LETTERS TO THE EDITOR
|Year : 2022 | Volume
| Issue : 3 | Page : 569-572
Predictors of late seizures in patients with cerebral venous sinus thrombosis: A retrospective analysis
Pritam Raja1, Ravindranadh C Mundlamuri1, Prathyusha P Vasuki2, Girish B Kulkarni1, Raghavendra Kenchaiah1, Ajay Asranna1, LG Viswanathan1, Rohan Mahale1, VH Ganaraja1, Shamick Biswas3, Karthik Kulanthaivelu3, Sanjib Sinha1
1 Department of Neurology, NIMHANS, Bengaluru, Karnataka, India
2 Department of Biostatistics, NIMHANS, Bengaluru, Karnataka, India
3 Department of NIIR, NIMHANS, Bengaluru, Karnataka, India
|Date of Submission||14-Oct-2021|
|Date of Acceptance||24-Jan-2022|
|Date of Web Publication||25-Jun-2022|
Ravindranadh C Mundlamuri
Department of Neurology, NIMHANS, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raja P, Mundlamuri RC, Vasuki PP, Kulkarni GB, Kenchaiah R, Asranna A, Viswanathan L G, Mahale R, Ganaraja V H, Biswas S, Kulanthaivelu K, Sinha S. Predictors of late seizures in patients with cerebral venous sinus thrombosis: A retrospective analysis. Ann Indian Acad Neurol 2022;25:569-72
|How to cite this URL:|
Raja P, Mundlamuri RC, Vasuki PP, Kulkarni GB, Kenchaiah R, Asranna A, Viswanathan L G, Mahale R, Ganaraja V H, Biswas S, Kulanthaivelu K, Sinha S. Predictors of late seizures in patients with cerebral venous sinus thrombosis: A retrospective analysis. Ann Indian Acad Neurol [serial online] 2022 [cited 2022 Aug 9];25:569-72. Available from: https://www.annalsofian.org/text.asp?2022/25/3/569/345413
Cerebral venous sinus thrombosis (CVST) is a subtype of stroke with extremely varied clinical presentations and imaging findings, and it has good outcomes in the majority. The annual incidence of CVST is approximately 2–5 cases per million per year population. It typically occurs in young adults. It has been reported that up to 44.3% of patients may have seizures in the early stage of the disease, and 9.5% of patients may have late seizures. Seizures secondary to CVST are categorized into early/acute symptomatic (within 14 days after the diagnosis) and late/remote symptomatic seizures (beyond 14 days after diagnosis). In a study by Ferro et al., late seizures were more frequent in CVST patients with early symptomatic seizure and hemorrhagic infarct. In another study by Sánchez van Kammen et al., early seizure, intracerebral hemorrhage, subdural hematoma, and decompressive hemicraniectomy were found to be predictors of late seizures. However, there is no clear consensus on the validity of these predictors. In the present study, we tried to find the predictors of late seizures in patients with CVST, based on clinical, imaging, and biochemical variables.
We conducted a retrospective, cross-sectional, single center, hospital-based study. The hospital registry was screened retrospectively to identify records with a diagnosis of acute CVST from July 2019 to January 2013. Fifty consecutive patients diagnosed with acute CVST and available for follow-up to a minimum of 1 yearin each subgroup i.e., a) without seizures, b) with only early seizures, and c) with late seizures were included in the study [Figure 1]. Patients with seizures secondary to antiseizure medications (ASMs) withdrawal, alcohol withdrawal seizures, and patients with a history of seizures in the past were excluded from the study.
The demographic and clinical characteristics and imaging features of these three subgroups are described in the table [Table 1] and [Table 2]. The median (IQR) age for the late seizure subgroup was 35 (27.7–47.2) years, the early seizure subgroup was 36 (27.544.0) years, and for the no seizure subgroup was 34 (27.5–40.2) years. The gender ratio (M:F) in the late, early, and no seizure subgroups were 21:29, 19:31, and 29:21, respectively. Forty-six (92%) of 50 patients with late seizure were on ASMs, of which 30 (65%) patients were on single ASMs only. The median duration of first late seizure recurrence was 8.5 (4–18.25) months. During a median (IQR) follow-up duration of 22 (12–30) months, 12 (24%) of 50 patients had more than one episode of late seizure. Late-recurrence of seizures were more commonly found in patients with a motor deficit (χ2 = 8.067, P = 0.018) and language dysfunction (χ2 = 7.197, P = 0.027) at presentation. On imaging, hemorrhagic infarct (χ2 = 10.69, P = 0.005), involvement of frontal lobe (χ2 = 29.91, P < 0.001), raised intracranial pressure, and cortical vein thrombosis (χ2 = 11.67, P = 0.003) were found to be significantly associated with late seizures as per the univariate analysis. The risk factor in the form of alcohol consumption (χ2 = 10.16, P = 0.001) was also found to be significantly associated with late seizures [Table 1]. Multinomial regression analysis was done to analyze the data. The deviance Chi-square test suggested that the model was fit for data analysis. Regression analysis showed that the patients with frontal lobe involvement (P = 0.044) and hemorrhagic stroke (P = 0.002) were more likely to be associated with late seizures in comparison to the patient with no seizure group. While in comparison to the early and late seizure group, cortical vein involvement and frontal lobe involvement were more likely to be associated with late seizures. The correct classification percentage of the fitted model is 68% (Supplementary data).
|Table 1: Demographic, baseline clinical profile, laboratory investigation of patients|
Click here to view
Seizures and epilepsy can influence the management and outcome of CVST, both in the acute stage as well as in follow-up. The appropriate and rational use of ASMs is essential for better outcomes. Predictors of seizure occurrence in early and late phases CVST will help the clinicians to decide on initiation as well as the duration of treatment with ASMs. Multiple large cohort studies have shown that the presence of focal deficits, hemorrhagic infarct, the involvement of frontal lobe, and superior sagittal sinus was significantly associated with the occurrence of early seizures in patients with CVST.,,, However, much less is known about predictors of late seizures. Hence, the present study aimed at determining the predictive factors for late seizures in patients with CVST. On multinomial regression analysis, frontal lobe involvement and hemorrhagic infarct were significantly associated with late seizures when compared with the “no seizures” group. This is the first time we are proposing the involvement of the frontal lobe in patients with CVST as a predictor for late seizures, which needs to be confirmed in prospective studies. The hemorrhagic infarct and cortical involvement are found to be associated with late seizure in other stroke types. The subdural hematoma and decompression surgery were not found to be significantly associated with the late seizures in the current study. In this study, of 50 patients with late seizures, 46 (92%) patients had early seizures as well suggesting it as a predictor for late seizures, but the prevalence of late seizures in the early seizures subgroup has not been studied. Other studies attempted to determine the predictors of late seizures were compared [Table 3]. The late seizures as well as the duration of ASMs in patients CVST can have a negative impact on the physical and mental health of patients, especially in women of childbearing age and their families. In this study, 32% of the patients had a seizure after 1-year symptom onset, whereas 12% of patients had seizure recurrence even after 2 years of symptom onset. The finding highlights that one should have a cautious approach while tapering ASM, especially when the patient has above described predictors of late seizures.
The strengths of the study were that it was a single center study with a relatively uniform treatment protocol and follow-up. The limitations of our study are the following: 1) retrospective data, 2) small sample size, and 3) full panel of investigations were not available uniformly for all patients. This might justify the need of a prospective study to determine the exact predictors for late seizures.
Statistical analyses by Dr P.V. Prathyusha, Research Assistant, Department of Biostatistics, NIMHANS, Bengaluru, 560029.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Devasagayam 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.
Capecchi M, Abbattista M, Martinelli I. Cerebral venous sinus thrombosis. J Thromb Haemost 2018;16:1918-31.
Ferro JM, Correia M, Rosas MJ, Pinto AN, Neves G. Seizures in cerebral vein and dural sinus thrombosis. Cerebrovasc Dis 2003;15:78-83.
Mahale R, Mehta A, John AA, Buddaraju K, Shankar AK, Javali M, et al
. Acute seizures in cerebral venous sinus thrombosis: What predicts it? Epilepsy Res 2016;123:1-5. doi: 10.1016/j.eplepsyres. 2016.01.011.
Sánchez van Kammen M, Lindgren E, Silvis SM, Hiltunen S, Heldner MR, Serrano F, et al
. Late seizures in cerebral venous thrombosis. Neurology 2020;95:e1716-23.
Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F. Prognosis of cerebral vein and dural sinus thrombosis: Results of the international study on cerebral vein and dural sinus thrombosis (ISCVT). Stroke 2004;35:664-70.
Ferro JM, Canhão P, Bousser MG, Stam J, Barinagarrementeria F. Early seizures in cerebral vein and dural sinus thrombosis: Risk factors and role of antiepileptics. Stroke 2008;39:1152-8.
Kalita J, Chandra S, Misra UK. Significance of seizure in cerebral venous sinus thrombosis. Seizure 2012;21:639-42.
Goyal G, Singh R. Predictors of presenting seizures in acute cerebral vein and dural sinus thrombosis. J Epilepsy Res 2020;10:74-8.
Zhang C, Wang X, Wang Y, Zhang JG, Hu W, Ge M, et al
. Risk factors for post-stroke seizures: A systematic review and meta-analysis. Epilepsy Res 2014;108:1806-16.
[Table 1], [Table 2], [Table 3]