Rajiv Gandhi University of Health Sciences, Karnataka s18

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

: DR.KOTTE NAGARJUNA REDDY, Name of the candidate and DEPARTMENT OF GENERAL MEDICINE, 1 address ( in block letters) MAHADEVAPPA RAMPURE MEDICAL, COLLEGE, GULBARGA-585105. Permanent address : DR.KOTTE NAGARJUNA REDDY, S/O K.KONDAREDDY, P.VENGANNAPALLI VILLAGE,PUPPALA POST, YADIKI MANDAL, ANANTAPUR DISTRICT, ANDHRA PRADESH : H.K.E. SOCIETY’S MAHADEVAPPA 2 Name of the institution RAMPURE MEDICAL COLLEGE, GULBARGA – 585105. 3 Course of study and subject : M.D (GENERAL MEDICINE) : 4 Date of admission to the course 30-05-2012 : CLINICAL AND NEUROIMAGING CORRELATION IN PATIENTS WITH CEREBRAL VENOUS THROMBOSIS 5 Title of Topic ADMITTED IN BASAVESWARA TEACHING AND GENERAL HOSPITAL,GULBARGA 6 Brief Resume of the intended work 6.1 Need for the study

Cerebral veno-sinus thrombosis involves the thrombosis of the cortical veins and the draining venous sinuses, either alone or in combination.

Cerebral sinus-venous thrombosis (CSVT) is a rare life-threatening disease with an estimated annual incidence of 3-4 cases per million in adults and 7 cases per million in neonates. Brain tumors, cerebral infections and traumas are local risk factors for CSVT, but the commonest encountered risk factors are oral contraceptive use, pregnancy and puerperium that make the disease predominant in female sex. In 15- 20 % of patients, the disease remains unprovoked, i.e., occurring in the absence of predisposing factors.(1)

Presentation complaints of the patients were as follows in order: acute and/or sub- acute headache (80.8%), impaired consciousness (25.5%), ear complaints (21.3%), paresis (19.1%) and epileptic seizures (14.9%). Chronic daily headache without any signs of neurological deficit was found in 10.6% of cases. Neurologic examinations of 40.4% of the CSVT patients were found to be normal. The sigmoid sinus was found to be involved in 35 patients (74.5%), the transverse sinus in 29 (61.7%) and superior sagittal sinus in 21 (44.7%). Impaired consciousness (p = 0.046), hemorrhagic infarct (p = 0.017), acute onset (p = 0.026), and presence of hemiparesis (p = 0.019) were found to be associated with increased mortality.(2)

Internal jugular vein abnormality closely correlated with the development of CVST, which is a newly identified risk factor for CVST.(3)

CT of the brain is useful to rule out many of the conditions that can be mimicked by CVT. It can also show abnormalities suggestive of CVT. The imaging features primarily caused by the occlusion are called direct signs-cord sign, dense triangle sign, empty delta sign. Indirect signs are due to secondary effects- gyral enhancement, tentorial enhancement, edema, hemorrhagic and ischemic infarctions. Incidence of cord and empty delta sign is 2-21%(2).CT venography, MRI, MR angiography, MR venography are investigations done in CVT.

Examination of CSF is useful for excluding infection, identifying blood in the subarachnoid space, quantifying intracranial tension. The CSF formula is often abnormal, with an elevated protein levels, excessive blood cells or leukocytosis.

The current study is undertaken to study the pattern and incidence of the clinical symptoms and signs, radiological findings and their correlation..

6.2 Review of Literature  A study conducted by Department of Radiology, Division of Neuroradiology, University of Maryland Hospital, Baltimore showed empty delta sign in 33%, gyral enhancement in 32%, small ventricles in 30%,normal CT in 10% of patients.(4)  A study conducted in Salpetriere Hospital, France showed headache in 74%,papilledema in 45%,hemiplegia in 34%,seizures in 29%.CT findings showed small ventricles in 50%,diffuse or localized swelling in 30%,gyral enhancement in 30%,empty delta sign in12%,tentorial enhancement in 15% of patients.(5)  A study conducted in Department of Neurology, Rashid hospital, Dubai, Aga Khan University hospital, Karachi showed that headache in 88%, focal motor deficits in 45%,seizures in 39%,mental status changes in 37%,papilledema in 35%,visual symptoms in 16%,fever in 16%,dysarthria in 14% of patients.(6)  A study conducted in Department of Neurology,Lariboisiere hospital, France showed headache in 80%, papilledema in 50%, seizures in 40%, focal signs in 30-80%,.In upto 30% CT was normal.(7)  In a study conducted in Department of Neurology, NIMHANS, Bangalore, showed headache in 80%, seizures primary generalized in 40% followed by secondary generalization in 30%, isolated intracranial hypertension in 20%, syndrome of acute motor deficits in 70% of patients. Incidence of cord and empty delta sign to be 2-21% (8).  A study conducted in Departments of Neurology and Radiology, National Taiwan University Hospital, Taipei, Taiwan, showed seizures in 70%, signs of intracranial hypertension in 60%,hemiplegia in 60%,fever in 50%.CT findings were focal hypodensity area with mass effect in 87%,cord sign in 50%,gyral enhancement in 77%,empty delta sign in 22% of patientS.(9)  A study conducted in Department of Radiology, University of Florida college of Medicine, Gainesville showed empty delta sign in 28.6%, dense vein in 20%,compressed ventricles in14%,unilateral hemorrhage in 8.5% of patients. (10).  Didier leys,charlotte cordonnier et al CVT is nowadays a disease that is easy to diagnose with MRI provided the clinician raised this hypothesis even in patients with only mild and nonspecific symptoms. (11)  Karthikeyand,vijay s, et al,The clinical manifestations of CVT are often vague and are easily mistaken for those caused by other neurological disease processes. NECT is the most common initial imaging study for many of the clinical diagnostic considerations that CVT mimics. The characteristic CT appearances and signs strongly suggest CVT but CT is seldom conclusively diagnostic.(12)

6.3 Objectives of the study

1)To study the pattern and frequency of clinical presentation 2) To study the varied findings and its incidence In CT scan studies 3) To correlate the clinical findings with radiological findings 4) To study incidence of venous strokes in patients of strokes in our population.

7 Materials and methods 7.1 Source of data Cerebral venous thrombosis patients admitted to the BASAVESWARA TEACHING AND GENERAL HOSPITAL GULBARGA, will be taken for the study. 7.2 Methods of collection of data

Definition of the study:

Study subjects: patients admitted in Basaveswara teaching and General hospital, Gulbarga with suspecting clinical features of cerebral venous thrombosis , during the period of data collection/study period satisfying the inclusion and exclusion criteria will be taken for the clinicoradiological study.

Inclusion criteria:

1. Patients with suspected cerebral venous thrombosis by clinical features, 2. Any age group presenting with Cerebral venous thrombosis, 3. Puerperal and non puerperal group.

Exclusion criteria:

1. Hypertension, 2. Primary seizure disorder, 3. HIV positive patients, Study method:

The present study is a clinical and neuroimaging correlation in patients with cerebral venous thrombosis admitted in Basaveswara teaching and General hospital, Gulbarga.   THE STUDY PERIOD: is from NOVEMBER-2012 to SEPTEMBER- 2014  STUDY SAMPLE SIZE : A total of 50 patients of Cerebral venous thrombosis are taking for study.

All these patients are evaluated thoroughly by clinical, radiological, laboratory methods. All patients will undergo CT scan study.

Statistical methods:

Statistical analysis is performed using Chi square test and correlation.

Following investigations are needed for the study.

 Hb%, TC, DC, ESR, platelet count.  BT,CT,PT with INR, aPTT  CSF analysis  Blood Urea, Serum creatinine & electrolytes.  Urine routine.  ECG  Elisa for HIV.  CT scan of Brain  Fundus examination  MR venography under special circumstances  RBS,Lipid profile. .

Does the study require any investigation on intervention to be conducted on 7.3 patient or other humans or animals? if so describe briefly.

7.4 HAS Ethical clearance been obtained from your institution in case of 7.3 Yes, Ethical clearance has been obtained from research and dissertation committee/ethical committee of the institution for the study 8 LIST OF REFERENCES: 1. Martinelli I, Passamonti SM, Rossi E, De Stefano V Cerebral sinus venous thrombosis Intern Emerg Med. 2012 Oct;7 Suppl 3:221-5. doi: 10.1007/s11739-012-0806-9.. 2. Uzar E, Ekici F, Acar A, Yucel Y, Bakir S, Tekbas G, Oncel O, Tasdemir N. Cerebral venous sinus thrombosis: an analyses of 47 patients. Eur Rev Med Pharmacol Sc i. 2012 Nov;16(11):1499-5Format 3. Jia LY, Hua Y, Ji XM, Liu JT. Correlation analysis of internal jugular vein abnormalities and cerebral venous sinus thrombosis. Chin Med J (Engl). 2012 Oct;125(20):3671-4. 4. Rao KCVG, Knipp HC, Wagner EJ. Computed tomography findings in cerebral sinus and venous thrombosis. Radiology. 1981;140:391-398. 5. Bousser MG, Chiras J, Bories J, Castaigne P. Cerebral venous thrombosis-a review of 38 cases. Stroke 1985:16 (2): 199–213 6. Wasay M, Azeemuddin M. Neuroimaging of cerebral venous thrombosis. J Neuroimaging.2005;15(2):118-28. 7. Isabelle Crassard, Marie-Germaine Bousser. Cerebral venous thrombosis. J Neuro-Ophthalmol 2004;24 :156-63. 8. D Nagaraja. Veno-occlusive disease of the brain.Ravindra Kumar Garg,editor. Reviews in tropical 9. Rong-Guey Horng, Ping-Keung Yip, Wen-Yih Teeng, Hon-Man Liu, Hou- Chang Chiu, Rong-chi Chen. Cerebral venous thrombosis:clinical and radiological analysis of 9 angiographically proven patients. Acta Neurologica Sinica 1992;1:37-43 10.Chat Virapongse, Craig Cazenave, Ronald Quisling, Mohammad Sarwar, Steve Hunter. The empty delta sign:frequency and significance in 76 cases of dural venous thrombosis. Radiology 1987;162:779-85. 11.Didier Leys, Charlotte Cordonnier. Cerebral venous thrombosis: Update on clinical manifestations, diagnosis and management. Ann Indian Acad Neurol 2008;11:79-87. 12.Karthikeyan D, Vijay S, Kumar T, Kanth L. Cerebral venous thrombosis- spectrum of CT findings. Indian J Radiol Imaging 2004;14:129-37 9 Signature of Candidate

Good and informative, this study is done first 10 Remarks of guide time in this part of Karnataka.

11 11.1 Dr. BASAVARAJ MANGSHETTY, Name and designation M.D of the Guide Professor , Department of General medicine, M.R Medical College, Gulbarga.

11.2 Signature

11.3 Co- guide (if any)

11.4 Signature

Dr.VEERANNA 11.5 Head of the Department M.D,DM. Professor and head , Department of general medicine, M. R Medical College, Gulbarga.

11.6 Signature

12 12.1 Remarks of the Chairman and Principal

12.2 Signature