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Cerebral Venous Thrombosis: A Mimic of Brain Metastases in Colorectal Cancer Associated with a Better Prognosis

Cerebral Venous Thrombosis: A Mimic of Brain Metastases in Colorectal Cancer Associated with a... Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 109412, 3 pages http://dx.doi.org/10.1155/2013/109412 Case Report Cerebral Venous Thrombosis: A Mimic of Brain Metastases in Colorectal Cancer Associated with a Better Prognosis Nida Iqbal and Atul Sharma Department of MedicalOncology, Dr.B.R.A.Institute Rotary Cancer Hospital,All IndiaInstitute of MedicalSciences, New Delhi 110029, India Correspondence should be addressed to Atul Sharma; atul1@hotmail.com Received 6 May 2013; Accepted 30 May 2013 Academic Editors: Y.-F. Jiao and Y. Yamada Copyright © 2013 N. Iqbal and A. Sharma. 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. Malignancy is known to be one of the predisposing factors of cerebral venous thrombosis (CVT) due to its hypercoagulable state. CVT is a rare disorder which can lead to frequent misdiagnoses of brain metastases in such cases. We report here the case of a 35- year-old female with metastatic colon adenocarcinoma presenting with sudden neurological symptoms. Brain MRI and magnetic resonance venography confirmed the presence of CVT. She was treated with low molecular weight heparin followed by warfarin. She recovered and is doing well on warfarin after 5 months of diagnosis of CVT. CVT should be strongly suspected as a cause of neurological dysfunction in any case of disseminated malignancy including colon adenocarcinoma. Rapid diagnosis and initiation of therapy should be considered because of its favourable outcome. 1. Introduction Herein, we report a case of metastatic colorectal can- cer who developed cerebral venous thrombosis while on Cerebral venous thrombosis (CVT), that is, any throm- chemotherapy. bosis that occurs in intracranial veins or sinuses, [1]isa rare disorder aeff cting approximately 5 persons per million per year with huge regional variations [2]. It accounts for 2. Case Report approximately 0.5% of all the strokes and most commonly affects young adults. Many disorders can either cause or A 35-year-old female, a diagnosed case of metastatic colorec- just predispose to CVT. They include medical, surgical, tal adenocarcinoma, (Figure 1) was on palliative chemother- and obstetrical causes of deep vein thrombosis, genetic and apy with capecitabine and irinotecan (CAPIRI) when she acquired prothrombotic disorders, cancer and hematological presented with the history of sudden onset of headache, disorders, inflammatory systemic disorders, pregnancy and blurring of vision, weakness of left side of body, and multiple puerperium, infections, and local causes such as tumors, episodes of vomitings. She had no history of hypertension, arteriovenous malformations, trauma, central nervous sys- diabetes, pregnancy or use of oral contraceptives. On physical tem infections, and infections of the ear, sinus, mouth, examination, she was conscious, oriented, and having mild face, and neck [1]. Cerebral venous thrombosis has a wide dysarthria and grade 3 power of left side of the body. er Th e spectrum of clinical manifestations and modes of onset that were no signs of meningismus. Fundus examination revealed may mimic many other neurological disorders and lead bilateral papilledema. Contrast enhanced CT scan of head to frequent misdiagnosis and delay in treatment. Before revealed mild edema in right frontal lobe. Brain MRI revealed the advent of computed tomography (CT) and magnetic hemorrhagic infarct in right parietal lobe (Figure 2(a)), and resonance imaging (MRI), CVT was usually diagnosed at magnetic resonance (MR) venography revealed occlusion of autopsy. It has got a favourable outcome with case fatality superior and inferior sagittal sinuses, both transverse sinuses, of less than 10% [1]. Cerebral venous thrombosis is a rare and bilateral sigmoid sinuses with thrombus (Figures 2(b) paraneoplastic syndrome. and 2(c)). Laboratory parameters revealed a normal complete 2 Case Reports in Oncological Medicine Figure 1: H&E of colon showing invasive adenocarcinoma. (a) (b) (c) Figure 2: Brain MRI and magnetic resonance (MR) venography (AP view). (a) Hemorrhagic infarction was noted in the right parietal lobe on T2-weighed imaging. (b), (c) MR venography showed occlusion of the superior and inferior sagittal sinuses, both transverse sinuses, and bilateral sigmoid sinuses. blood count, sedimentation rate, blood sugar, lipid profile, uncommon in cancer. Potential mechanisms for an asso- and kidney and liver function tests. Electrocardiogram and ciation of cancer with cerebral venous thrombosis (CVT) echocardiography were also normal. include direct tumor compression, tumor invasion of cerebral To rule out any coexisting prothrombotic condition, sinuses, the hypercoagulable state associated with cancer, homocysteine levels, protein C, protein S, factor V, and or the chemotherapeutic side eeff cts [ 3–5]. Cerebral venous antithrombin III were done which were within normal thrombosis hasbeenreportedtobeassociatedwithvar- limits. For disease assessment, contrast enhanced CT scan of ious cancers like squamous cell cervical cancer [6], non- abdomen and pelvis was done which revealed the disease to Hodgkin’s lymphoma [7], and breast cancer [8]. Cerebral be in complete remission. She was started on low molecular sinus venous thrombosis associated with chemotherapy has weight heparin. eTh re was marked improvement in her so far been described in a patient with colon cancer treated symptoms, and she was discharged in stable condition on with FOLFIRI/bevacizumab [9], in a patient with a brain oral warfarin. She is doing well even aeft r 5 months from the tumor treated with temozolomide, focal brain radiotherapy diagnosis of cerebral venous thrombosis. plus bevacizumab [10], in an adolescent with Ewing sarcoma treated with cisplatin, ifosfamide, adriamycin, and vincristine [11], and in two patients of nonseminomatous germ cell tumor treated with cisplatin, bleomycin, and etoposide [12]. Like 3. Discussion our case, a case of cerebral venous thrombosis in a patient of rectal cancer has been described, but that was associated Cerebrovascular events may be the rfi st clinical manifes- tations in patients with underlying malignancy or may with cerebral metastases also [13]. develop subsequently during the course. Systemic throm- Cerebral venous thrombosis should always be kept in the bosis like deep vein thrombosis or pulmonary embolism differential diagnosis of any form of neurological symptoms is well recognized in cancer patients, although CVTs are in a patient with cancer even without cerebral metastases Case Reports in Oncological Medicine 3 andevenifthe diseaseisincompleteremission as in our case. As CVT has got a favourable outcome unlike other neurological syndromes, early diagnosis with MRI/MR venography and rapid institution of therapy with heparin should be considered. Conflict of Interests eTh authors declare that they have no conflict of interests. References [1] J. M. Ferro, P. Canhao ˜ , J. Stam, M.-G. Bousser, and F. Bari- nagarrementeria, “Prognosis of cerebral vein and dural sinus thrombosis: results of the international study on cerebral vein and dural sinus thrombosis (ISCVT),” Stroke,vol.35, no.3,pp. 664–670, 2004. [2] M.-G. Bousser and J. M. Ferro, “Cerebral venous thrombosis: an update,” The Lancet Neurology ,vol.6,no. 2, pp.162–170,2007. [3] J. J. Raizer and L. M. DeAngelis, “Cerebral sinus thrombosis diagnosed by MRI and MR venography in cancer patients,” Neurology, vol. 54, no. 6, pp. 1222–1226, 2000. [4] L. R. Rogers, “Cerebrovascular complications in patients with cancer,” Seminars in Neurology,vol.24,no.4,pp.453–460,2004. [5] L. Astudillo, M. Lacroix-Triki, F. Cousin, and C. Chevreau, “A rarely diagnosed paraneoplastic syndrome: cerebral venous thrombosis,” Revue de Medecine Interne, vol. 28, no. 10, pp. 716– 717, 2007. [6] M.F.Lop ´ ez-Pelaez, ´ J. M. Millan, ´ and J. De Vergas, “Fatal cerebral venous sinus thrombosis as major complication of metastatic cervical mass: computed tomography and magnetic resonance findings,” Journal of Laryngology and Otology,vol. 114, no. 10, pp. 798–801, 2000. [7]T.P.Enevoldsonand R. W. Ross Russell, “Cerebralvenous thrombosis: new causes for an old syndrome?” Quarterly Journal of Medicine,vol.77, no.284,pp. 1255–1275, 1990. [8] T. Soda, K. Edagawa, K. Tsuji, M. Dehara, Y. Nakajima, and M. Ito, “A case of deep cerebral venous thrombosis associated with breast cancer,” Clinical Neurology, vol. 48, no. 9, pp. 646–650, [9] A. Ozen, I. Cicin, A. Sezer et al., “Dural sinus vein thrombosis in a patient with colon cancer treated with FOLFIRI/beva- cizumab,” Journal of Cancer Research and Therapeutics ,vol.5, no. 2, pp. 130–132, 2009. [10] J. A. Vargo, B. M. Snelling, E. R. Ghareeb et al., “Dural venous sinus thrombosis in anaplastic astrocytoma following concurrent temozolomide and focal brain radiotherapy plus bevacizumab,” JournalofNeuro-Oncology,vol.104,no. 2, pp. 595–598, 2011. [11] E. Unal, A. Yazar, Y. Koksal, U. Caliskan, Y. Paksoy, and E. Kalkan, “Cerebral venous sinus thrombosis in an adolescent with Ewing sarcoma,” Child’s Nervous System,vol.24, no.9,pp. 983–986, 2008. [12] C. Papet, A. Gutzeit, and M. Pless, “Two cases of cerebral sinus venous thrombosis following chemotherapy for non- seminomatous germ cell tumor,” Case Reports in Oncology,vol. 4, no. 3, pp. 555–559, 2011. [13] L. Tot ´ h, S. Szakal ´ l, Z. Kap ´ oszta, and M. Udvardy, “Cerebral deep vein thrombosis associated with rectal cancer,” Orvosi Hetilap, vol. 141, no.46, pp.2493–2496,2000. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Cerebral Venous Thrombosis: A Mimic of Brain Metastases in Colorectal Cancer Associated with a Better Prognosis

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Copyright © 2013 Nida Iqbal and Atul Sharma. 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.
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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 109412, 3 pages http://dx.doi.org/10.1155/2013/109412 Case Report Cerebral Venous Thrombosis: A Mimic of Brain Metastases in Colorectal Cancer Associated with a Better Prognosis Nida Iqbal and Atul Sharma Department of MedicalOncology, Dr.B.R.A.Institute Rotary Cancer Hospital,All IndiaInstitute of MedicalSciences, New Delhi 110029, India Correspondence should be addressed to Atul Sharma; atul1@hotmail.com Received 6 May 2013; Accepted 30 May 2013 Academic Editors: Y.-F. Jiao and Y. Yamada Copyright © 2013 N. Iqbal and A. Sharma. 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. Malignancy is known to be one of the predisposing factors of cerebral venous thrombosis (CVT) due to its hypercoagulable state. CVT is a rare disorder which can lead to frequent misdiagnoses of brain metastases in such cases. We report here the case of a 35- year-old female with metastatic colon adenocarcinoma presenting with sudden neurological symptoms. Brain MRI and magnetic resonance venography confirmed the presence of CVT. She was treated with low molecular weight heparin followed by warfarin. She recovered and is doing well on warfarin after 5 months of diagnosis of CVT. CVT should be strongly suspected as a cause of neurological dysfunction in any case of disseminated malignancy including colon adenocarcinoma. Rapid diagnosis and initiation of therapy should be considered because of its favourable outcome. 1. Introduction Herein, we report a case of metastatic colorectal can- cer who developed cerebral venous thrombosis while on Cerebral venous thrombosis (CVT), that is, any throm- chemotherapy. bosis that occurs in intracranial veins or sinuses, [1]isa rare disorder aeff cting approximately 5 persons per million per year with huge regional variations [2]. It accounts for 2. Case Report approximately 0.5% of all the strokes and most commonly affects young adults. Many disorders can either cause or A 35-year-old female, a diagnosed case of metastatic colorec- just predispose to CVT. They include medical, surgical, tal adenocarcinoma, (Figure 1) was on palliative chemother- and obstetrical causes of deep vein thrombosis, genetic and apy with capecitabine and irinotecan (CAPIRI) when she acquired prothrombotic disorders, cancer and hematological presented with the history of sudden onset of headache, disorders, inflammatory systemic disorders, pregnancy and blurring of vision, weakness of left side of body, and multiple puerperium, infections, and local causes such as tumors, episodes of vomitings. She had no history of hypertension, arteriovenous malformations, trauma, central nervous sys- diabetes, pregnancy or use of oral contraceptives. On physical tem infections, and infections of the ear, sinus, mouth, examination, she was conscious, oriented, and having mild face, and neck [1]. Cerebral venous thrombosis has a wide dysarthria and grade 3 power of left side of the body. er Th e spectrum of clinical manifestations and modes of onset that were no signs of meningismus. Fundus examination revealed may mimic many other neurological disorders and lead bilateral papilledema. Contrast enhanced CT scan of head to frequent misdiagnosis and delay in treatment. Before revealed mild edema in right frontal lobe. Brain MRI revealed the advent of computed tomography (CT) and magnetic hemorrhagic infarct in right parietal lobe (Figure 2(a)), and resonance imaging (MRI), CVT was usually diagnosed at magnetic resonance (MR) venography revealed occlusion of autopsy. It has got a favourable outcome with case fatality superior and inferior sagittal sinuses, both transverse sinuses, of less than 10% [1]. Cerebral venous thrombosis is a rare and bilateral sigmoid sinuses with thrombus (Figures 2(b) paraneoplastic syndrome. and 2(c)). Laboratory parameters revealed a normal complete 2 Case Reports in Oncological Medicine Figure 1: H&E of colon showing invasive adenocarcinoma. (a) (b) (c) Figure 2: Brain MRI and magnetic resonance (MR) venography (AP view). (a) Hemorrhagic infarction was noted in the right parietal lobe on T2-weighed imaging. (b), (c) MR venography showed occlusion of the superior and inferior sagittal sinuses, both transverse sinuses, and bilateral sigmoid sinuses. blood count, sedimentation rate, blood sugar, lipid profile, uncommon in cancer. Potential mechanisms for an asso- and kidney and liver function tests. Electrocardiogram and ciation of cancer with cerebral venous thrombosis (CVT) echocardiography were also normal. include direct tumor compression, tumor invasion of cerebral To rule out any coexisting prothrombotic condition, sinuses, the hypercoagulable state associated with cancer, homocysteine levels, protein C, protein S, factor V, and or the chemotherapeutic side eeff cts [ 3–5]. Cerebral venous antithrombin III were done which were within normal thrombosis hasbeenreportedtobeassociatedwithvar- limits. For disease assessment, contrast enhanced CT scan of ious cancers like squamous cell cervical cancer [6], non- abdomen and pelvis was done which revealed the disease to Hodgkin’s lymphoma [7], and breast cancer [8]. Cerebral be in complete remission. She was started on low molecular sinus venous thrombosis associated with chemotherapy has weight heparin. eTh re was marked improvement in her so far been described in a patient with colon cancer treated symptoms, and she was discharged in stable condition on with FOLFIRI/bevacizumab [9], in a patient with a brain oral warfarin. She is doing well even aeft r 5 months from the tumor treated with temozolomide, focal brain radiotherapy diagnosis of cerebral venous thrombosis. plus bevacizumab [10], in an adolescent with Ewing sarcoma treated with cisplatin, ifosfamide, adriamycin, and vincristine [11], and in two patients of nonseminomatous germ cell tumor treated with cisplatin, bleomycin, and etoposide [12]. Like 3. Discussion our case, a case of cerebral venous thrombosis in a patient of rectal cancer has been described, but that was associated Cerebrovascular events may be the rfi st clinical manifes- tations in patients with underlying malignancy or may with cerebral metastases also [13]. develop subsequently during the course. Systemic throm- Cerebral venous thrombosis should always be kept in the bosis like deep vein thrombosis or pulmonary embolism differential diagnosis of any form of neurological symptoms is well recognized in cancer patients, although CVTs are in a patient with cancer even without cerebral metastases Case Reports in Oncological Medicine 3 andevenifthe diseaseisincompleteremission as in our case. As CVT has got a favourable outcome unlike other neurological syndromes, early diagnosis with MRI/MR venography and rapid institution of therapy with heparin should be considered. Conflict of Interests eTh authors declare that they have no conflict of interests. References [1] J. M. Ferro, P. Canhao ˜ , J. Stam, M.-G. Bousser, and F. Bari- nagarrementeria, “Prognosis of cerebral vein and dural sinus thrombosis: results of the international study on cerebral vein and dural sinus thrombosis (ISCVT),” Stroke,vol.35, no.3,pp. 664–670, 2004. [2] M.-G. Bousser and J. M. Ferro, “Cerebral venous thrombosis: an update,” The Lancet Neurology ,vol.6,no. 2, pp.162–170,2007. [3] J. J. Raizer and L. M. DeAngelis, “Cerebral sinus thrombosis diagnosed by MRI and MR venography in cancer patients,” Neurology, vol. 54, no. 6, pp. 1222–1226, 2000. [4] L. R. Rogers, “Cerebrovascular complications in patients with cancer,” Seminars in Neurology,vol.24,no.4,pp.453–460,2004. [5] L. Astudillo, M. Lacroix-Triki, F. Cousin, and C. Chevreau, “A rarely diagnosed paraneoplastic syndrome: cerebral venous thrombosis,” Revue de Medecine Interne, vol. 28, no. 10, pp. 716– 717, 2007. [6] M.F.Lop ´ ez-Pelaez, ´ J. M. Millan, ´ and J. De Vergas, “Fatal cerebral venous sinus thrombosis as major complication of metastatic cervical mass: computed tomography and magnetic resonance findings,” Journal of Laryngology and Otology,vol. 114, no. 10, pp. 798–801, 2000. [7]T.P.Enevoldsonand R. W. Ross Russell, “Cerebralvenous thrombosis: new causes for an old syndrome?” Quarterly Journal of Medicine,vol.77, no.284,pp. 1255–1275, 1990. [8] T. Soda, K. Edagawa, K. Tsuji, M. Dehara, Y. Nakajima, and M. Ito, “A case of deep cerebral venous thrombosis associated with breast cancer,” Clinical Neurology, vol. 48, no. 9, pp. 646–650, [9] A. Ozen, I. Cicin, A. Sezer et al., “Dural sinus vein thrombosis in a patient with colon cancer treated with FOLFIRI/beva- cizumab,” Journal of Cancer Research and Therapeutics ,vol.5, no. 2, pp. 130–132, 2009. [10] J. A. Vargo, B. M. Snelling, E. R. Ghareeb et al., “Dural venous sinus thrombosis in anaplastic astrocytoma following concurrent temozolomide and focal brain radiotherapy plus bevacizumab,” JournalofNeuro-Oncology,vol.104,no. 2, pp. 595–598, 2011. [11] E. Unal, A. Yazar, Y. Koksal, U. Caliskan, Y. Paksoy, and E. Kalkan, “Cerebral venous sinus thrombosis in an adolescent with Ewing sarcoma,” Child’s Nervous System,vol.24, no.9,pp. 983–986, 2008. [12] C. Papet, A. Gutzeit, and M. Pless, “Two cases of cerebral sinus venous thrombosis following chemotherapy for non- seminomatous germ cell tumor,” Case Reports in Oncology,vol. 4, no. 3, pp. 555–559, 2011. [13] L. Tot ´ h, S. Szakal ´ l, Z. Kap ´ oszta, and M. Udvardy, “Cerebral deep vein thrombosis associated with rectal cancer,” Orvosi Hetilap, vol. 141, no.46, pp.2493–2496,2000. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: Jun 13, 2013

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