Stroke Research and Treatment
Volume 2020 (2020), Article ID 8610903, 8 pages
https://doi.org/10.1155/2020/8610903

Research Article

Cerebral Venous Sinus Thrombosis in Women: Subgroup Analysis of the VENOST Study

Derya Uluduz,¹ Sevki Sahin,² Taskin Duman,³ Serefnur Ozturk,⁴ Vildan Yayla,⁵ Nazire Afsar,⁶ Nevzat Uzuner,⁷ Ipek Midi,⁸ Nilgun Cinar,² Mehmet Ali Sungur,⁹ Fusun Mayda Domac,¹⁰ Birsen Ince,¹ Baki Goksan,¹ Cemile Handan Misirli,¹¹ Mustafa Bakar,¹² Hasan Huseyin Kozak,¹³ Sena Colakoglu,³ Ali Yavuz Karahan,¹⁴ Eylem Ozaydin Goksu,¹⁵ Fatih Ozdag,¹⁶ Mehmet Guney Senol,¹⁶ Vedat Ali Yurekli,¹⁷ Ufuk Aluclu,¹⁸ Serkan Demir,¹⁹ Hayriye Kucukoglu,²⁰ Serdar Oruc,²¹ Nilufer Yesilot,²² Ozge Yimaz Kusbeci,²³ Bijen Nazliel,²⁴ Firdevs Ezgi Ucan Tokuc,¹⁵ Hesna Bektas,²⁵ Fatma Nida Tascilar,²⁶ Emrah Aytac,²⁷ Mustafa Gokce,²⁸ Hale Zeynep Batur Caglayan,²⁴ Ahmet Tufekci,²⁹ Gulnur Uzuner,⁷ Dilek Necioglu Orken,³⁰ Osman Ozgur Yalin,³¹ Uygar Utku,²⁸ Arda Yilmaz,³² Hamit Genc,³² Murat Cabalar,³³ Aysel Milanlioglu,³⁴ Hakan Ekmekci,⁴ Burcu Zeydan,³⁵ Sevim Baybas,³⁶ Yuksel Kablan,³⁷ Basak Karakurum Goksel,³⁸ Mustafa Acikgoz,²⁶ Hatice Kurucu,¹ Seden Demirci,³⁹ and Taskin Gunes⁴⁰

¹School of Medicine, Department of Neurology, Istanbul Cerrahpasa University, Istanbul, Turkey
²School of Medicine, Department of Neurology, Maltepe University, Istanbul, Turkey
³School of Medicine, Department of Neurology, Mustafa Kemal University, Hatay, Turkey
⁴Selcuk University, School of Medicine, Department of Neurology, Konya, Turkey
⁵University of Health Science, Hamidiye School of Medicine, Sadi Konuk Research and Training Hospital, Department of Neurology, Istanbul, Turkey
⁶Acibadem University, School of Medicine, Department of Neurology, Istanbul, Turkey
⁷Osmangazi University, School of Medicine, Department of Neurology, Eskisehir, Turkey
⁸Marmara University, School of Medicine, Department of Neurology, Istanbul, Turkey
⁹Duzce University, School of Medicine, Department of Biostatistics, Duzce, Turkey
¹⁰University of Health Science, Hamidiye School of Medicine, Erenkoy Research and Training Hospital for Neurologic and Psychiatric Diseases, Department of Neurology, Istanbul, Turkey
¹¹University of Health Science, Hamidiye School of Medicine, Haydarpasa Training and Research Hospital, Department of Neurology, Istanbul, Turkey
¹²Uludag University, School of Medicine, Department of Neurology, Bursa, Turkey
¹³Nemettin Erbakan University, School of Medicine, Department of Neurology, Konya, Turkey
¹⁴Usak University, School of Medicine, Department of Physical Medicine and Rehabilitation, Usak, Turkey
¹⁵Antalya Research and Training Hospital, Clinic of Neurology, Antalya, Turkey
¹⁶University of Health Science, Hamidiye School of Medicine, Sultan Abdulhamid Han Research and Training Hospital, Department of Neurology, Istanbul, Turkey
¹⁷Suleyman Demirel University, School of Medicine, Department of Neurology, Isparta, Turkey
¹⁸Dicle University, School of Medicine, Department of Neurology, Diyarbakır, Turkey
¹⁹Sancaktepe Research and Training Hospital, Clinic of Neurology, Istanbul, Turkey
²⁰Sultan Abdulhamid Research and Training Hospital, Clinic of Neurology, Istanbul, Turkey
²¹Kocatepe University, School of Medicine, Department of Neurology, Afyon, Turkey
²²Istanbul University, School of Medicine, Department of Neurology, Istanbul, Turkey
²³Bozyaka Education, Research and Traning Hospital, Clinic of Neurology, Izmir, Turkey
²⁴Gazi University, School of Medicine, Department of Neurology, Ankara, Turkey
²⁵Ataturk Research and Training Hospital, Clinic of Neurology, Ankara, Turkey
²⁶Bulent Ecevit University, School of Medicine, Department of Neurology, Zonguldak, Turkey
²⁷Firat University, School of Medicine, Department of Neurology, Elazig, Turkey
²⁸Sutcu Imam University, School of Medicine, Department of Neurology, Kahramanmaras, Turkey
²⁹Recep Tayyip Erdogan University, School of Medicine, Department of Neurology, Rize, Turkey
³⁰Bilim University, School of Medicine, Department of Neurology, Istanbul, Turkey
³¹Istanbul Research and Training Hospital, Clinic of Neurology, Istanbul, Turkey
³²Mersin University, School of Medicine, Department of Neurology, Mersin, Turkey
³³Sadi Konuk Research and Training Hospital, Clinic of Neurology, Istanbul, Turkey
³⁴Yuzuncu Yil University, School of Medicine, Department of Neurology, Van, Turkey
³⁵Mayo Clinic, College of Medicine, Department of Neurology, Rochester, MN., USA
³⁶Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurology Training and Research Hospital, Clinic of Neurology, Istanbul, Turkey
³⁷Inonu University, School of Medicine, Department of Neurology, Malatya, Turkey
³⁸Baskent University, School of Medicine, Department of Neurology, Ankara, Turkey
³⁹Akdeniz University, School of Medicine, Department of Neurology, Antalya, Turkey
⁴⁰Maltepe Government Hospital, Clinic of Neurology, Istanbul, Turkey

Correspondence should be addressed to Sevki Sahin; drsahin@gmail.com and Taskin Duman; taskinduman@yahoo.com

Received 30 November 2019; Accepted 15 May 2020; Published 1 September 2020

Academic Editor: Francisco Campos

Copyright © 2020 Derya Uluduz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. Early diagnosis of cerebral venous sinus thrombosis (CVST) associated with reproductive health-related risk factors (RHRF) including pregnancy, puerperium, and oral contraceptive (OC) use can prevent severe neurological sequelae; thus, the symptoms must be documented in detail for each group. Methods. Out of 1144 patients with CVST, a total of 777 women were enrolled from a multicenter for the study of cerebral venous sinus thrombosis (VENOST). Demographic, biochemical, clinical, and radiological aspects were compared for 324 cases with RHRF and 453 cases without RHRF. Results. The mean age of the RHRF (-) group (43.2 ± 13 years) was significantly higher than of the RHRF (+) group ( years). A previous history of deep venous thrombosis (3%), isolated cavernous sinus involvement (1%), cranial neuropathy (13%), comorbid malignancy (7%), and its disability scores after 12 months (9%) were significantly higher in the RHRF (-) group. The RHRF (+) group consisted of 44% cases of puerperium, 33% cases of OC users and 23% of pregnant women. The mean age was found to be higher in OC users ( years). A previous history of deep venous thrombosis was slightly higher in the pregnancy subgroup (4%). Epileptic seizures were more common in the puerperium group (44%). Conclusion. The results of our study indicate that the risk of CSVT increases parallel to age, OC use, and puerperium period. In addition, when considering the frequency of findings and symptoms, epileptic seizures in the puerperium subgroup of the RHRF (+) group and malignancies in the RHRF (-) group may accompany the CSVT. In daily practice, predicting these risks for the CSVT and early recognition of the symptoms will provide significant benefits to patients.

1. Introduction

Cerebral venous sinus thrombosis (CVST) is an uncommon form of stroke [1]. Several risk factors for CVST have been recognized including pregnancy, puerperium, oral contraceptive (OC) use, infections, inflammatory diseases, and thrombophilia. CVST is believed to be more common in women than in men [1, 2]. In addition, there is uniform age distribution in men, while 60% of women with CVST are clustered at 20-35 years old [1–4]. In some studies, one of third cases was clustered in periods of pregnancy and puerperium [5].

This study was performed to evaluate details about CVST among women and focused on reproductive health-related risk factors (RHRF) such as pregnancy, puerperium, and OC use.

2. Materials and Methods

This study includes 777 female CVST cases of the VENOST cohort. VENOST is a retrospective and multicenter observational study that includes 1144 patients with CVST diagnosed at 35 national neurology centers. In diagnosing CVST, the criteria defined in the VENOST study were used [1].

The patients were divided into two groups according to reproductive health-related risk factors (RHRF) such as oral contraceptive use, puerperium, and pregnancy as the RHRF (+) group and the RHRF (-) group. At the initial admission, both groups were evaluated according to demographics, clinical symptoms, and neurological signs. Radiological workup included brain computed tomography (CT), brain magnetic resonance imaging (MRI), MR venography, and/or digital subtraction angiography. Etiological factors, acute and maintenance treatment, and follow-up results were evaluated for each group. Then, the RHRF (+) group was divided into three subgroups according to risk factors such as oral contraceptive use, puerperium, and pregnancy, and these sub-groups were evaluated using the same risk factors. Putative etiological risk factors included the following: infections (systemic or paracranial infection—otitis media, mastoiditis, or sinusitis), systemic inflammatory diseases, rheumatologic or connective tissue disease, malignancies, and hematologic diseases; and other specified causes were recorded.

The type of onset was considered to be acute if the duration of symptoms was less than 48 hours on admission, subacute if the duration was between 48 hours and 1 month, and chronic if the symptom duration was longer than 1 month. The study was approved by the ethics committee of the coordinating center (Acceptance No. 83045809/604/02-12333).

3. Results

In this study, 58% () of the total 777 female cases were classified as RHRF (-) and 42% () of them as RHRF (+). The mean ages of the RHRF (+) group and the RHRF (-) group were and , respectively, and were significantly different.

Acute onset is more frequent in the RHRF (+) group, whereas a subacute chronic mode of onset is more common in the RHRF (-) group. The most common symptoms were headache, visual field defects, and cranial neuropathies in the RHRF (-) group and headache and epileptic seizure in the RHRF (+) group. The comparison of these two groups according to clinical symptoms and signs: epileptic seizures (34%), nausea and vomiting (33%), and focal neurologic deficit (25%), was more common in the RHRF (+) group and visual field defect (29%) and cranial nerve palsies (13%) were more common in the RHRF (-) group.

In the total female group investigations, CVST was diagnosed with cranial MRI and MRV in 682 patients, with cranial MRI in 46 patients, with only cranial MRV in 31 patients, and with cranial CT and MRV in 14 patients. Parenchymal lesions were detected in 333 (42.8%) female patients including 160 (49.3%) in the RHRF (+) group and 173 (38.1%) in the RHRF (-) group (). Parenchimal lesion involvement, especially hemorrhagic transformation (, 25%), was more common in the RHRF (+) group. Venous involvement was found in 1 sinus in 373 (48%) female patients, in 2 sinuses in 274 (35%) patients, and in more than 2 sinuses in 130 (17%) patients. In the comparison of these two groups, there was no difference in intravenous involvement. Transverse sinus involvement was the most common site thrombosis within the total female group (, 73%), within the RHRF (+) group (, 75%), and within the RHRF (-) group (, 73%). The sigmoid sinus and sagittal sinus involvements were followed by transverse sinus in two groups.

Demographic aspects and comparative data of cases with RHRF (+) and RHRF (-) are displayed in Table 1.

Table 1: Compared data of demographic and clinical aspects of groups.

Compared data
RHRF (-)
RHRF (+)

Age

    Years

%

%
<0.001

Mode of onset

    Acute
187a
42
195b
62

    Subacute
150a
34
82b
26
<0.001

    Chronic
110a
25
38b
12

Clinical symptoms and signs

    Isolated headache
119
26
66
20
0.057

    Headache
387
85
282
87
0.523

    Nausea and vomiting
116
26
107
33
0.024

    Epileptic seizures
98
22
110
34
<0.001

    Visual field defect
131
29
66
20
0.007

    Focal neurological deficit
72
16
81
25
0.002

    Altered consciousness
78
17
67
21
0.222

    Cranial nerve palsies
59
13
24
7
0.012

Radiological work-up

    Cranial MRI
23
5
23
7
0.492

    Cranial MRV
19
4
12
4

    Cranial MRI+MRV
398
88
284
88

    Cranial CT+MRV
10
2
4
1

Number of sinuses involved

    1 sinus
230
51
143
44
0.281

    2 sinuses
148
33
126
39

    More than 2 sinuses
75
16
55
17

Involved sinuses

    Isolated transverse sinuses
122
27
78
24
0.369

    Isolated sagittal sinuses
66
15
44
14
0.697

    Isolated sigmoid sinuses
18
4
7
2
0.158

    Isolated cortical veins
8
2
11
3
0.147

    Isolated jugular sinuses
9
2
1
0
0.052

    Isolated cavernous sinuses
6
1
0
0
0.044

    Transverse sinuses
329
73
243
75
0.459

    Sigmoid sinuses
183
40
127
39
0.736

    Sagittal sinuses
157
35
134
41
0.057

    Internal jugular vein
71
16
47
15
0.655

    Cortical veins
13
3
16
5
0.134

    Cavernous sinuses
12
3
3
1
0.085

Parenchymal involvement

    No lesion
280a
62
164b
51
0.003

    Infarction
87a
19
66a
20

    Hemorrhagic infarction
68a
15
80b
25

    Intracerebral hemorrhage
18a
4
14a
4

MRI: magnetic resonance imaging; MRV: magnetic resonance venography; CT: computed tomography.

A positive previous history of venous thromboembolism and malignancy was detected in 6% and 7% in the RHRF (-) group. Hematological parameters were completed in 206 (26.5%) patients, and no differences were detected between the two groups. When the RHRF (+) group was investigated, it was found to be the largest group in the puerperium period (43.8%) but the smallest group in the pregnancy period (22.8%). Rankin scores, which suggested neurological disability after 12 months, were found significantly high in the RHRF (-) group. Etiological factors and outcome according to groups are presented in Table 2.

Table 2: Comparison of etiological factors and outcome according to the RHRF (-) group or the RHRF (+) group.

Compared data
RHRF (-)
RHRF (+)

%
%

Infections

    Paracranial (focal) systemic
20
4
13
4
0.963

7
2
5
2

History of VTE

    Cerebral
11a
2
2a
0.6

    Deep venous thrombosis
14a
3
3b
1
0.024

    Other
6a
1
2a
0.6

    Malignancy
32
7
1
0.3
<0.001

    Family history VTE
5
1
1
0.3
0.409

    MTHFR mutation

    Heterozygote
19
7
9
4
0.120

    Homozygote
24
8
9
4

    Hyperhomocysteinemia
12
3
9
3
0.952

    Prothrombin mutation
5
2
7
3
0.249

    Protein C/S deficiency
25
7
13
5
0.302

    Factor V Leiden mutation
11
4
11
5
0.405

    Thrombocytosis
2
0.5
2
1
0.753

    Polycythemia vera
3
1
0
0
0.267

    Anticardiolipin Ab
2
0.5
1
0.4
0.752

    PAI mutation
4
1
2
1
0.681

    Antithrombin III deficiency
3
1
1
0.4
0.642

    Hyperfibrinogenemia
0
0
2
1
0.178

    Antiphospholipid Ab
7
2
4
2
0.767

    Activated protein C
5
1
4
2
0.892

    Resistance
13
4
4
2
0.114

    High ANA titers

First month Rankin

    0-1
304
80
236
81
0.276

    2
40
11
37
13

    >3
38
10
20
7

Third month Rankin

    0-1
287
89
227
91

    2
21
7
17
7
0.235

    >3
15
5
5
2

Sixth month Rankin

    0-1
262
90
215
96

    2
16
6
6
3
0.061

    >3
13
5
4
2

12th month Rankin

    0-1
239
91
185
97

    2
11
4
4
2
0.031

    >3
13
5
2
1

ANA: antinuclear antibody; MTHFR: methylenetetrahydrofolate reductase; PAI: plasminogen activator inhibitor; VTE: venous thromboembolism.

The mean age of OC users was higher than other groups. The mode of acute clinical onset was high in all subgroups of RHRF (+) cases. In addition, chronic onset and intracerebral hemorrhage ratio were found more frequently in the OC user group than in the other subgroups. Epileptic seizures were found to be significantly higher in the puerperium group. Demographic and clinical characteristics of subgroup analyses are shown in Table 3.

Table 3: Comparison of demographic and clinical characteristics of subgroups according to reproductive health-related risks.

Compared data of reproductive health-related risk factors
Pregnancy
Puerperium
Oral contraceptive use

, 23%
, 44%
, 33%

Age

    Years
a

a

b

<0.001

Mode of onset

    Acute
51a
70
85a
62
59a
56

    Subacute
14a
19
42a
31
26b
25
<0.030

    Chronic
8a,b
11
10b
7
20a
19

Clinical symptoms and signs

    Isolated headache
16
22
24
17
26
24
0.361

    Headache
69
93
117
82
96
89
0.062

    Nausea and vomiting
22
30
43
30
42
39
0.283

    Epileptic seizures
18a
24
63b
44
29a
27
0.002

    Visual field defect
17
23
28
20
21
19
0.817

    Focal neurological
11
15
41
29
29
27
0.068

    Deficit
16
22
34
24
17
16
0.277

    Altered consciousness
6
8
8
6
10
9
0.537

    Cranial nerve palsies

Radiological workup

    Cranial MRI
4
6
12
9
7
7
0.975

    Cranial MRV
3
4
6
4
3
3

    Cranial    MRI+MRV
65
89
122
86
97
90

    Cranial CT+MRV
1
1
2
1
1
1

Number of sinuses involved

    1 sinus
35
47
68
48
40
37
0.490

    2 sinuses
26
35
51
36
49
45

    More than 2 sinuses
13
18
23
16
19
18

Involved sinuses

    Isolated transverse
21
28
34
24
23
21
0.547

    Sinuses
11
15
20
14
13
12
0.838

    Isolated sagittal
2
3
3
2
2
1
0.926

    Sinuses
1
1
9
6
1
1
0.051

    Isolated sigmoid
0
0
1
1
0
0
0.526

    Sinuses
0
0
0
0
0
0
—

    Isolated cortical veins
57
77
99
70
87
81
0.132

    Isolated jugular sinus
30
41
53
37
44
41
0.830

    Isolated cavernous
25
34
60
42
49
45
0.284

    Sinuses
13
18
17
12
17
16
0.490

    Transverse sinuses
2
3
11
8
3
3
0.120

    Sigmoid sinuses
0
0
2
1
1
1
0.798

    Sagittal sinuses

    Internal jugular vein

    Cortical veins

    Cavernous sinuses

Parenchymal involvement

    No lesion
48a
65
63b
44
53b
49
0.002

    Infarction
12a
16
37a
26
17a
16

    Hemorrhagic
12a
16
40a
28
28a
26

    Infarction
2a
3
2a
1
10b
9

    Intracerebral

    Hemorrhage

MRI: magnetic resonance imaging; MRV: magnetic resonance venography; CT: computed tomography.

A history of deep venous thrombosis ratio was found high in the pregnancy group. Hematologic and genetic tests and Ranking scales were similar among the groups. A comparison of etiological factors and outcomes of subgroups is seen in Table 4.

Table 4: Etiological factors and outcome of subgroups according to reproductive health-related risks.

Compared data of reproductive health-related risk factors
Pregnancy
Puerperium
Oral contraceptive use

%

Infections

    Paracranial (focal)
2
3
4
3
7
7
0.589

    Systemic
1
1
3
2
1
1

History of VTE

    Cerebral
0a
0
1a
1
1a
1

    Deep venous thrombosis
3a
4
0b
0
0b
0
0.030

    Other
0a
0
2a
1
0a
0

    Malignancy
0
0
1
1
0
0
0.526

    Family history VTE
1
1
0
0
0
0
0.228

    MTHFR mutation

    Heterozygote, homozygote
1
2
5
5
3
5
0.385

    Hyperhomocysteinemia
1
2
7
7
1
2
0.204

    Prothrombin mutation
0
0
5
4
4
5
0.240

    Protein C/S deficiency
0
0
3
3
4
6
0.361

    Factor V Leiden mutation
3
5
8
7
2
2
0.335

    Thrombocytosis
4
9
3
3
4
6
0.716

    Polycythemia vera
1
2
1
1
0
0
0.241

    Anticardiolipin Ab
0
0
0
0
0
0
—

    PAI mutation
0
0
1
1
0
0
0.517

    Antithrombin III deficiency
0
0
1
1
1
2
0.718

    Hyperfibrinogenemia
0
0
0
0
1
1
0.568

    Antiphospholipid Ab
2
3
0
0
0
0
0.057

    Activated protein C
1
2
3
3
0
0
0.362

    Resistance
1
2
1
1
2
2
0.821

    High ANA titers
0
0
4
4
0
0
0.122

First month Rankin

    0-1
49
78
102
78
85
86
0.177

    2
7
11
18
14
12
12

    >3
7
11
11
8
2
2

Third month Rankin

    0-1
45
92
103
89
79
94

    2
3
6
10
9
4
5
0.828

    >3
1
2
3
3
1
1

Sixth month Rankin

    0-1
44
96
100
94
71
97

    2
1
2
4
4
1
1
0.937

    >3
1
2
2
2
1
1

12th month Rankin

    0-1
34
97
87
95
64
100

    2
1
3
3
3
0
0
0.409

    >3
0
0
2
2
0
0

ANA: antinuclear antibody; MTHFR: methylenetetrahydrofolate reductase; PAI: plasminogen activator inhibitor; VTE: venous thromboembolism.

4. Discussion

Pregnancy, puerperium, and hormone replacement treatment increase the tendency to cerebral venous sinus thrombosis (CVST) in women. CVST is much more frequently seen in women than in men -a ratio of 3/1 [6]. In the study of Coutinho et al., female ratio was found to be 75% and female gender-specific risk factors at 65% [4]. In the International Study on Cerebral Venous and Dural Sinus Thrombosis (ISCVST), the female ratio was found to be 75% of patients. Gender-specific risk factors such as OCs, pregnancy, puerperium, and hormone replacement therapy were responsible [7]. The results of meta-analyses showed that gender-specific risk factors were only not effective in children and the elderly female groups and that the use of OCs increased venous thrombosis development in reproductive age females [8]. In our study, the female ratio was found to be 68% and gender-specific risks which were grouped as RHRF (+) by us were found in 41% of women. Our findings are similar to the results of previous studies.

In our study, the mean age of women with reproductive health-related risk factors (RHRF) was lower than that of the RHRF (-) group. In subgroup analyses of RHRF (+) cases, the mean age of OC users was higher than that of the other groups. This difference may be related to planning of the age of pregnancy [3].

Previous venous thrombosis history, thrombophilia, certain medical comorbidities, obesity, smoking, and postpartum hemorrhage increase the risk of CVST [9, 10]. In our study, the highest part of the RHRF (+) group consisted of cases of puerperium. Puerperium often occurs in the sixth to eighth week after delivery. In different population-based case-control studies on venous thrombosis, it was explained that risk increased 5-fold in the pregnancy period and a 60-fold in the puerperium [11]. Also, it has been reported that it occurs more commonly after a cesarean birth than a vaginal birth [12]. Infection, high maternal age and excessive vomiting during pregnancy increase the development of CVST [13]. All of the hormone levels, cardiovascular system, and pregnancy-related hematologic changes return to the baseline state within the slow process of puerperium. Human chorionic gonadotropin (hCG) and sex steroids are at low levels for the first 2-3 weeks. These changes may cause the tendency to thrombosis [14–16].

In our study, headache was the most frequent symptom for all subgroups. However, epileptic seizures were higher in the puerperium group. In the study of Kashkoush et al., the highest frequencies of symptom were found to be headache (74%), seizure (50%), and an altered consciousness (45%) in puerperium [17].

The inherited mutations in anticoagulant or thrombolytic factors genes (the Factor V Leiden, the prothrombin Factor II) and mutations in genes coding for proteins C and S may increase the risk of developing venous thrombosis [18]. We did not find any relationship between inherited risk factors and CVST.

Venous thrombosis risk increases with OC use. Combined OCs containing estrogen and progesterone have higher risk [19]. When the patient has a history of previous CVST, the recurrence risk is increased by OC use [20, 21]. We did not determine the content of the OCs. In the RHRF (-) group, a previous history of CVST was high. In the subgroup analysis, a previous history of CVST was high in the “pregnancy group.” Very little is known about the relapse rate during pregnancy and puerperium in women with a history of CVST [22]. The results of our study suggest that physicians must keep in mind the possible recurrence of CVST in pregnancy.

In our study, malignancy was more frequent in the RHRF (-) group. It has been reported that cancer patients have an increased risk of tendency of venous thrombosis [23].

In the study by Lee et al., it has been reported that the transverse sinus is involved in the majority of cases (75.6%). Sigmoid sinus and superior sagittal sinus involvement followed it at ratios of 58.5% and 29.3%, respectively [24]. In our study, the “transverse sinus” was affected more than other venous sinuses. On the other hand, isolated cavernous sinus involvement was significantly high in RHRF (-) group. Cavernous sinus involvement is high in the presence of septicemia and malignancy [25]. Therefore, in our study, this result was expected to be more in the RHRF (-) group.

It has been reported that the prognosis in pregnant patients is better than in nonpregnant patients with CVST if they receive timely treatment [26]. In the VENOST main study, the prognosis of CVST was found to be better in women than men [1]. In our subgroup analysis, the prognosis was found to be worse in the RHRF (-) group.

5. Conclusions

Our results indicate that when CVST was detected in women with RHFR (-), the existence of malignancy should be investigated. The previous history of CVST may be related to recurrence in pregnancy. Clinical onset may present with chronic headache in CSVT cases related to OC use. Epileptic seizures may be a more frequent symptom in puerperal CSVT cases. Physicians must keep these situations in mind.

Data Availability

All data will be available on request.

Conflicts of Interest

The authors declared that they have no conflicts of interest for this article.

Authors’ Contributions

Sevki Sahin and Taskin Duman have contributed equally.

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