RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION.

1.  NAME OF THE CANDIDATE:DR R LAKSHMI VISRUJA

AND ADDRESS.

(In block letters) NO 186, 4TH MAIN

BEML LAYOUT

BASAVESWARANAGAR

BANGALORE-560079

2.  NAME OF THE INSTITUTION:BANGALORE MEDICAL COLLEGE In block letters AND RESEARCH INSTITUTE,

BANGALORE.

3.  COURSE OF STUDY: M.D. IN GENERAL MEDICINE.

AND SUBJECT

4.  DATE OF ADMISSION:02-05-2009.

TO THE COURSE

TITLE OF THE TOPIC: CEREBRAL VENOUS THROMBOSIS-A CLINICORADIOLOGICAL STUDY

5.  BRIEF RESUME OF THE INTENDED WORK:

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. Incidence is 3-4 cases per million. This distinct condition frequently affects young adults and children. Puerperal CVT has been reported to be 10-12 times more frequent in India than the West(1) .

The presenting features of CVT usually depend on the sinuses involved, pace of occlusion, involvement of cortical veins and the presence of collaterals. Mode of onset is acute, subacute or chronic. CVT has four patterns/syndromes- syndrome of acute motor deficit, syndrome of increased intracranial tension without motor weakness, syndrome of cavernous sinus thrombosis, syndrome of deep venous thrombosis(2) .

The common symptoms include headache, focal seizures, vomiting, focal deficits and fever. The most frequent symptom is headache in over 90% of patients. Seizures occur in about 40-70% of patients. Neurologic signs develop in half of patients with sinus thrombosis and include monoparesis, hemiparesis or paraparesis.

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..

REVIEW OF LITERATURE:

·  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%(2).

·  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(3).

·  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 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(5).

·  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(6).

·  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(7).

·  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(8).

OBJECTIVE 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 stroke in patients of stroke in our

population

6.  MATERIALS AND METHODS:

SOURCE OF DATA:

The present study will be conducted in the Department of Medicine, Victoria hospital & Bowring and Lady Curzon hospital, Bangalore medical college and research institute, Bangalore. Cerebral venous thrombosis patients admitted to the hospital will be taken for the study.

METHOD OF COLLECTION OF DATA:

Definition of study

·  Study subjects: Fifty patients admitted to the hospital with diagnosis of cerebral venous thrombosis, with or without clinical findings, during the period of data collection/study period satisfying the inclusion and exclusion criteria will be taken for the clinicoradiological study.

Inclusion criteria:

·  Patients diagnosed by the imaging studies.

·  Any age group presenting with Cerebral venous thrombosis.

·  Puerperal and non puerperal group

Exclusion criteria:

·  Hypertension

·  Primary seizure disorders

·  HIV positive cases.

7.1 Study methods:

The present study is a clinical study.

·  The study period is from october-2009 to September 2011.

·  A total of 50 patients of Cerebral venous thrombosis are taken for study

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

7.2 Statistical methods.

Statistical analysis is performed using Chi square test and correlation.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY.

NO

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.

·  RBS, Lipid profiles.

·  CT scan of Brain

·  Fundus examination

·  MR venography under special circumstances

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASEOF 7.3?

YES

8.0 LIST OF REFERENCES: JOURNALS AND TEXT BOOKS:

1. D Nagaraja. Cerebral veno-sinus thrombosis. Shah S N API – Text book of medicine.8th ed.Mumbai:The Association of Physicians of India;2008. p.1165-67.

2. D Nagaraja. Veno-occlusive disease of the brain.Ravindra Kumar Garg,editor. Reviews in tropical neurology.2002.p.199-212.

3. 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

4. Rao KCVG, Knipp HC, Wagner EJ. Computed tomography findings in cerebral sinus and venous thrombosis. Radiology. 1981;140:391-398.

5. 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.

6. Bousser MG, Chiras J, Bories J, Castaigne P. Cerebral venous thrombosis-a review of 38 cases. Stroke 1985:16 (2): 199–213.

7. Wasay M, Azeemuddin M. Neuroimaging of cerebral venous thrombosis. J Neuroimaging.2005;15(2):118-28.

8. Isabelle Crassard, Marie-Germaine Bousser. Cerebral venous thrombosis. J Neuro-Ophthalmol 2004;24:156-63.

9. Christopher R, Nagaraja D, Dixit NS, Narayanan CP. JCR: Journal of Clinical Rheumatology:2007;13(4):238-239

10. Marie-Germaine Bousser, Jose M Ferro. Cerebral Venous Thrombosis. Lancet Neurol 2007;6:162-70

11. Karthikeyan D, Vijay S, Kumar T, Kanth L. Cerebral venous thrombosis-spectrum of CT findings. Indian J Radiol Imaging 2004;14:129-37.

12. Didier Leys, Charlotte Cordonnier. Cerebral venous thrombosis: Update on clinical manifestations, diagnosis and management. Ann Indian Acad Neurol 2008;11:79-87.

13. Cerebral venous thrombosis. Walter George Bradley. Neurology in clinical practice.4th ed.Philadelphia:Butterworth Heinemann;2004. p.1243-46.

9.0 SIGNATURE OF THE CANDIDATE:

DR.R LAKSHMI VISRUJA

10.0: REMARKS OF THE GUIDE:

Incidence of Cerebral venous thrombosis is higher in Indian population compared to Western population. This study has been undertaken to understand the varied presentations and to compare the clinical findings with radiological features. Also the presenting patterns of Puerperal and Non-puerperal groups will be compared.

11.0: NAME AND DESIGNATION OF THE GUIDE:

(In block letters)

11.1 GUIDE; PROF. DR. VASANTHA KAMATH. M.D, FICP

WHO Fellow in Rheumatology,

PROFESSOR AND HEAD,

DEPARTMENT OF MEDICINE,

BANGALORE MEDICAL COLLEGE AND

RESEARCH INSTITUTE, BANGALORE

.

11.2 SIGNATURE:

11.3 CO-GUIDE (IF ANY): PROF. DR. D.NAGARAJA D.P.M,D.M in Neurology,

FAMS,FIAN,FICP

DIRECTOR AND VICE-CHANCELLOR

PROFESSOR OF NEUROLOGY

NIMHANS

BANGALORE

11.4 SIGNATURE OF THE CO-GUIDE:

11.5 HEAD OF THE DEPARTMENT: PROF.DR.VASANTHA KAMATH. M.D,FICP

WHO Fellow in Rheumatology,

PROFESSOR AND HEAD,

DEPARTMENT OF MEDICINE,

BANGALORE MEDICAL COLLEGE

. AND RESEARCH INSTITUTE

BANGALORE

11.6 SIGNATURE:

12.12.1REMARKS OF THE CHAIRMAN & PRINCIPAL:

12.2 SIGNATURE: