Downloaded from http://journals.lww.com/theneurologist by BhDMf5ePHKbH4TTImqenVNlUEzghFiXbpo9hUSxlFlFAWCaqQMzNmKAekkDaPiLL on 09/15/2020 Acute Seizures in Cerebral Venous Sinus Thrombosis Risk Factors and Prognosis Sibel Gazioglu, MD, Ahmet Yildirim, MD, Elif G. Kokturk, MD, Demet Seker, MD, Vildan Altunayoglu Cakmak, MD, and Sibel K. Velioglu, MD Background: Cerebral venous sinus thrombosis (CVST) often presents with acute seizures, and recurrent seizures may also be seen in the long term in some patients. The purpose of this retrospective study was to investigate the frequency and type of acute seizures and to define the risk factors. Methods: Sixty-two patients diagnosed with CVST between September 2007 and October 2018 were retrospectively evaluated for the occur- rence of acute seizures. Seizures which developed as a presenting symptom or occurred within 2 weeks of diagnosis were defined as acute seizures. Demographic, clinical, and radiologic characteristics were compared between patients with or without acute seizures. Results: Twenty (32.3%) of the 62 CVST patients had acute seizures. Univariate analysis revealed a significant association between acute seizures and aphasia (P = 0.03), motor deficit (P < 0.001), sensory deficit (P = 0.018), severe ( ≥ 3) modified Rankin Scale scores on admission (P = 0.017), sagittal sinus thrombosis (P = 0.037), cortical vein thrombosis (P < 0.001), supratentorial lesions (P < 0.001), and hemorrhagic lesions (P < 0.001). Multivariate regression analysis identified supratentorial lesions (P = 0.015, odds ratio: 9.131, 95% confidence interval: 1.525-54.687) and cortical vein thrombosis (P = 0.034, odds ratio: 5.802, 95% confidence interval: 1.146-29.371) as independent factors for acute seizures. Although 25% of patients with acute seizures had recurrent seizures during hospitalization, only 2.6% of the 38 patients with long-term follow-up had recurrent seizures. Conclusions: Approximately one third of patients with CVST had acute seizures. Cortical vein thrombosis, supratentorial, and especially hem- orrhagic lesions were the most significant risk factors associated with acute seizures. Although seizure recurrence may occur early in the course, long-term recurrence is rare in CVST. Key Words: cerebral venous sinus thrombosis, acute, seizures, prognosis (The Neurologist 2020;25:126–130) C erebral venous sinus thrombosis (CVST) accounts for 0.5% to 1% of all strokes and the clinical presentation may vary from isolated headache to focal neurological symptoms and signs, seizures, and coma. 1,2 Epileptic seizures are known to be more frequent as a presenting symptom in CVST than in other types of stroke. 1,3–5 Epileptic seizures can occur in the early stage as a presenting symptom or within a few weeks after diagnosis and can start at later stages or recur in the long term. There is no specific guideline recommendation concerning the time required between seizure and stroke for the classification of seizures as acute; how- ever, the most commonly accepted time is within 2 weeks of diagnosis of stroke. 6 Seizures which develop as a presenting symptom or which occur within 2 weeks of the diagnosis are usually classi fied as acute seizures, while those which develop after this period are classified as late seizures. 6 Approximately one third of patients are reported to present with seizures before diagnosis, and nearly half have acute seizures in the early stages. 7–10 Although antiepileptic drug (AED) treatment is usually recom- mended in acute seizures, the optimal duration of treatment for is unknown. 4 Knowing the risk factors for and long-term prognosis of acute seizures after CVST may be helpful in both the early detection of patients at risk for epileptic seizures and in providing patients with proper treatment and information. The purpose of this retrospective study was to investigate the frequency and type of acute seizures and to define the risk factors for acute seizures in patients with CVST. We also assessed the treatment details, including the type of prescribed AED, duration of antiepileptic treatment, and long-term follow-up of seizures. METHODS Sixty-two patients diagnosed with CVST between September 2007 and October 2018 were included in this study. All patients’ medical records were reviewed retrospectively. All cases were diagnosed based on clinical presentation, magnetic resonance imaging, and magnetic resonance venography. Demographic and clinical characteristics, predisposing risk factors, radiologic features including occluded sinus and/or cerebral vein, and the type and location of parenchymal lesions were recorded. Functional dis- ability caused by presenting symptoms was assessed using the modified Rankin Scale (mRS) on admission. Presence or absence of seizure, time of onset of seizures, type, and frequency of seiz- ures, occurrence of status epilepticus (SE), and treatment details were recorded. Seizures were classified as focal onset, focal to bilateral tonic-clonic, or generalized onset seizures according to the International League Against Epilepsy (ILAE) 2017 operational classification of seizure types. 11 Seizures occurring as a presenting symptom or within 2 weeks’ diagnosis of CVST were classified as acute seizures. 6,12 Classification of the seizures in patients pre- senting with seizures depends on the description of the attack by a witness. No patients had a previous history of epilepsy before the diagnosis of CVST. Patients with at least 12 months’ regular follow-up visit data were included in the follow-up part of the study. The beginning of the follow-up period was regarded as beginning after the patients’ discharge. Information regarding long-term follow-up was obtained from outpatient clinic medical records. We also telephoned all patients with acute seizures, and if contact was made, we recorded the latest information con- cerning seizures and treatment. The presence of recurrent (2 or more) seizures and, if applicable, the time of seizure recurrence, type of seizures, treatment details in terms of type and dosage of From the Department of Neurology, Medical Faculty of Karadeniz Tech- nical University, Trabzon, Turkey. The authors declare no conflict of interest. Correspondence to: Sibel Gazioglu, MD, Department of Neurology, Medical Faculty of Karadeniz Technical University, Trabzon 61080, Turkey. E-mail: sibelgazioglu@hotmail.com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 2331-2637/20/2505-0126 DOI: 10.1097/NRL.0000000000000288 ORIGINAL ARTICLE 126 | www.theneurologist.org The Neurologist  Volume 25, Number 5, September 2020 Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.