Cerebral Venous Thrombosis – A Case Series

Priya Baby¹*, Bincy R.², Chandra S.R.³

¹Lecturer College of Nursing, NIMHANS, Hosur Road, Bangalore - 560029, India.

²Professor, College of Nursing, Trivandrum, India

³Professor & HOD, Dept. of Neurology, NIMHANS, Hosur Road, Bangalore - 560029, India

*Corresponding Authors E-mail: priam19@gmail.com

ABSTRACT:

Cerebral venous thrombosis (CVT) is a type of cerebrovascular disease that can occur at any age and it accounts for 0•5% of all strokes. Eventhough the disease is well understood, nursing studies reporting the clinical features and the various nursing problems in these patients is less. This case series of ten patients was undertaken to describe the clinical and demographic characteristics of patients admitted in the emergency department with a clinical diagnosis of cerebral venous thrombosis. Nine out of ten patients in the series were females. Out of the nine females eight were in the peurperium and one was pregnant. The most common clinical manifestations identified were headache, seizures, focal neurological deficits and altered consciousness which occurred alone as well as in combination. The duration between onset of symptoms and admission ranged from 1 to 7 days. The severity of stroke as measured by National Institute of Health Stroke Scale ranged from 0 to 22 with a mean of 8.It was observed that forced restriction of fluid was practiced in the post partal period of CVT affected mothers. The most commonly identified nursing problems were pain (headache), activity intolerance , fatigue , interrupted breast feeding, imbalanced nutrition less than body requirements , self care deficit and risk for injury related to anticoagulation and seizures. The observations in this case series when seen in light of the existing knowledge makes it explicit that the occurrence of CVT in India is very high among females especially related to pregnancy and child birth . Early recognition of the symptoms of CVT and educating the public regarding the importance of fluid intake during pregnancy and should be done by the nurses involved in the care of pregnant and puerperal mothers.

KEY WORDS: cerebral venous thrombosis, puerperium, stroke, pregnancy

INTRODUCTION:

Cerebral venous thrombosis (CVT) is a type of stroke that results from thrombosis of the intracranial venous sinuses, which drain blood from the brain. Cerebral vein and sinus thrombosis is rare compared with arterial stroke, and it often occurs in young people. CVT was first recognized at the beginning of 19^th century and was then considered as an infective disorder. Neuroimaging studies have modified the current knowledge we have on this disorder. It is now recognized as a nonseptic disorder with various clinical presentations. While high-quality epidemiologic studies of CVT are lacking, the available data suggest that CVT is uncommon¹. CVT is not uncommon in Asia especially in south Asian subcontinent including India, Pakistan and Bangladesh.

Several studies have been reported on this disorder, and its treatment modalities especially from the Indian subcontinent². The International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) was a multinational, multicentric series and it, threw much light into the clinical presentation, risk factors, outcome, and prognostic factors of these patients³.Even though the ISCVT, included 89 centers in 21 countries, results of this study are generalizable to CVT patients around the world with the exception of Africa or Asia because very few patients from these continents were included.³

Pangayara reported that CVT in India accounted for half of all strokes in the young and 40% of strokes in women^4.The clinical presentation of CVT is highly variable, ranging from cases with mild symptoms and normal neurological examination to others who present with coma and have a severe neurological dysfunction^6,7. Nurses need to be aware of the most usual clinical manifestations seen in this group of patients for early recognition and intervention.

METHODOLOGY:

The objective of this case series was to describe the clinical and demographic characteristics of patients admitted in the emergency department with a clinical diagnosis of cerebral venous thrombosis. The study sample consisted of ten patients with CVT admitted consecutively in the emergency department of a selected tertiary care hospital in Bangalore. All adult patients with a diagnosis of CVT confirmed by a CT, MRI or MRV, were included in the study. An informed consent was obtained from the patients or from their kith and kin if they were not able to do so due to altered sensorium. Data were collected from the patient and medical records. The severity of stroke was measured using the national institute of health stroke scale (NIHSS), the scoring of which ranges from 0 to 42.

RESULTS:

The mean age of the sample was 23.4 years with a range of 19 to 27. Out of the ten patients, 9 were females. Eight of them were married and two of them were unmarried. All the females were house wives and the male was a semiskilled worker. One of these patients was an illiterate, whereas 8 of them had primary school education and one had a collegiate education. A vast majority of the sample(9) hailed from rural areas and one was from semiurban area. There was no subject who had come from urban area.

As shown in table 1, the subjects varied widely in the time taken before admission from the time of onset. The duration of hospitalization also varied widely with a mean of 10.55 ±6.61.

Table 1: Characteristics of the series

Variable	Minimum	Maximum	Mean ±S.D
Age	19	27	23.4±2.83
Post partum day at the time of admission (n=8)	7	20	13±5.41
Duration between hospitalization and onset of symptoms(in days)	1	7	3±1.82
Duration of hospitalization (in days)	2	22	10.55±6.61
NIHSS score	0	22	8±8.91

Among the female subjects (n=9), eight were in the post partum period, while the other one was pregnant. Among the post partum subjects, one had a cesarean section while all the others delivered vaginally. The risk factor identified in the male subject was alcoholism. The post partum day in which the ladies had the onset of symptoms ranged from 7 to 20 with a mean of 13days±5.41.

With regard to clinical presentation, 8 of the patients had headache as the major complaint. Three patients had seizures. Three patients presented with altered sensorium. One of them had a unilateral paresis. The clinical spectrum seen in this case series is comparable with other reports^3,8.

DISCUSSION:

Thus this case series intends to describe the clinical and demographic characteristics of patients admitted with cerebral venous thrombosis, in the emergency department of a tertiary care hospital, Bangalore.

A case series of ten patients admitted consecutively to the emergency department was selected for the study using convenient sampling. Vast majority of the subjects (90%) were females. Higher incidence of CVT in females when compared to males, has been reported in other trails also^{4,5, 8}. The mean age of the patients in this study is 23 years which is much lower than the other reports, which range from 29 to 42 years^4,5,8. The most common risk factor encountered in the study was the post partum status. CVT in relation to pregnancy and child birth is well documented⁹. A series from Pakistan also report peurperium as one of the most common risk factors identified⁴. Unlike the western reports of CVT, where the most common risk factor among females is OCP intake, none in the series had a supporting history. One of the observations made is that the fluid intake is restricted during post partum period, which may aggravate the thrombotic status and predispose the mother to develop venous thrombosis in the post partum phase. The other blood investigations of the subjects to identify thrombotic status were not done in the present study. Thus the presence or absent of these risk factors in them cannot be commented upon.

The observations in this case series when seen in light of the existing knowledge makes it explicit that the occurrence of CVT is very high among females especially related to pregnancy and child birth. Nurses who are working in the obstetrics department need to be informed about the high prevalence of CVT among post partum women in India. The knowledge about various clinical presentations in this group can help early identification and treatment. Moreover early identification and treatment is important because the morbidity associated with the illness not only affects the mother, but the newborn and the family. Nurses need to educate the public regarding the importance of healthy practices during post partum period, including adequate food and fluid intake.

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7. Einhaupl KM, Villringer A, Harberl RL et al. Clinical spectrum of sinus venous thrombosis. In: Cerebral Sinus Thrombosis: Experimental and Clinical Aspects. Plenum Press, 1990, NY, USA 149-56.

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Received on 16.08.2012 Modified on 25.09.2012

Asian J. Nur. Edu. and Research 2(4): Oct-Dec. 2012; Page 181-183