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The Role of Corticosteroids in Primary Antiphospholipid Antibody Syndrome Presenting As Cerebral Venous Thrombosis in Young Females at Peripartum

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The Role of Corticosteroids in Primary Antiphospholipid Antibody Syndrome Presenting As Cerebral Venous Thrombosis in Young Females at Peripartum E. A. Ashok Kumar, P. Jijiya Bai. The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum. IAIM, 2016; 3(8): 97-110. Original Research Article The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum E. A. Ashok Kumar1*, P. Jijiya Bai2 1Professor, Department of Medicine, 2Professor, Department of Pathology, MNR Medical College and Hospital, Medak, Telangana, India *Corresponding author email: [email protected] International Archives of Integrated Medicine, Vol. 3, Issue 8, August, 2016. Copy right © 2016, IAIM, All Rights Reserved. Available online at http://iaimjournal.com/ ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Received on: 11-07-2016 Accepted on: 30-07-2016 Source of support: Nil Conflict of interest: None declared. How to cite this article: E. A. Ashok Kumar, P. Jijiya Bai. The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum. IAIM, 2016; 3(8): 97-110. Abstract The clinical study of cerebral venous thrombosis in antiphospholipid antibody syndrome in young females at peripartum was done to study the incidence of antiphospholipid antibodies in highly susceptible population groups most commonly at peripartum women. The presence of these antibodies points towards increased susceptibility to thrombosis and ischemic stroke apart from other manifestations in peripartum period. The age group most affected was between 20-25 years. Most of them were primipara. Many of the patients underwent Cesarean section before the presentation with the specific neurological complaint. None of the patients gave positive history for use of oral contraceptive pills. This study showed a 69% incidence of antiphospholipid antibodies out of the total patients studied. It was also found that 66% of the APL positive patients had radiological evidence of cerebral venous thrombosis. To help clarify the significance of aCL in CVT, this study was systematically analyzed and the clinical, radiological, treatment, and outcome information of patients with CVT tested for aCL immunereactivity at our institution and the pertinent literature was systematically reviewed. It was also studied that the most of the patients improved with corticosteroids. Page 97 E. A. Ashok Kumar, P. Jijiya Bai. The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum. IAIM, 2016; 3(8): 97-110. Key words Corticosteroids, Antiphospholipid antibody syndrome (APS), Cerebral venous thrombosis (CVT), Peripartum. Introduction Cerebral sinus venous thrombosis Antiphospholipid antibodies are predominantly Thrombosis of the venous channels in the brain acquired serum immunoglobulins with affinity is an uncommon cause of cerebral infarction for anionic and neutral phospholipid-containing relative to arterial disease but is an important moieties, such as cellular membranes of vascular consideration because of its potential morbidity. endothelium. The two most extensively studied Symptoms associated with the condition are aPL are the aCL and the LA [1, 2]. In the past related to the area of thrombosis. Cerebral decade, the antiphospholipid syndrome (APS) infarction may occur with cortical vein or sagittal has been described in which systemic and sinus thrombosis due to tissue congestion with cerebral venous and arterial occlusions are seen obstruction. Lateral sinus thrombosis may be at a relatively young age and with a relatively associated with headache and a pseudotumor high risk of recurrent thrombo-occlusive events cerebri like picture, Extension into the jugular [3-6]. bulb may cause jugular foramen syndrome; cranial nerve palsies may be seen in cavernous CVT is a rare disorder carrying a relatively high sinus thrombosis as a compressive phenomenon. mortality (10% to 15%) [7, 8]. With the advent of No racial predilection has been observed. CVT is MRI and MR angiography and digital subtraction believed to be more common in women than angiography, the prevalence and natural history men, in the age group of 20 to 35 years [11]. of CVT are being refined [9]. Risk factors for CVT include systemic non-infectious conditions Clinical features such as pregnancy and puerperium, Clinical features are Headache, Nausea and hyperviscosity syndromes, Behçet's disease, vomiting, Pseudotumor cerebri, Seizures or coagulopathies including activated protein C Coma, and Focal neurological deficit. Mental resistance and factor V Leiden mutation, and status may be quite variable, with patients collagen vascular diseases. showing no changes in alertness, developing mild confusion, or progressing to coma. Cranial The presence of aPL (aCL or LA) has been nerve findings may include papilledema, suggested as a risk factor for CVT, but the hemianopia, oculomotor and abducens palsies, clinical, radiological, and outcome profiles have facial weakness, and if the thrombosis extends to not been determined or systematically studied, the jugular vein, the patient may develop mainly because of the scarcity of the reported involvement of cranial nerves IX, X, XI, and XII cases. Whether the presence or absence of aPL in with jugular foramen syndrome. patients with CVT has clinical relevance remains unknown. Furthermore, the exact mechanism by Thrombosis of the superior sagittal sinus may which aPL promotes thrombosis and the therapy present with unilateral paralysis that then extends of choice also remain largely unknown. to the other side secondary to extension of the clot into the cerebral veins. Because of the Antiphospholipid syndrome (APS) causes location, this may present as a unilateral lower significant difficulties in obstetrics and extremity weakness or paraplegia. Cavernous pregnancy, including maternal venous and sinus thrombosis with obstruction of the arteraial thrombosis, fetal growth retardation, ophthalmic veins may be associated with infertility, and Recurrent Miscarriage Syndrome proptosis and ipsilateral periorbital edema. (RMS) [10]. Page 98 E. A. Ashok Kumar, P. Jijiya Bai. The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum. IAIM, 2016; 3(8): 97-110. Causes MRI Infection, Trauma, Pregnancy and puerperium, MRI shows the pattern of an infarct that does not Inflammatory bowel diseases, Hematological follow the distribution of an expected arterial conditions like PNH, TTP, polycythemia, sickle occlusion. It may show absence of flow void in cell anemia, Collagen vascular diseases, the normal venous channels. MR Venography Nephrotic syndrome ,dehydration, cirrhosis liver (MRV) is an excellent method of visualizing the and Hypercoagulable states like APLA dural venous sinuses and larger cerebral veins. syndrome, Protein C and protein S deficiency, Single-slice phase-contrast angiography AT III def, Factor V leiden mutation. (SSPCA) takes less than 30 seconds and provides rapid and reliable information. Many Laboratory Studies neurologists now consider it to be the procedure Clinical laboratory studies are useful for of choice in diagnosing cerebral venous determining the possible causes of thrombosis [12]. cerebral venous thrombosis (CVT). Diagnosis of the condition is made on CT scan the basis of clinical presentation and CT scan is an important imaging technique, as it imaging studies. is often the first imaging study obtained. It may Complete Blood Picture (CBP) is show evidence of infarction that does not performed to look for polycythemia as correspond to an arterial distribution. However, an etiologic factor. in the absence of a hemorrhagic component, Antiphospholipid and anticardiolipin demonstration of the infarct may be delayed up antibodies should be obtained to evaluate to 48-72 hours. CT scan of the mastoids may be for antiphospholipid syndrome. Other helpful in lateral sinus thrombosis. Empty delta tests that may indicate hypercoagulable sign (Figure - 1, 2) appears on contrast scans as states include protein S, protein C, enhancement of the collateral veins in the antithrombin III, lupus anticoagulant, superior sagittal sinus (SSS) walls surrounding a and Leiden factor V mutation. These non-enhanced thrombus in the sinus. However, evaluations should not be made while the the sign is frequently absent. The dense triangle patient is on anticoagulant therapy. sign formed by fresh coagulated blood in the SSS Sickle cell preparation or hemoglobin and the cord sign representing thrombosed electrophoresis should be obtained in cortical vein are extremely rare. CT Angiography individuals of African descent. (Figure - 3) has also been used to visualize the Erythrocyte sedimentation rate and cerebral venous system. CT venography was antinuclear antibody should be superior to MR in identification of cerebral veins performed for screening of systemic and dural sinuses. CT Venography was lupus erythematosus, Wegener’s equivalent to MR in identification of dural sinus granulomatosis, and temporal arteritis. If thrombosis and therefore is a viable alternative to elevated, further evaluation including MR Venography in the examination of patients complement levels, anti-DNA with suspected dural sinus thrombosis. antibodies, and neutrophil cytoplasmic antibodies (ANCA) could be considered. Contrast studies Urine protein should be checked and, if Carotid
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