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ARTICLES: A. Quattrone, F. Bono, R. L. Oliveri, A. Gambardella, D. Pirritano, A. Labate, A. Lucisano, P. Valentino, M. Zappia, U. Aguglia, A. Lavano, F. Fera, and K. Pardatscher Cerebral venous thrombosis and isolated intracranial hypertension without papilledema in CDH Neurology 2001; 57: 31-36 [Abstract] [Full text] [PDF]

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Reply to Dr. Totah

A Quattrone, "F Bono, RL Oliveri, et al."   (25 September 2001)

Cerebral venous thrombosis and isolated intracranial hypertension without papilledema in CDH

Abraham Totah   (25 September 2001)

Reply to Dr. Totah 25 September 2001
A Quattrone Facolia di Medicina e Chirurgia Magna Graecia Catanzaro Italy, "F Bono, RL Oliveri, et al." Send Correspondence to journal: Re: Reply to Dr. Totah quattrone.unicz{at}interbusiness.it A Quattrone, et al.	We appreciate Dr. Totah’s interest in our article in which we describe the occurrence of cerebral venous thrombosis (CVT) in subjects with chronic daily headache (CDH). [1] Dr. Totah raises some issues on the reliability of MR venography (MRV) in detecting CVT. MRV is the method of choice for the diagnosis of CVT, because it is a non-invasive technique which can demonstrate the absence of flow in the thrombosed sinus or the frayed appearance of a thrombosed sinus that had subsequently recanalized. [2, 3] However, there are pitfalls of this technique, which may, in doubtful cases, make cerebral angiography necessary. We agree with Dr. Totah that flowing abnormalities of transverse sinus (TS) not related to vein thrombosis, especially when unilateral, may occasionally be observed on MRV in normal subjects. A common problem is the lack of flow in the proximal portion of TS due to hypoplasia of the sinus, a normal variant that can simulate thrombosis on MRV. [2, 3, 4] By contrast, we disagree with Dr. Totah regarding the significance of the bilateral flowing abnormalities of TS. Indeed, a recent MRV study showed that flow gaps in the dominant TS were never observed in healthy subjects, indicating that involvement of both TS rarely occurs in normal individuals, and should be considered as a pathologic condition.[5] In accordance with these data, we demonstrated in our paper that only five of 114 subjects with CDH had flowing abnormalities in both TS. [1] It is noteworthy that four of these five subjects had isolated intracranial hypertension, a condition which is known to be associated with CVT. Our findings strongly indicate that flow gaps in the distal portion of both TS are highly suggestive of venous thrombosis which can lead to intracranial hypertension (with or without papilledema). On this basis, we retain that subjects who present with CDH showing bilateral flowing abnormalities in the distal portion of TS should undergo lumbar puncture to exclude isolated intracranial hypertension. Finally, we agree with Dr. Totah that a therapeutic trial should be considered in such patients. References: 1. Quattrone A, Bono F, Oliveri RL, et al. Cerebral venous thrombosis and isolated intracranial hypertension without papilledema in CDH. Neurology 2001; 57:31-36. 2. Perl J, Turski PA, Masaryk TJ. MR angiography. Techniques and clinical applications. In: Scott W, ed. Magnetic resonance imaging of the brain and the spine. 2nd ed. Philadelphia: Lippincott-Raven, 1996: 1547- 1618. 3. Bousser MG, Russell RR. Cerebral venous thrombosis. London: Saunders, 1997 4. Mas JL, Meder JF, Meary E, et al. Magnetic resonance imaging in lateral sinus hypoplasia and thrombosis. Stroke 1990; 21:1350-1356. 5. Ayanzen RH, Bird CR, Keller PJ, et al. Cerebral MR venography: normal anatomy and potential diagnostic pitfalls. AJNR 2000; 21:74-78.
Cerebral venous thrombosis and isolated intracranial hypertension without papilledema in CDH 25 September 2001
Abraham Totah Clearwater FL Send Correspondence to journal: Re: Cerebral venous thrombosis and isolated intracranial hypertension without papilledema in CDH sandi_moriarity{at}urmc.rochester.edu Abraham Totah	I wish to thank Quattrone et al. for their engaging article on CDH and CVH. [1] Their finding that almost 10% of the population with chronic daily headache have evidence of cerebral venous thrombosis is remarkable. However, I do have concerns over the exclusive reliance on MR venography. In my experience, the area of transverse sinuses that is pointed out on the MR vengorams in the article is highly variable with narrowing, especially when bilateral, not necessarily indicative of venous thrombosis. In other examples presented, the area of abnormality is so focal leaving one to wonder why the clot has not extended to involve a larger area of the vessel. It would have been interesting if conventional venography were included to corroborate the findings. Finally, I will be eagerly anticipating a therapeutic trial of the subset of patients with CDH and DVH. Reference: 1) Quattrone A, Bono F, Oliveri RL et al. Cerebral venous thrombosis and isolated intracranial hypertension without papilledema in CDH. Neurology 2001;57:31-36.