Annals of Indian Academy of Neurology
  Users Online: 65 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size


 
Table of Contents
CASE REPORT
Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 35-38
 

Use of thrombolytic therapy in cerebral venous sinus thrombosis with ulcerative colitis


1 Department of Neurology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, India
2 Department of Clinical Research, Yashoda Group of Hospitals, Somajiguda, Hyderabad, India

Date of Submission23-Oct-2010
Date of Decision09-Jan-2011
Date of Acceptance19-Feb-2011
Date of Web Publication29-Feb-2012

Correspondence Address:
Subhash Kaul
Department of Neurology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh
India
Login to access the Email id


DOI: 10.4103/0972-2327.93276

PMID: 22412271

Get Permissions

 

   Abstract 

Cerebral venous thrombosis developing concurrently with active ulcerative colitis poses a therapeutic dilemma. We report the case of a 31-year-old woman who developed dural venous sinus thrombosis during the course of active ulcerative colitis in whom we accomplished clot lysis using intrasinus urokinase. The success of the procedure was assessed by improvement in the patient's neurological condition and resolution of imaging features without any bleeding complications. We also reviewed literature on various modalities of treatment of sinus venous thrombosis in patients with ulcerative colitis and outcome.


Keywords: Cerebral venous sinus thrombosis, intrasinus urokinase, thrombolytic therapy, ulcerative colitis


How to cite this article:
Kothur K, Kaul S, Rammurthi S, Bandaru VS, Suryaprabha ST, Mrudula K R. Use of thrombolytic therapy in cerebral venous sinus thrombosis with ulcerative colitis. Ann Indian Acad Neurol 2012;15:35-8

How to cite this URL:
Kothur K, Kaul S, Rammurthi S, Bandaru VS, Suryaprabha ST, Mrudula K R. Use of thrombolytic therapy in cerebral venous sinus thrombosis with ulcerative colitis. Ann Indian Acad Neurol [serial online] 2012 [cited 2014 Oct 21];15:35-8. Available from: http://www.annalsofian.org/text.asp?2012/15/1/35/93276



   Introduction Top


Ulcerative colitis (UC) is often complicated by various extra-intestinal manifestations during its clinical course. Of these manifestations, thromboembolic complications are well recognized, and their incidence has been reported as varying from 1.2% to 7.5%. [1],[2] Use of anticoagulants or thrombolytic agents against thrombosis associated with UC is controversial due to risk of hemorrhage from gastrointestinal tract. We report a young patient with ulcerative colitis who suffered an hemorrhagic infarction of brain due to venous sinus thrombosis who was successfully treated with local intrasinus urokinase with excellent outcome. We also reviewed the literature about various treatment modalities used in reported cases, which would help in guiding management of similar cases in future.


   Case Report Top


A 31-year-old woman, known patient of UC on steroids for the past one year, presented with headache for one day. Next day she developed sudden onset of weakness of right upper limb and lower limb, associated with progressive inability to speak and comprehend. She did not have vomiting, seizures or loss of consciousness. She also complained of irregular bloody diarrhea and was on amino salycilic acid. There was no history of rash, joint pains or jaundice. She had unexplained first trimester abortions twice. On examination, she had pallor without significant lymphadenopathy. She was conscious and had global aphasia. She had right hemianopia, bilateral papilledema, right upper motor neuron facial nerve palsy and right hemiplegia with power of 1/5 in right upper limb and 2/5 in right lower limb. CT and MRI brain showed hemorrhagic infarct in left parietal region [Figure 1] a and b. MR venogram revealed thrombosis involving superior sagittal sinus and right transverse sinus, later confirmed by digital subtraction angiography [Figure 2]a. Other laboratory investigations revealed microcytic hypochromic anemia with hemoglobin of 8.5 g/dl. HIV, antinuclear antibody and anticardiolipin antibody was negative. Prothrombotic work up (APLA, Lupus anticoagulant, Protein C, Protein S, Antithrombin 3, ANA, homocysteine) was negative. Colonoscopy revealed multiple hemorrhage prone erosions involving the sigmoid colon. Initially she was started on Low molecular weight heparin for 24 h. As her clinical status continued to worsen, she was taken up for intra sagittal sinus thrombolysis. A catheter was advanced through the right femoral vein to the occluded sagittal sinus. After confirmation of catheter tip, intra sagittal sinus urokinase was given initially as a bolus of 100,000 units which was followed up with continuous urokinase infusion at the rate of 70,000 units per hour by keeping catheter in situ. Check venogram was done at 12, 24, and 48 h. Venogram at 48 h showed partial opening up of superior sagittal sinus and complete opening of right transverse sinus [Figure 2]b. Subsequently infusion was stopped and she was started on low molecular weight heparin later changed to warfarin. Throughout her hospital stay prothrombin and activated partial thrombin time were monitored. During hospital stay she also developed right focal seizures which were controlled with Phenytoin. She was started on full dose Prednisolone and Amino salicylic acid for UC. She showed a rapid neurological improvement in power (upper and lower limb was 4/5) within 3 days and began to speak words with improving comprehension in 1 week. She did not have any bleeding complications. In follow-up 2 months later, she recovered to the point of no residual symptoms.
Figure 1: (a) CT and (b) T2 weighted MRI images showing hemorrhagic infarction of left parietal lobe

Click here to view
Figure 2: (a) Lateral view of the digital subtraction venogram showing poor ante grade flow and substantial superficial collateral drainage indicate thrombosis in the superior sagittal sinus. (b) Repeat digital subtraction venogram, after the infusion of 100,000 U of urokinase through the micro catheter, demonstrating partial recanalization of the superior sagittal sinus

Click here to view



   Discussion Top


There is no consensus in the literature regarding the treatment for the thromboembolic complications in UC. Many reports have followed conservative management as anticoagulant therapy was considered potentially dangerous, because of risk of mucosal bleeding from the UC lesion. [3] We reviewed various treatment modalities used in treatment of ulcerative colitis with CSVT using medline search, findings of which are summarized in [Table 1] and [Table 2] [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] . Out of 19 cases reported (including our case), 12 patients received no active therapy and there were 3 deaths. Five of them had residual defects as shown in [Table 2]. Seven patients received heparin and there was one death. Out of seven, three patients were taken up for thrombolytic therapy in view of progressive clinical deterioration on heparin. Low molecular heparin was tried in three cases. Though two patients improved, one died in this group. So far thrombolytic therapy has been tried only in eight cases of CVST (including our case) with underlying ulcerative colitis. Five of them had no residual neurological deficit in follow up and no deaths were reported in this group. [13],[15] No bleeding complication [intracerebral/other sites]were noted. This is thought to be due to the relatively rapid metabolism of the thrombolytic agent and, thus, the relatively low arterial concentration of the fibrinolytic agent. In our patient also, there was no increase in cerebral or mucosal bleeding after the thrombolytic therapy. Unlike heparin anticoagulation therapy, thrombolytic agents can promptly accomplish two therapeutic goals: (1) attenuation of thrombus progression; and (2) restoration of venous flow. Furthermore, because of the flexible catheters and the rapid systemic inactivation of urokinase, the systemic and intracranial complications appear to be no more than those of systemic anticoagulation in the acute period.
Table 1: Clinical, imaging features, mode of treatment and outcome in patients with ulcerative colitis and sinus venous thrombosis

Click here to view
Table 2: Comparison of outcome in various treatment groups in Ulcerative colitis with sinus thrombosis

Click here to view


The outcome in patients with ulcerative colitis has been poor in the past; 50%--80% of these patients had neurologic sequelae with significant mortality. [2] Given high morbidity and mortality associated and insignificant risk of bleeding complications, early recognition of thrombotic complications and management of patients who have severe neurologic deficit due to CVST with thrombolysis is important for optimal outcome even in presence of active colitis.


   Conclusion Top


The presence of neurologic signs or symptoms or the identification of a parenchymal hematoma in a patient with known ulcerative colitis should prompt a careful search for underlying cortical venous or dural sinus thrombosis. We suggest that patients be managed on individual basis and that thrombolysis could be considered for those patients who have severe neurologic deficit at admission or who continue to deteriorate despite optimal heparin therapy given severe mortality and morbidity associated with disease. This mode of management may be used even in the presence of ulcerative colitis with close monitoring for bleeding complication.

 
   References Top

1.Lossos A, River Y, Eliakim A, Steiner I. Neurologic aspects of inflamatory bowel disease. Neurology 1995;45:416-9.  Back to cited text no. 1
[PUBMED]    
2.Chaun H, Beckman JH, Sparling TG. Cerebral venous thrombosis in ulcerative colitis and review of the literature. Gastroenterol 1991;15:129-32.  Back to cited text no. 2
    
3.Averback P. Primary cerebral venous thrombosis in young adults: The diverse manifestations of an underrecognized disease. Ann Neurol 1978;3:81-6.  Back to cited text no. 3
[PUBMED]    
4.Cecchi L, Gianni R, Santoro E, Leopardi A, Taccetti G, Baruffi MC, et al. Thrombosis of the superior sagittal sinus and ulcerative colitis. A case report. Ann Ital Med Int 1992;7:176-8.  Back to cited text no. 4
[PUBMED]    
5.Moriyama E, Shinohara C, Tokunaga K, Kamitani M, Norikane H, Matsumoto Y, et al. Cerebral sinus thrombosis in a patient with ulcerative colitis-case report. Neurol Med Ohir (Tokyo) 1992;32:232-5.  Back to cited text no. 5
    
6.Musio F, Older SA, Jenkins T, Gregorie EM. Case report: Cerebral Venous Thrombosis as a Manifestation of Acute Ulcerative Colitis. Am J Med Sci 1993;305:28-35.  Back to cited text no. 6
[PUBMED]    
7.Yerby MS, Bailey GM. Superior sagittal sinus thrombosis 10 years after surgery for ulcerative colitis. Stroke 1980;11:294-6.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Umit H, Asil T, Celik Y, Tezel A, Dokmeci G, Tuncbilek N, et al. Cerebral sinus thrombosis in patients with inflammatory bowel disease: A case report. World J Gastroenterol 2005;11:5404-7.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Papi C, Ciaco A, Acierno G, Di Battista G, Talamanca LF, Lo Russo F, et al. Severe ulcerative colitis, dural sinus thrombosis, and the lupus anticoagulant. Am J Gastroenterol 1995;90:1514-7.  Back to cited text no. 9
[PUBMED]    
10.Das R, Vssishta RK, Banerjee AK. Aseptic cerebral venous thrombosis associated with idiopathic ulcerative colitis: A report of two cases. Clin Neurol Neurosurg 1996;98:179-82.  Back to cited text no. 10
    
11.Derdeyn CP, Powers WJ. Isolated cortical venous thrombosis and ulcerative colitis. AJNR Am J Neuroradiol 1998;19:488-90.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Philips MF, Bagley LJ, Sinson GP, Raps EC, Galetta SL, Zager EL, et al. Endovascular thrombolysis for symptomatic cerebral venous thrombosis. J Neurosurg 1999;90:65-71.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Tsujikawa T, Urabe M, Bamba H, Andoh A, Sasaki M, Koyama S, et al. Haemorrhagic cerebral sinus thrombosis associated with ulcerative colitis: A case report of successful treatment by anticoagulant therapy. J Gastroenterol Hepatol 2000;15:688-92.   Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.Wasay M, Bakshi R, Kojan S, Bobustuc G, Dubey N, Unwin DH. Nonrandomized Comparison of Local Urokinase Thrombolysis Versus Systemic Heparin Anticoagulation for Superior Sagittal Sinus Thrombosis Editorial Comment Stroke 2001;32:2310-7.  Back to cited text no. 14
    
15.Srivastava AK, Khanna N, Sardana V, Gaekwad S, Prasad K, Behari M. Cerebral venous thrombosis in ulcerative colitis. Neurol India 2002;50:215-7.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
16.Murata S, Ishikawa N, Oshikawa S, Yamaga J, Ootsuka M, Date H, et al. Cerebral sinus thrombosis associated with severe active ulcerative colitis. Intern Med 2004;43:400-3.   Back to cited text no. 16
[PUBMED]  [FULLTEXT]  
17.Hasegawa H, Yokomori H, Tsuji T, Hirose R. Hemorrhagic cerebral sinus thrombosis in a case of controlled ulcerative colitis. Intern Med 2005;44:155.   Back to cited text no. 17
[PUBMED]  [FULLTEXT]  
18.Fischer CM, Smith JL, Sanchez LD. Headache in a patient with ulcerative colitis. Intern Emerg Med 2006;1 :155-9.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]


This article has been cited by
1 Neurologic Manifestations of Gastrointestinal and Liver Diseases
Josť M. Ferro,Sofia Oliveira
Current Neurology and Neuroscience Reports. 2014; 14(10)
[Pubmed]
2 result 1 Document Neurologic manifestations of inflammatory bowel diseases
Ferro, J.M., Oliveira, S.N., Correia, L.
Handbook of Clinical Neurology. 2014;
[Pubmed]



 

Top
Print this article  Email this article

    

 
   Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (609 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed1700    
    Printed57    
    Emailed1    
    PDF Downloaded46    
    Comments [Add]    
    Cited by others 2    

Recommend this journal