# Talk:Cerebral venous sinus thrombosis

I have expanded the article with some sources at my disposition, including the quick review in the BMJ 2007. However, I am trying to get my hands on two further sources that I think seriously deserve consideration:

Einhäupl K, Bousser MG, de Bruijn SF; et al. (2006). "EFNS guideline on the treatment of cerebral venous and sinus thrombosis". Eur. J. Neurol. 13 (6): 553–9. doi:10.1111/j.1468-1331.2006.01398.x. PMID 16796579. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
Stam J (2005). "Thrombosis of the cerebral veins and sinuses". N. Engl. J. Med. 352 (17): 1791–8. doi:10.1056/NEJMra042354. PMID 15858188.
The entire November 2006 edition of the J Pak Med Assoc seems to be devoted to this condition...
The entire content seems to be available free: http://www.jpma.org.pk/Issues_Articles/IssuesArticles.aspx?IssueID=66 JFW | T@lk 12:53, 15 June 2008 (UTC)
Thanks to Arcadian, Davidruben and indirectly Dave Iberri for starting this. JFW | T@lk 21:46, 24 October 2007 (UTC)

And: Dentali F, Gianni M, Crowther MA, Ageno W (2006). "Natural history of cerebral vein thrombosis: a systematic review". Blood. 108 (4): 1129–34. doi:10.1182/blood-2005-12-4795. PMID 16609071.{{cite journal}}:  CS1 maint: multiple names: authors list (link) JFW | T@lk 14:35, 26 October 2007 (UTC)
And: Kimber J (2002). "Cerebral venous sinus thrombosis". QJM : monthly journal of the Association of Physicians. 95 (3): 137–42. PMID 11865168. (FREE) JFW | T@lk 20:38, 28 October 2007 (UTC)

Just lost about 30 minutes work due to a caching problem typical of internet explorer. Have no time to continue further, but will do so tomorrow evening. JFW | T@lk 15:28, 26 October 2007 (UTC)

Nominated for GA. Let's see. JFW | T@lk 18:31, 13 April 2008 (UTC)

I have temporarily removed the following:

Other less well understood situations that increase the risk for cerebral sinus thrombosis are hyperthyroidism citing Dai A, Wasay M, Dubey N, Giglio P, Bakshi R (2000). "Superior sagittal sinus thrombosis secondary to hyperthyroidism". Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 9 (2): 89–90. doi:10.1053/jscd.2000.0090089. PMID 17895204.{{cite journal}}:  CS1 maint: multiple names: authors list (link) and myelodysplastic syndrome.citing Finelli PF, Harrison RB, Uphoff DF (1998). "Myelodysplastic syndrome and sagittal sinus thrombosis". Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 7 (3): 211–2. PMID 17895084.{{cite journal}}:  CS1 maint: multiple names: authors list (link)
Both these states (hyperthyroidism and MDS) are only mentioned on the basis of case reports in a relatively low-impact factor publication. While I have not seen the fulltext, I don't think either of them demonstrate causality beyond "wow, our patient has two rare conditions, they must be related". JFW | T@lk 19:49, 13 April 2008 (UTC)

I have asked our radiology spy Glitzy queen00 (talk · contribs) for some neuroimaging. JFW | T@lk 21:21, 13 April 2008 (UTC)

More about CVST in kids: PMID 11496852 (NEJM) and PMID 15699061 (Brain).
Obstetric prognosis of CVST: does it come back? PMID 12754362. JFW | T@lk 22:20, 13 April 2008 (UTC)

It is indeed. Application has been successful, congratulations to all contributors. CycloneNimrod (talk) 11:53, 17 April 2008 (UTC)

It took a little while to find one so this is the best I can get for now! I hope it meets all standards? As always, I'm happy to help! Heather 11:03, 25 April 2008 (UTC)Glitzy_queen00

Cheers! See your talkpage. JFW | T@lk 06:02, 29 April 2008 (UTC)

It is interesting that the history of CVST is hard to disentangle from idiopathic intracranial hypertension. A single case from 1887 and some from the 1930s seem to have led to the recognition that CVST is an independent entity. Does everyone with possible IIH still undergo a venogram? PMC 2011899 has some historical content. JFW | T@lk 17:22, 27 May 2008 (UTC)

According to eMedicine, CT is now the central diagnostic technique in most disorders of cerebral venous drainage. However, it also says that "venography is worthwhile". Also: "Although CT is certainly adequate in most instances, MRI and magnetic resonance venography are effective in ruling out both a mass lesion and a potential dural sinus thrombosis." Regards, CycloneNimrod talk?contribs? 08:40, 1 June 2008 (UTC)
Thanks. I was more interested in the historical question of when IIH and CVST became distinct clinical entities. We now know that IIH is not usually caused by infections, so was otitic hydrocephalus perhaps a missed case of otitis causing a sinus thrombosis? I will have a look at Emedicine to see if they provide historical context. JFW | T@lk 12:28, 1 June 2008 (UTC)

Thank heavens for PubMed Central:
PMC 2011899 - child, 1956
PMC 1026412 - 1980, a rather thorough summary of 795 cases, mostly post-mortem
PMC 1802934 - Ray & Dunbar on using cerebral venography to distinguish from IIH
Problematically, no case has actually been labeled "first described" by any sources. JFW | T@lk 11:53, 15 June 2008 (UTC)

I'm not sure but I'm pretty sure risk factors come under epidemiology but currently they are listed under signs and symptoms. I'll wait for a reply before I change it (or before anyone else should change it) but I think it makes more sense to be in epidemiology. Regards, CycloneNimrod talk?contribs? 16:14, 6 June 2008 (UTC)

Perhaps a brief summary in the intro (e.g. postpartum) and then moving it? JFW | T@lk 12:21, 8 June 2008 (UTC)

Much recent work in Europe has been done in The Netherlands by the Cerebral Venous Sinus Thrombosis Study Group and more recently by the ISCVT. There are some highly relevant recent studies that are not cited in Stam (because the review predates these studies). PMID 10762517, however, appeared in 2000 but is not discussed prominently by the reviewer - it discusses functional outcomes, surely worth mentioning in a neurological condition previously diagnosed mostly after death.... JFW | T@lk 13:26, 15 June 2008 (UTC)

Temporarily removed:

Progressive speech disorders, decreased cognition and decreasing visual acuity have also been reported amongst cases of CVST. citing Longmore, Murray (2007). Oxford Handbook of Clinicial Medicine. Oxford. ISBN 0-19-856837-1. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
This was added to the section on raised intracranial pressure. Surely, these simply reflect symptoms we are already mentioning in people who are awake and talking. I will borrow someone's OHCM at work today and see in what context these symptoms are mentioned. JFW | T@lk 06:18, 16 June 2008 (UTC)

I have reviewed OHCM 7th edition page 472. It is a very comprehensive entry: it lists a large number of associated causes including some that we are not listing (unsure what their source is!) and suggests that particular symptoms could be localising signs in CVST. It also lists cavernous sinus thrombosis amongst the other forms, even though this seems to be generally regarded as a separate condition. Other interesting points are: (1) it insists on T2-weighed gradient echo sequences to identify cortical vein thromboses, (2) it lists a number of predictors for death from a study published in Stroke on 7 July 2005 but I cannot find the relevant paper[1], (3) it is vague on the importance of anticoagulation. JFW | T@lk 18:49, 18 June 2008 (UTC)

J Roy Soc Med carried a four-article series in 2000. A bit outdated, but there we go: http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&TransSchema=title&term=93%5Bvolume%5D%20AND%205%5Bissue%5D%20AND%20Cerebral%20venous%20thrombosis JFW | T@lk 18:50, 26 June 2008 (UTC)

PMID 18625874 - Stam again breaking a lance for anticoagulation despite borderline statistics. Should prompt larger trials, methinks.
PMID 18340091 - slightly more data on thrombolysis, from ISCVT.
PMID 18309177 - seizures are likely to recur and one seizure + CVST therefore indicates need for antiepileptics.
Much of this is primary research, so it's time we wait for a further review. JFW | T@lk 20:25, 22 July 2008 (UTC)
Totally missed doi:10.1016/S1474-4422(07)70029-7 (Bousser in Lancet Neurol). For another time. JFW | T@lk 23:40, 10 April 2010 (UTC)

doi:10.1160/TH09-12-0827 - Italian guidelines. No new points, but in English and makes the point that warfarin should only be introduced when the patient is stable. JFW | T@lk 17:05, 17 February 2011 (UTC)
doi:10.1111/j.1538-7836.2012.04637.x - recent meta-analysis of the use of D-dimer. Could be cited instead of the primary sources we're currently dependent on. JFW | T@lk 03:04, 1 April 2012 (UTC)
doi:10.1111/j.1365-2141.2012.09249.x - new British guidelines from a haematology perspective. JFW | T@lk 07:57, 10 October 2012 (UTC)
Another doi:10.1007/s11886-014-0523-2 JFW | T@lk 08:50, 27 June 2016 (UTC)

The article's lede states that cerebral venous sinus thrombosis is a form of stroke, but perhaps it may be prudent to revise that statement to allow for cases of thrombosis that occur without persistent and clinically important neurologic sequelae. U.S. Secretary of State Hillary Clinton's doctors have reported that she has been found to have experienced a transverse sinus thrombosis that was discovered on an MRI performed during "routine" follow-up a concussion sustained 2 1/2 weeks earlier. The doctors have said in their public statements that she did not have a stroke and has had no neurologic injury. Assuming their statement is correct, and that her diagnosis lies within the realm of cerebral venous sinus thrombosis, this article as it is currently written does not appear to include cases of CVST that do not involve stroke or neurologic injury, such as Clinton's. I haven't carefully reviewed sources, but my sense is that the article could be revised to say that CVST is a rare form of thrombosis that may cause stroke, assuming sources can be found that state that.Dezastru (talk) 00:51, 2 January 2013 (UTC)

I agree that in the absence of focal neurology secondary to venous infarction it would not be appropriate to refer to this as a form of stroke (although it would fit in the larger category of cerebrovascular disease). JFW | T@lk 14:26, 2 January 2013 (UTC)

How does one treat the CVST in a patient with a coagulopathy? Clearly anticoagulants are forbidden.   (NB - repasted it because it was inserted before the footnotes of the previous section - if this happens again perhaps someone else can fix it)

doi:10.1111/jth.14210 JFW | T@lk 14:26, 9 October 2018 (UTC)

Also: doi:10.7861/clinmedicine.18-1-75 JFW | T@lk 09:49, 14 June 2019 (UTC)

doi:10.1016/j.jstrokecerebrovasdis.2017.04.020 is really quite a large case series, and the finding that 5.1% had cancer was interesting. Unfortunately the abstract is unclear as to whether this was due to local activity (i.e. thrombosis caused by a brain tumour or metastasis) or whether this was not related to the site of the tumour and more likely attributable to rheological factors.
The article has been cited 17 times on Scopus but I can't tell whether they cite this article specifically to demonstrate the association between cancer and CVST. JFW | T@lk 09:42, 14 June 2019 (UTC)

Ref name AHAASA updated with 2014 new guideline --DrSorrowMD (talk) 11:44, 22 May 2020 (UTC)

research from Professor Paal Andre Holme of Norway’s Oslo University Hospital AND the same results found INDEPENDENTLY by the team of Professor Andreas Greinacher, Univ. Greifswald Germany.
A SCIENTIFIC paper will soon be out so be ready for that.
THis is just from REUTERS but RELIABLE.
If we in wiki want to be up to date, PLEASE can someone who knows the ins and outs of wiki better than me (I am not able to do this) PLEASE take this seriously. 
https://www.reuters.com/article/us-health-coronavirus-vaccine-idUSKBN2BC01M
The point is not whether the finding is 1 in Million, the point is wiki readers have the right to access new info and we must not hide it, but say clearly it is a rare event, AND confirm that the credentials of the researchers who did the work are first rate. So do take this finding seriously please and THANKS A LOT in advance to anyone taking up the challenge. Yes, it can cause worry, but TRANSPARENCY AND HONEST REPORTING OF NEW FACTS is the antidote to fear.  — Preceding unsigned comment added by 87.123.203.106 (talk) 19:22, 22 March 2021 (UTC) 

Sorry I have refactored the title of this section because it was very long. JFW | T@lk 09:54, 15 April 2021 (UTC)

I was told I can not add this paragraph since it contradicts the numbers above:

Cerebral venous sinus thrombosis is typically so rare that no reliable numbers are available. It is estimated that usually about two to five cases per million people and year can be observed. citing "MHRA issues new advice, concluding a possible link between COVID-19 Vaccine AstraZeneca and extremely rare, unlikely to occur blood clots". AHA Journals (Press release). 19 Jul 2016. Retrieved 8 April 2021.
I do not fully understand if there is a certain system within the order of this section, giving numbers from 2006 first (3-4 per million), then older from 1995 (70 per million), then 1973 (9 % of all deaths), then from 2001 for children (6.7 per million). The section above is more recent from 2016, naming 2-5 per million. This may represent a different result in different studies. It is that rare that you do not have very reliable numbers. But the purpose of this section with most recent numbers was to give a comparison of usual CVST numbers of up to 5 per million and year, compared to 70 per 20 million vaccinations within one month. I do not dare to calculate this from 20 mio vaccinations to 10 mio people (vaccinated twice), nor would I multiply the numbers from one month to a year by 12. This would result in 14 cases per million and year. This comparison would be up to the user. But I feel it is required to provide some help, by what magnitude the significant increase is, which may be caused by the vaccination. --Traut (talk) 16:28, 8 April 2021 (UTC)

@Traut: "I was told" is not quite true. We just disagree that this information should be added in the form that you did. Firstly, you used {{cite press release}} on an article from 2016 and with the wrong "title" field. Secondly, you wanted to add that the annual incidence is 2-5 per 106 which partially contradicts the content in Section 7. Finally, commenting on the background rate could easily be construed as editorialising. JFW | T@lk 12:06, 11 April 2021 (UTC)
A, I see. So it would Template:Cite_journal instead? But what's the problem about the contradiction? Is data from an article in the Eur. J. Neurol from 2006 more reliable than from the AHA Journal from 2016? Why can't different studies come to different results? But what's your suggesion how to compare CVST rates assumed to be caused by the vaccination to usual rates? --Traut (talk) 12:34, 11 April 2021 (UTC)
Perhaps we need to stick to a single source for adult incidence. Could I propose doi:10.1038/nrneurol.2017.104? This could be used to update other old references too. JFW | T@lk 12:09, 11 April 2021 (UTC)
What's the information that you can quote from that reference? For me that's blocked by a paywall. --Traut (talk) 12:37, 11 April 2021 (UTC)
@Traut: Would doi:10.1111/jth.14210 be any better? JFW | T@lk 10:12, 15 April 2021 (UTC)
not really - it doesn't name numbers of its own. But it does reference to
* two to five cases per million from 3 Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005; 352: 1791– 8 and 4 Bousser M‐G, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007; 6: 162– 70.
versus more recent
* 13.2 and 15.7 annual cases per million from 5 Coutinho JM, Zuurbier SM, Aramideh M, Stam J. The incidence of cerebral venous thrombosis: a cross‐sectional study. Stroke 2012; 43: 3375– 7 and 6 D evasagayam S, Wyatt B, Leyden J, Kleinig T. Cerebral venous sinus thrombosis incidence is higher than previously thought: a retrospective population‐based study. Stroke 2016; 47: 2180– 2.
--Traut (talk) 10:32, 15 April 2021 (UTC)
There seems to be active editing on the facts of this section, but at some point the 1995 study got cited as "doubled incidence" at "7 per 100.000"; but relative to the other numbers in the paragraph that would be a *twenty-fold* increase.  The above paragraphs here in Talk suggest that the number is correct (at 70 per million) and the description is off, so I'm adjusting the description to match, but plesae fix the other way if I got that wrong. /blahedo (t) 15:44, 13 April 2021 (UTC)

I just reverted, for the second time, the inclusion of the Johnson & Johnson vaccine in the Causes section. The additions were made by 47.220.171.134 and 141.126.102.7. Please don't add that claim again without a good source. Unless I'm mistaken, we're well away for proving a causal link. Firefangledfeathers (talk)  — Preceding undated comment added 16:41, 13 April 2021 (UTC) 

I agree that we are still some way away from Bradford Hill level causation. JFW | T@lk 19:39, 13 April 2021 (UTC)
A sentence could be added under a new research section stating it's under investigation. A sentence could also be added to the treatment section about how heparin is contraindicated in these cases.[2] Biosthmors (talk) 00:12, 14 April 2021 (UTC)

Removed pending discussion:

Heparin should not, however, be used in cases of blood clots associated with the Johnson & Johnson coronavirus vaccine, or the Oxford–AstraZeneca COVID-19 vaccine as it may worsen the condition.
Comments would be useful. I think this should not be the introduction as the absolute number of cases of VITT-CVT is still small. JFW | T@lk 12:59, 29 April 2021 (UTC)

doi:10.1161/STROKEAHA.121.035564 may be useful if it is felt that a subsection is now required. JFW | T@lk 13:30, 2 May 2021 (UTC)