses. Statistical significance was always
2.1. Study selection
defined as p < 0.05 and continuous variables are reported as aver-
ages with 95% confidence intervals unless otherwise mentioned.
The authors queried the Pubmed and the Cochrane Library data-
bases for relevant articles utilized in this study. We utilized the fol-
lowing search command to identify articles published through 3. Results
September 2016: ‘‘(((pregnant) OR pregnancy) OR puerperium)
AND ((sinus thrombosis) OR sinus occlusion)”. Articles were ini- 3.1. Study selection
tially screened for relevance based on title and/or abstract content.
Subsequently, we conducted a full-text review of the articles Our search identified 425 potential articles for review. After
remaining to assess for patient eligibility for the study. We title and abstract examination for relevance to the current study,
included English-written case reports and case series describing we screened out 352 articles. Of the 73 titles remaining, 12 were
CVST in pregnancy and/or puerperium. Studies were included in excluded due to lacking clinical outcome; 5 due to lacking inter-
our pooled analysis if they included individual patient symptoms, vention data; 4 due to CVST occurrence more than 6 weeks post-
management approach, and discharge or follow-up condition. partum; and 2 due to comorbid terminal cancer that confounded
Patients were excluded if they presented with symptoms greater the follow-up outcome data. Fifty articles (5 case series, 45 case
than 6 weeks from delivery postpartum based on the literature reports) were included in the final analysis, which included 66
definition of puerperium [31]. Patients were additionally excluded patients for data extraction (Fig. 1) [32–81]. Individual studies
if they were lacking clinical outcome, lacking intervention data, or are described in further detail in Supplemental Table 1.
if they presented with comorbidities that confounded the outcome.
3.2. Baseline patient information, presentation, and diagnosis
2.2. Data extraction
The mean age of patients at presentation was 26.5 (95% confi-
The following variables were extracted: (1) patient age, (2) dence interval, 25.3–27.7) years. Of 66 patients in the cohort, 24
pregnant vs. puerperal, (3) gestational age or postpartum length, (36%) were pregnant, 42 (64%) were puerperal. Forty-six patients
(4) presence of pre-eclampsia or associated thrombophilia, (5) clin- (70%) were primigravid (Table 1). The most prevalent signs and
ical presentation, (6) radiographic evidence of cerebral infarction symptoms were headache (74%), seizure (50%), motor weakness
or hemorrhage, (7) the duration from symptom onset to diagnosis, (38%), coma or obtundation (45%), and visual disturbances (24%).
(8) method of diagnosis, (9) location of thrombus, (10) intervention Other less frequent signs and symptoms included nausea (17%),
strategy and complications, (11) duration from intervention to vomiting (23%), paresthesias/numbness (8%), neck stiffness (8%),
symptom improvement, (12) radiographic evidence of sinus photophobia (5%), and dysarthria/aphasia (8%). CVST was diag-
recanalization, (13) time and clinical condition at last follow-up, nosed most frequently with MRI (magnetic resonance imaging)
(14) vaginal vs. caesarean section delivery, (15) use of epidural or and MRV (MR-venography) although there were six cases of false
spinal analgesia during delivery, and (16) fetal outcome. Interven- negatives (5-MRI, 1-MRV) on initial imaging that resulted in a
tion strategy was categorized into one of the three categories delay in diagnosis [41,42,65,73,79]. Other common delays in diag-
including anticoagulation (heparin, warfarin, enoxaparin, or nadro- nosis resulted from presumptive or concurrent diagnoses of post-
parin sodium), intra-arterial (IA) thrombolysis with urokinase (UK) dural puncture headaches after epidural analgesia (12%) and the
or tissue plasminogen activator (tPA) alone, and IA thrombectomy onset of eclampsia (5%) [35,36,38,41,49,50,52,59,71,77,80].
with thrombolysis. The need for decompressive craniectomy was Thrombi were most frequently localized to the superior sagittal
also noted. Patients were included in the IA thrombolysis alone (70%) and transverse/sigmoid sinuses (58%), although most often
group if they received IA tPA or UK without thrombectomy, regard- (56%), patients presented with clots involving multiple elements
less of anticoagulation therapy. The primary outcome was mea- of the venous sinus system. Concurrent thrombophilia was elicited
sured utilizing the modified Rankin Scale (mRS) with excellent from patient history or further lab studies in 38% of patients.
outcome defined as mRS 0; in some cases, mRS was deduced based
on descriptions in the articles. All outcome data was utilized for 3.3. Intervention outcomes and complications
this study regardless of follow-up length.
Of the total patient cohort, 60 (91%) patients were anticoagu-
2.3. Statistical analysis lated; 17 (26%) received IA thrombolysis alone; 5 (8%) received
IA thrombectomy. Five patients ultimately required decompressive
We initially performed a univariate analysis to determine vari- craniectomy (8%) (Table 2). We observed a high frequency of coma-
ables significantly associated with the main outcome (mRS 0 or tose patients within the IA thrombolysis alone (76%), IA thrombec-
mRS >0, dependent categorical variable). Categorical variables tomy (80%), and decompressive craniectomy (83%) groups
were organized into contingency tables against the outcome vari- (Table 1).
able for analysis using either a chi-squared test or Fisher’s exact Regardless of treatment approach, 59% of patients achieved an
test. A Fisher’s exact test was utilized in cases when the expected excellent clinical outcome (mRS 0), with the majority (94%) of
counts in any of the cells within a contingency table were less than patients achieving a good clinical outcome (mRS 0-2). Mortality
A.I. Kashkoush et al. / Journal of Clinical Neuroscience 39 (2017) 9–15 11

Fig. 1. Flow diagram of study selection strategy.

Table 1
Baseline patient characteristics stratified by treatment.

Variable Intervention Strategy Total, n = 66


Anticoagulation, n = 60 IA thrombolysis, n = 17 IA thrombectomy + thrombolysis, Decompression, n = 5
(91%) (26%) n = 5 (8%) (8%)
Age (years) 26.6 (21.5–31.7) 25.1 (23.7–27.5) 25.2 (19.2–31.2) 26 (21.2–30.8) 27 (25.8–
28.2)
Pregnant 20 (33%) 3 (18%) 3 (60%) 3 (60%) 24 (36%)
Repeat Pregnancy 20 (33%) 2 (12%) 1 (20%) 0 (0%) 20 (30%)
Signs/symptoms
Headache 44 (73%) 6 (35%) 2 (40%) 5 (100%) 49 (74%)
Seizure 29 (48%) 8 (47%) 3 (60%) 3 (60%) 33 (50%)
Motor weakness 21 (35%) 6 (35%) 4 (80%) 4 (80%) 25 (38%)
Visual 16 (27%) 2 (12%) 1 (20%) 1 (20%) 16 (24%)
disturbance/papilledema
Coma/obtundation 24 (40%) 13 (76%) 4 (80%) 4 (80%) 30 (45%)
Thrombophilia 23 (38%) 2 (12%) 3 (60%) 1 (20%) 25 (38%)
Pre-eclampsia 4 (7%) 1 (6%) 0 (0%) 0 (0%) 5 (8%)
Clot Location
Superior sagittal sinus 43 (72%) 15 (88%) 5 (100%) 4 (80%) 46 (70%)
Lateral/sigmoid/jugular 38 (63%) 13 (76%) 4 (80%) 3 (60%) 42 (64%)
Deep – Straight/Galen/ICV 8 (13%) 3 (18%) 2 (40%) 2 (40%) 10 (15%)
Intracranial hemorrhage 12 (20%) 2 (12%) 2 (40%) 2 (40%) 13 (20%)
Epidural/spinal analgesia* 10 (17%) 0 (0%) 0 (0%) 1 (20%) 10 (15%)
Delivery method*
Vaginal 13 (22%) 1 (6%) 2 (40%) 0 (0%) 13 (20%)
Caesarean section 27 (45%) 13 (76%) 0 (0%) 2 (40%) 29 (44%)

ICV: internal cerebral vein; Galen: cerebral vein of Galen.


*
Only tabulated for 42 puerperal patients.

was observed in 1 (2%) patient with underlying Budd-Chiari syn- pregnancy loss. Mean time of clinical improvement from treatment
drome [32]. Rates of mRS 0 outcomes were 62%, 18%, and 60%, onset was 16.5 days (11.9–21.1), with no significant differences
for anticoagulation, IA thrombolysis alone, and mechanical IA across treatment modality. There was a large variation in the time
thrombectomy, respectively. Intracranial hemorrhage (ICH) was to sinus patency, with average recanalization time being 39.8
the most cited complication, which occurred in 4 (6%) patients (15.5–64.0) days. Mean follow-up time for the entire cohort was
receiving both anticoagulation and IA thrombolytic therapy. In 2 5.9 (3.8–8.0) months.
of these cases, ICH occurred after anticoagulation but before
thrombolysis, however, in the other 2 cases it was difficult to 3.4. Risk factor analysis
assess if bleeding was the direct result of thrombolysis or as a
delayed effect of anticoagulation therapy [39,40,60,67]. Fetal out- Univariate analysis demonstrated that headache and coma/
comes were reported in 26 cases, with 17 pregnancies resulting obtundation were significantly associated with clinical outcome
in live births and 9 resulting in therapeutic abortion or unintended (Table 3). Of 49 patients who presented with headache, 69%
12 A.I. Kashkoush et al. / Journal of Clinical Neuroscience 39 (2017) 9–15

Table 2
Outcomes and complications by treatment modality.

Variable Intervention Strategy Total, n = 66


Anticoagulation, IA thrombolysis, Mechanical Decompression,
n = 60 (91%) n = 17 (26%) thrombectomy, n = 5 (8%) n = 5 (9%)
Clinical outcome
mRS 0 37 (62%) 3 (18%) 3 (60%) 1 (20%) 39 (59%)
mRS 1 15 (25%) 11 (65%) 1 (20%) 3 (60%) 18 (27%)
mRS 2 5 (8%) 2 (12%) 0 (0%) 1 (20%) 5 (8%)
mRS 3 0 (0%) 0 (5%) 1 (20%) 0 (0%) 1 (2%)
mRS 4 1 (2%) 0 (0%) 0 (0%) 0 (0%) 1 (2%)
mRS 5 1 (2%) 1 (6%) 0 (0%) 0 (0%) 1 (2%)
mRS 6 (Death) 1 (2%) 0 (0%) 0 (0%) 0 (0%) 1 (2%)
Fetal Outcomes*
Healthy 16 (27%) 2 (12%) 2 (40%) 1 (20%) 17 (26%)
Therapeutic abortion/unintended death 6 (10%) 2 (12%) 1 (20%) 2 (40%) 9 (14%)
Complications
Intracranial hemorrhage 4 (7%) 3 (18%) 1 (20%) 0 (0%) 4 (6%)
Cerebral infarction 1 (2%) 0 (0%) 1 (20%) 0 (0%) 1 (2%)
Mean time to clinical improvement (days) 16.5 (11.9–21.1) 13.3 (5.9–20.7) 15.6 (4.5–26.7) 15.5 (10.11–20.89) 16.5 (11.9–21.1)
Mean time to recanalization (days) 37.0 (10.0–64.0) 2.8 (1.3–4.3) 14.6 (5.4–23.8) 64.5 (16.8–112.2) 39.8 (15.5–64.0)
Mean follow-up (months) 5.6 (3.4–7.8) 4.5 (3.3–5.7) 18.1 (2.9–33.3) 7.4 (0–18.5) 5.9 (3.8–7.0)
*
Fetal outcomes only reported in 26 patients.

Table 3
Univariate effects on clinical outcome.

Variable* Clinical outcome p-value


mRS > 0, n = 27 (41%) mRS = 0, n = 39 (59%)
Age (years) 25.8 (23.8–27.8) 27.0 (25.4–28.6) 0.368
Pregnant 9 (33%) 15 (39%) 0.796
Repeat pregnancy 4 (57%) 16 (59%) 1.000
Signs/symptoms
Headache 15 (56%) 34 (87%) 0.009*
Seizure 14 (52%) 19 (49%) 0.802
Motor weakness 14 (52%) 11 (29%) 0.052
Visual disturbance/papilledema 6 (22%) 10 (26%) 0.750
Coma/obtundation 18 (67%) 10 (26%) 0.003*
Thrombophilias/pre-eclampsia 9 (33%) 18 (46%) 0.298
Time to diagnosis (days) 5.3 (2.5–8.1) 6.1 (3.9–8.3) 0.554
Clot Location
Superior sagittal sinus 22 (82%) 24 (63%) 0.109
Lateral/sigmoid/jugular 18 (17%) 24 (62%) 0.670
Deep – straight/Galen/ICV 4 (15%) 6 (15%) 1.000
Intracranial hemorrhage 6 (22%) 8 (21%) 0.687
Vaginal delivery 7 (58%) 11 (50%) 0.729

ICV: internal cerebral vein; Galen: cerebral vein of Galen.


*
Statistical significance at p < 0.05.

(34/49) achieved mRS 0 at last follow-up (p = 0.009). Of 28 patients 3.5. Sub-group analyses
that presented with coma or obtundation at the time of treatment,
26% (10/28) were mRS 0 at last follow-up (p = 0.003). Multivariate As expected, patients treated with IA thrombolysis with or
logistical regression demonstrated that presentation with head- without thrombectomy were significantly more likely to present
ache alone was associated with excellent outcome on multivariate in coma than those treated with anticoagulation alone
analysis (p = 0.04) and coma/obtundation predicted against excel- (p < 0.001). For patients presenting with headache alone treated
lent outcome (p = 0.03) (Table 4). Notably, patient age, primigravid with only anticoagulation, clinical outcome was excellent in 89%
status, time to diagnosis, associated thrombophilic condition, clot (25/28) of cases and the proportion of patients reaching mRS 0-2
location and the presence of hemorrhage did not significantly status was 96% (27/28). We performed sub-group analyses to com-
influence outcome. pare outcomes between IA thrombolysis alone and IA thrombec-
tomy with thrombolysis (Table 5). There were no differences in
headache and coma/obtundation status between IA thrombolysis
alone and IA thrombectomy with thrombolysis groups. As com-
Table 4
pared to IA thrombolysis alone, patients undergoing IA thromboly-
Multivariate logistical regression for combinatorial effects on mRS 0 outcome.
sis with IA thrombectomy demonstrated a trend toward better
Variable Odds ratio 95% Confidence p-value outcome (p = 0.10).
interval
Lower Upper
4. Discussion
Headache 3.90 1.08 13.90 0.037*
Coma/obtundation 0.28 0.09 0.85 0.025*
The clinical diagnosis of CVST is challenging because of its rare
*
Statistical significance at p < 0.05. occurrence and highly variable clinical presentation. We observed
A.I. Kashkoush et al. / Journal of Clinical Neuroscience 39 (2017) 9–15 13

Table 5
Sub-group analysis of IA thrombolysis vs. mechanical thrombectomy outcomes.

Variable IA thrombolysis alone, n = 17 (77%) IA thrombectomy, n = 5 (23%) Total, n = 22 p-value


Headache 6 (35%) 2 (40%) 8 (36%) 0.848
Coma/obtundation 13 (77%) 4 (80%) 17 (77%) 0.869
mRS 0 3 (18%) 3 (60%) 6 (27%) 0.100
mRS 0-2 16 (94%) 4 (80%) 18 (82%) 0.411

high frequencies of headache (74%), seizure (50%), motor weakness ies, such as the ongoing randomized clinical TO-ACT trial, which
(38%), and comatose/obtunded status (45%), which is consistent compares clinical outcomes in patients receiving thrombolysis or
with the presentation in non-pregnant/puerperal patients [9]. In standard heparin therapy [17,83,84]. The idiosyncrasies of preg-
the current study, we observed that clinical suspicion for CVST is nancy and puerperium present unique challenges in the manage-
further complicated in patients who presented with headaches in ment of CVST, placing restrictions on pharmacological and
the immediate postpartum setting who received epidural analgesia procedural management of CVST [29,85].
during delivery, which occurred in approximately 12% (8/66) of Our study reinforces that in patients with just headache treated
patients [36,38,41,49,50,59,77,80]. Patients who follow this clinical with anticoagulation alone, outcome is generally excellent.
course are often empirically treated for post-dural puncture head- Although unfractionated heparin is preferable for non-pregnant
aches and receive hydration, caffeine, and oral analgesic therapy patients due to its titratability and swift reversibility, it is associ-
followed by epidural blood patch placement. CVST diagnosis is thus ated with teratogenicity and increased fetal bleeding [28]. Enoxa-
frequently delayed in these patients until further clinical deteriora- parin, a low-molecular weight heparin, provides a good safety
tion or treatment failure results in referral for MR-imaging. Another profile, does not cross the placenta, or leave the body through
set of patients that is especially vulnerable to diagnosis delays breast milk [86]. It also lowers the risk of and recurrence rate of
include pre-eclamptic patients with CVST that develop seizures, pre/eclampsia and negates the risks associated with the Angioten-
observed in 5% (3/66) of patients in this study [35,52,71]. These sin Converting Enzyme DD genotype in patients affected by CVST
patients are empirically treated with magnesium sulfate for (number needed to treat, NNT = 5) [28]. For patients presenting
eclampsia and are only referred for MRI after treatment failure. in extremis, our study suggests that acute IA thrombectomy in
This study suggests that clinical presentation at the time of addition to thrombolysis may be beneficial. Notably, neither UK
treatment is strongly associated with long-term clinical outcomes, nor tPA yield ill effects to the developing fetus or infant, and
thus emphasizing the utility of recognizing common CVST signs thrombolytic therapy should not be withheld in potentially lethal
and symptoms. In this study, patients with headache alone at the or debilitating thromboembolic disease even if the patient is preg-
time of treatment were 3.9 times more likely to achieve long- nant [87]. Other studies have also demonstrated benefits to
term excellent outcomes and patients treated after clinical deteri- endovascular therapy with respect to CVST recanalization
oration to a comatose state were 3.6 times more likely to suffer [88,89]. However, these studies evaluate for outcomes in the gen-
long-term clinical deficits. This finding suggests that CVST treat- eral population, and specific analyses regarding pregnant or puer-
ment is optimized if initiated before clinical deterioration, which peral populations are limited. Further evaluation regarding IA
is problematic because many patients are only diagnosed because therapy in pregnant and puerperal patients is warranted in order
of a decreasing neurological exam status. to establish endovascular treatment guidelines.
Initiation of treatment begins upon imaging confirmation of
CVST. The patient outcome will depend a great deal upon the indi- 4.2. Study limitations
vidual case and its causation rather than exclusively on the treat-
ment; even the best intervention may not be able to salvage a This study is limited by its incorporation of retrospective stud-
patient with a poor prognosis [82]. The largest prospective study ies, lack of radiographic outcomes, and un-matched treatment
describing CVST outcomes has been the International Study on groups. It is difficult to ascertain the comparative utility between
Cerebral Vein and Dural Sinus Thrombosis, which enrolled 624 treatment modalities based on the results from this study. We fur-
patients and reported mRS outcomes at 6 months [9]. Both preg- ther observed inconsistency in reporting presentation and follow-
nant and non-pregnant patients were enrolled and most (83.3%) up outcomes across articles, which may introduce a reporting bias
of patients were treated with heparin in the acute stage, which into our sample. Furthermore, this study may be subject to selec-
was comparable to the anticoagulation rate in our study (91%). tion and publication bias since the majority (90%) of cases are
Although 77 pregnant patients were included in that study, discus- extracted from case reports. As case reports are often dedicated
sion of reported outcomes affecting this group was fairly limited to describing rare clinical sequelae or successful outcomes, our
and there was no comparison of outcomes between pregnant and cohort may not represent the typical pregnant/puerperal patient
non-pregnant cases. Outcomes included one (1.3%) patient that who presents with CVST.
was reported to have a seizure and 3 (3.9%) pregnancies that
resulted in abortion. Overall, at 6-month follow-up, 79% of the total 5. Conclusion
cohort was mRS 0-1; 10.4% was mRS 2-3; and 2.2% was mRS 4-5. In
our study, 86% patients were mRS 0-1; 9.5% were mRS 2-3; and 3% Clinical status at the time of treatment is the most predictive
were mRS 4-5. This difference in outcomes is most likely due to dif- factor of excellent outcomes in pregnant and puerperal patients
ferences in sample size and study design rather than the effect of with CVST, and thus therapy should be initiated before clinical
pregnancy itself; our study was biased by reporting/publication deterioration. Postpartum headaches refractory to epidural blood
bias of case reports as well. patching and intractable seizures should elicit a high degree of
clinical suspicion for intracranial pathology (vs. post-dural punc-
4.1. Management guidelines ture headaches and eclampsia). MRI can establish a CVST diagnosis
but should not be utilized to rule out the condition. Anticoagula-
Evaluating the management of CVST in pregnancy is vital as tion is first-line therapy for CVST management, although this study
pregnant patients are often excluded from large multicenter stud- suggests that endovascular approaches, specifically IA thromboly-
14 A.I. Kashkoush et al. / Journal of Clinical Neuroscience 39 (2017) 9–15

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