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Original article
Cerebral venous thrombosis in children an 18-year review of a Portuguese hospital
Trombosis venosa cerebral en niños: una revisión de 18 años en un hospital portugués
J. Tenentea,
Corresponding author
joanatenente@hotmail.com

Corresponding author.
, S. Lopesb, P. Bemc, M. Vila-Reald, D. Ferreirab, A.F. Geraldoe, F. Santosd
a Pediatric Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
b Imunohemotherapy Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
c Neurroradiology Department, ULS Matosinhos, Hospital Pedro Hispano, Portugal
d Neuropediatric Unit, Pediatric Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
e Diagnostic Neurroradiology Unit, Imaging Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cerebral venous thrombosis &#40;CVT&#41; is a rare cause of stroke that affects mainly young adults and children&#44; in contrast to arterial stroke and venous thromboembolism&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> CVT has an incidence of 0&#46;4&#8211;0&#46;7 cases per infant per year&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> The incidence has increased over time&#44; probably due to increased clinical awareness as well as improvement in neuroimaging techniques that enable the diagnosis of less severe cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> Indeed&#44; the diagnosis of CVT needs to be confirmed by neuroimaging&#44; including computed tomography &#40;CT&#41; and&#47;or magnetic resonance imaging &#40;MRI&#41; with venography and&#47;or catheter angiography&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">CVT represents a serious and life-threatening disease with significant morbidity and mortality&#44; usually due to hemorrhagic or non-hemorrhagic venous infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Affected patients usually present with non-focal neurological signs and symptoms&#44; including headache&#44; seizures and vomiting&#46; Other possible presentations include focal neurologic deficits &#40;hemiparesis and aphasia&#41;&#44; isolated intracranial hypertension&#44; diffuse encephalopathy or cavernous sinus syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">CVT is a multicausal disease triggered by the interaction of several risk factors&#44; such as inherited or acquired thrombophilia&#44; pregnancy and the most common&#44; infection&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">When assessing the thrombotic risk&#44; it is important to assess genetic and environmental risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Hereditary thrombophilia&#44; with a prevalence of &#60;1&#37; in the general population&#44; may be caused primarily by deficiencies of natural anticoagulants including protein C and protein S or by genetic mutation of prothrombin or factor V&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> Several conditions&#44; such as antiphospholipid syndrome &#40;APS&#41;&#44; are associated with acquired thrombophilia&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> Anticoagulation is the primary treatment regardless of the cause&#46; Although intracerebral thrombosis secondary to thrombophilia is not very rare&#44; it may be susceptible to misdiagnosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As this is a rare disorder in pediatric patients&#44; there are only a few published case series of cases of CVT focused in children and we aimed to provide a description of all our pediatric diagnosed cases of CVT&#44; including their clinical presentation&#44; laboratory and neuroimaging studies and outcomes&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">This is a retrospective single-center observational and analytical study of all consecutive pediatric patients admitted to Centro Hospitalar Vila Nova de Gaia&#47;Espinho&#44; Portugal from 2003 to 2021 with the diagnosis of cerebral venous thrombosis&#46; The diagnosis was made based on the clinical presentation and confirmed by neuroimaging &#40;CT and&#47;or MRI with venography &#40;CTV&#47;MRV&#41;&#41; at the time of the initial diagnosis&#46; Demographic and clinical information&#44; as well as imaging findings&#44; predictor and prothrombotic factors&#44; treatment strategies and outcome of CVT&#44; were documented for each patient&#46; No patients were excluded&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Epidemiology</span><p id="par0040" class="elsevierStylePara elsevierViewall">Twelve patients were included&#46; Fifty-eight per cent &#40;7&#47;12&#41; were female&#46; Mean age was 7&#46;3 years-old &#40;range&#58; 1 day to 16 years-old&#41;&#44; including two newborn patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical presentation</span><p id="par0045" class="elsevierStylePara elsevierViewall">The most common clinical presentation in our cohort was vomiting &#40;50&#37;&#41;&#44; headache &#40;42&#37;&#41; and behavioral alterations&#44; such as irritability or prostration &#40;33&#37;&#41;&#46; Other described signs and symptoms were fever &#40;33&#37;&#41;&#44; seizures &#40;17&#37;&#41; and one case of right hemiparesis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Neuroimaging studies</span><p id="par0050" class="elsevierStylePara elsevierViewall">Neuroimaging studies were available for review by the authors in 11&#47;12 patients&#46; In one patient imaging findings were retrieved from the clinical chart&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">CT&#47;CTV and&#47;or MRI&#47;MRV were performed during the acute episode in 11&#47;12 and 9&#47;12 patients&#44; respectively&#44; with all of them showing CVT&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In 67&#37; &#40;8&#47;12&#41; of cases multiple sinuses were involved&#46; Transverse &#40;9&#47;12&#41; and sigmoid &#40;6&#47;12&#41; sinuses were the most frequently affected ones&#44; followed by the superior sagittal sinus &#40;3&#47;12&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Three cases had superficial cerebral cortical veins thrombosis&#44; that was isolated in one newborn patient&#46; There was one case of deep venous system thrombosis&#46; Only one patient &#40;1&#47;12&#44; 8&#37;&#41; showed signs of venous hemorrhagic infarction as well as subarachnoid hemorrhage&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Diagnosis or trigger</span><p id="par0065" class="elsevierStylePara elsevierViewall">The most common trigger for cerebral venous thrombosis was infection &#40;50&#37;&#41;&#46; There were two cases of acute mastoiditis&#44; two cases of bacterial meningitis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; one case of deep neck abscess and one case of meningoradiculitis due to herpes-7&#46; Nephrotic syndrome is a well-known prothrombic trigger and was found in two cases&#46; The use of oral contraceptive was considered as a possible trigger in the adolescent females&#46; One of them also has Down syndrome with obesity and hypothyroidism which may have also been contributing factors&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Initial CT&#47;CTV allowed the diagnosis of two cases of mastoiditis &#40;one with epicrania abscess&#41;&#44; one case of deep neck abscess and two cases suspicious of cerebral empyema&#44; both of them latter confirmed by MRI and lumbar puncture&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">There were two additional cases where no etiological cause was found&#58; one case of right thalamic venous stroke with thrombosis of the straight sinus&#44; galen and cerebral veins and one newborn with left transverse sinus and cortical veins thrombosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; with a perinatal history of a cesarean section birth with ventouse&#44; for stationary labor&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Screening for prothrombotic factors</span><p id="par0080" class="elsevierStylePara elsevierViewall">Screening for genetic and acquired prothrombotic factors was made after the recommended anticoagulation period for each case&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Prothrombotic factors were investigated in 83&#37; &#40;10&#47;12&#41; of cases since two patients lost Immunohemotherapy follow-up at our hospital&#46; Laboratory testing included evaluation of antithrombin&#44; APS antibodies&#44; lupus anticoagulant&#44; serum homocysteine levels&#44; functional protein C&#44; functional protein S and fibrinogen&#46; All patients had normal results&#46; Genetic prothrombotic factors such as methylenetetrahydrofolate reductase &#40;MTHFR&#41;&#44; plasminogen activator inhibitor type 1 &#40;PAI-1&#41;&#44; prothrombin and factor V gene mutations were also investigated&#46; No mutations were found in three patients&#46; Five had heterozygous mutations in one or two genes and one was homozygous for the 4G&#47;4G polymorphism of the PAI-1 gene&#46; All had normal homocysteine levels&#44; so no major genetic prothrombic factor was found in our series&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0090" class="elsevierStylePara elsevierViewall">Except for the two newborns&#44; all other 10 patients were promptly anticoagulated with low molecular weight heparin&#46; Oral warfarin was started after the acute phase in three of them&#46; The total anticoagulation therapy time varied from 3 to 18 months&#46; Subsequently all patients were followed-up in an Immunohemotherapy consultation and the need for maintenance of anticoagulation was decided based on the imaging study and on the value of d-dimers &#40;adjusted for age&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In addition&#44; corticosteroids were administered in the acute phase to one third of patients &#40;4&#47;10&#41;&#44; two of them with nephrotic syndrome&#44; one with deep neck abscess and the other with acute mastoiditis&#46; Finally&#44; 75&#37; &#40;9&#47;12&#41; of patients were treated with antibiotics and two patients also initiated antiviral therapy&#46; The newborn presenting with seizures was started on empiric antibiotics&#44; treated with a single dose of phenytoin and admitted to the NICU&#46; He was discharged ten days later&#44; with infra-therapeutic levels of phenytoin and no other convulsive episodes&#46; Antibiotics were suspended at 72 hours as all blood tests and blood and cerebrospinal fluid cultures were negative for infection&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Clinical outcome</span><p id="par0100" class="elsevierStylePara elsevierViewall">Clinical follow-up ranged from 21 months to 18 years &#40;median 12 years&#41;&#46; Only one case was lost to follow-up&#46; No deaths were reported&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Three patients evolved with neurological sequelae at last clinical follow-up&#44; one case of right hemiparesis and learning difficulties with attention deficit hyperactivity disorder&#44; one with severe global development delay without speech and one case with epilepsy &#40;suspended medication after three year without seizure and normal EEG&#41; and global development delay&#44; with predominant affected speech&#46; These three patients had central nervous system infection &#40;two cases of bacterial meningitis and one of meningoradiculitis&#41; that most likely is the cause of the sequelae rather than the CVT&#46; The female adolescent with Down syndrome was intellectually disabled and could not read before the event&#44; and no aggravation happened&#46; Similar to the other female adolescent &#40;patient 12&#41;&#44; that had previous follow-up in a Pediatrics Consultation for intellectual disability and attention deficit hyperactivity disorder&#44; medicated previously with methylphenidate and no significant changes were found after the event&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In June 2021&#44; patient 1&#44; at 29-years-old&#44; went to the emergency room due to vomiting and headache and the head CT&#47;CTV showed thrombosis of the right lateral and the superior sagittal sinuses &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; She was admitted to the Neurology infirmary and discharged 5 days later&#46; She remains without any neurological deficits or other sequelae and no cause for the two CVT&#44; separated of 18 years&#44; has been found&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">No other recurrences occurred&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Recanalization</span><p id="par0120" class="elsevierStylePara elsevierViewall">Of the 12 included patients&#44; 10 of them performed at least one follow-up neuroimaging with either MRI&#47;MRV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41; and&#47;or CT&#47;CTV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; with a median follow-up time of 7 months &#40;range from 1 to 13 months&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Approximately 58&#37; of the patients &#40;7&#47;11&#41; experienced complete resolution of the thrombosis at the last neuroimaging study&#44; while three cases exhibited only with partial recanalization &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; None of the cases presented progression of the thrombus&#46; The patient that recurred 18 years later &#40;patient 1&#41; showed a <span class="elsevierStyleItalic">de novo</span> CVT involving different sinuses when compared with the thrombus distribution of the first event&#46; No dural arteriovenous fistulas were detected at longitudinal neuroimaging in any of the patients&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Herein we present the clinical and imaging findings at presentations of our 12 pediatric patients &#40;including two newborns&#41; with CVT&#44; as well as prothrombotic factors&#44; treatment strategies&#44; clinical outcomes and recanalization&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In children&#44; CVT is relatively equally distributed between genders in all age groups&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> However&#44; we found a higher proportion of females&#44; against to previous articles<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2&#44;9</span></a> eventually due to our small sample size&#46; Some studies exclude newborns since the clinical presentation is different&#44; but in this study we included two newborns&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Some reports describe seizures&#44; decreased consciousness and headaches as the most common initial symptoms&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> with seizures being common in newborns&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> Focal and diffuse neurologic signs are likely to occur<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> and other possible presenting symptoms may vary according to the cause&#47;trigger of the CVT&#46; As previously described&#44; neurologic signs as vomiting and headaches were the most common presenting symptoms in our study&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">There are three possible neuroimaging techniques to diagnose CVT&#58; CT&#47;CTV &#40;computed tomography-venography&#41;&#44; MRI&#47;MRV &#40;magnetic resonance imaging with venography&#41; and catheter angiography&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> MRI&#47;MRV is the imaging technique of choice for the diagnosis of CVT in children&#44; allowing visualization of the thrombus within the vessel combined with absent flow on MRV as well as presence of associated venous infarction and&#47;or subjacent causes&#44; without the use of ionizing radiation&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> However&#44; CT&#47;CTV is frequently the initial diagnostic imaging method in the acute setting due to the easy access in the emergency room and the speed of acquisition&#44; while diagnosis with catheter angiography is exceptional&#46; Indeed&#44; except for one newborn diagnosed at presentation by MRI&#47;MRV&#44; all our patients were initially investigated with CT&#47;CTV&#44; although majority of them also performed subsequently an MRI&#47;MRV&#46; Nevertheless&#44; sedation techniques may be required for both techniques&#44; especially MRI due to the longer acquisition time&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Multiple sinuses thrombosis was the most frequent scenario in our population&#44; which is concordant with previous pediatric studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8&#8211;10</span></a> Transverse and sigmoid sinuses thrombosis were the most frequently affected sinuses in our study&#44; followed by the superior sagittal sinus&#44; also as previously reported in children&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The most common trigger for cerebral venous thrombosis in our cohort was central nervous system &#40;CNS&#41; or head and neck infection&#44; as reported in most previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2&#44;3&#44;11</span></a> Most patients with CNS or head and neck infections had multiple sinuses involvement&#44; as well as the two cases of nephrotic syndrome&#46; Oral contraceptive may have contributed for the CVT in two female adolescents&#44; one with Down Syndrome&#44; obesity and hypothyroidism&#46; No trigger nor prothrombic factor was discovered in the first event of the patient with recurrent CVT&#46; In the subsequent CVT episode&#44; she was on oral contraceptives for more than three years against medical advice&#46; In newborns&#44; there is an increased risk of cerebral venous thrombosis that may be related with alternative mechanisms such as mechanical compression&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> The patient presenting with seizures in the neonatal period had no other risk factor and the cesarean section delivery with ventouse probably contributed to the CVT&#44; in a multifactorial process&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">It remains unclear whether all individuals with thrombosis should be screened for thrombophilia&#46; Screening is generally not recommended for the general population&#44; but there is consensus for some specific indications that include&#58; thrombosis during perinatal period&#44; following the use of oral contraceptives or estrogen replacement therapy and venous thromboembolism in uncommon sites such as the brain&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> Therefore&#44; there is a formal recommendation for screening prothrombotic factors in all the patients included in this study&#46; At our center&#44; the screening for thrombophilia is mainly performed after the recommended anticoagulation period&#46; All patients&#44; except the two lost to follow-up&#44; were investigated for prothrombotic factors&#46; No major genetic prothrombotic factor was found&#46; Nonetheless it is always important to exclude these since there may be an indication for lifetime anticoagulation&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The American Society of Hematology &#40;ASH&#41; recommends and suggests the use of anticoagulants in pediatric CVT with and without hemorrhagic venous infarction&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> Except for the two newborn patients&#44; all cases were anticoagulated with low molecular weight heparin &#40;LMWH&#41;&#46; Three patients were latter switched to warfarin&#46; ASH recommendations do not prefer LMWH to warfarin or the opposite and determine the decision depends on patients values and preferences&#44; underlying conditions and comorbidities and health resources&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> Most patients were treated for a period of 3&#8211;6 months&#46; One of them was treated for almost 18 months but he missed several appointments and continued anticoagulated longer than recommended by the specialist&#46; Prothrombotic factors were investigated in 83&#37; &#40;10&#47;12&#41; of cases&#46; A thrombophilia panel was performed including Protein C&#44; Protein S and antithrombin activity&#44; Activated protein C resistance&#44; and the genetic mutations of the factor V &#40;Leiden&#41;&#44; prothrombin&#44; Methylenetetrahydrofolate reductase and Plasminogen activator inhibitor 1 &#40;PAI-1&#41; gene&#46; Five had heterozygous mutations in one or two genes and one was homozygous for the 4G&#47;4G polymorphism of the PAI-1 gene&#46; All had normal homocysteine levels&#44; so no major genetic prothrombotic factor was found in our series&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Pediatric antiphospholipid syndrome was also excluded discarding the presence of lupus anticoagulant in plasma&#44; anticardiolipin antibodies of IgG or IgM isoforms and anti-beta-2 glycoprotein I &#40;anti-&#946;2GPI&#41; antibodies of IgG or IgM isoforms&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As the most common trigger of CVT in our cohort was CNS or neck&#47;head infection&#44; 75&#37; of patients was treated with antibiotics&#46; The used antibiotic varied depending on the primary infection focus&#46; Two patients were treated with antivirals because of the presenting symptoms&#58; one presented with right hemiparesis and the other was a 16-year-old female with seizures at day 2 of hospital admission&#46; Two cases of severe infection &#40;deep neck abscess and acute mastoiditis&#41; and the two cases of nephrotic syndrome were treated with corticosteroids&#46; Our two cases with nephrotic syndrome had hypoalbuminemia upon presentation&#44; and low albumin levels has been considered the major risk factor associated with thromboembolic events in this syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">No deaths occurred in our study during the follow-up time and most patients evolved without any major sequelae&#46; Only one case of recurrence after 18 years of the primal event&#44; both without any neurological sequelae&#46; Our data is similar to other pediatric studies&#44; with overall favorable prognosis being described in this age group&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> and mainly dependent on the etiological factor for thrombosis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> and the occurrence &#40;or not&#41; of venous infarction&#46; Indeed&#44; cerebral thromboembolism is the most common neurological complication of nephrotic syndrome with favorable outcome in approximately 90&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> Accordingly&#44; our two patients with CVT associated with nephrotic syndrome are now adults without any neurological sequelae&#46; Ritchey et al&#46; described a worse outcome for patients with cortical vein thrombosis without involvement of the dural sinuses&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> we have found similar results&#46; Indeed&#44; our patient with isolated cortical vein occlusion evolved with severe global development delay&#44; most likely due to the bacterial meningitis&#46; The other two patients with neurological sequelae had severe central nervous system infections&#44; one other case of bacterial meningitis with empyema and a case of meningoradiculitis due to herpes-7 and this girl maintained right hemiparesis and learning difficulties&#46; The injury related with CNS infection is more likely the cause of the long-term neurological sequelae than the CVT itself&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">There are currently no guidelines requiring a systematic venographic follow-up evaluation in children for assessment of recanalization nor establishing the ideal imaging method to confirm recanalization&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> Indeed&#44; long term recanalization is so far not considered a significant outcome factor of CVT<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> as persistent intracranial venous occlusion does not appear to mean worse outcome in both children and adults&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> Therefore&#44; imagiologic resolution of CVT is not always documented and depends on clinical judgement at an individual basis&#46; However&#44; clinical symptomatic control should be performed&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Although all our cases performed at least one neuroimaging study after the initial event&#44; in most cases they were acquired in the emergency room in the setting of other acute&#44; unrelated clinical reasons&#46; Nevertheless&#44; recanalization could be assessed in 10&#47;12 cases&#44; and considered complete in 8 of them&#46; Concerning the two cases with only partial recanalization&#44; it should be noted that their last imaging study was performed less than a year after the initial CVT event&#44; and therefore subsequent evolution towards complete recanalization cannot be fully excluded&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; a recent study demonstrated a very low yield of routine follow-up neuroimaging aiming to detect new dural arteriovenous fistulae 6 months after CVT<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> and accordingly we have neither detected development of this type of brain vascular malformations in any of our patients during imaging follow-up&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">The results of this cohort were overall similar to those currently found in current literature&#46; The clinical presentation of CVT in pediatric patients is not specific&#44; most often with headache and seizures&#44; therefore a high level of suspicion should be present&#46; MRI&#47;MRV is the preferred imaging method for diagnosis in children&#44; despite not always being available in an emergency setting&#46; Multiple sinuses involvement was the most common pattern&#44; with the transverse and sigmoid sinuses being the most affected vessels&#46; Anticoagulation should be started at diagnosis and the presence of hereditary or acquired thrombophilia evaluated after the minimum recommended time of anticoagulation&#46; Anticoagulation treatment with LMWH is recommended and important to reduce the mortality rate&#44; as seen in our case series&#46; CVT is frequently associated with CNS and&#47;or head and neck infections in children&#44; and the former can also lead to parenchymal injury and lead to high morbidity and poor outcomes as demonstrated in a few of our cases&#46; Recanalization does not appear to be a significant factor for prognosis and predictor of neurological outcome in both children and adults and there are currently no studies or guidelines concerning the expected time of recanalization and if follow-up neuroimaging control MRI&#47;MRV should be routinely performed and at what time point&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest&#46;</p></span></span>"
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          "identificador" => "xpalclavsec1892324"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Results"
          "secciones" => array:8 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Epidemiology"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Clinical presentation"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Neuroimaging studies"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Diagnosis or trigger"
            ]
            4 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Screening for prothrombotic factors"
            ]
            5 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Treatment"
            ]
            6 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Clinical outcome"
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            7 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Recanalization"
            ]
          ]
        ]
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          "titulo" => "Discussion"
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          "titulo" => "Conclusion"
        ]
        9 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflict of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-01-18"
    "fechaAceptado" => "2022-04-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1892323"
          "palabras" => array:6 [
            0 => "Cerebral venous thrombosis"
            1 => "Venous sinus thrombosis"
            2 => "Magnetic imaging resonance"
            3 => "Anticoagulation"
            4 => "Brain infarction"
            5 => "Pediatric stroke"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1892324"
          "palabras" => array:6 [
            0 => "Trombosis venosa cerebral"
            1 => "Trombosis del seno venoso"
            2 => "Resonancia magn&#233;tica"
            3 => "Anticoagulaci&#243;n"
            4 => "Infarto cerebral"
            5 => "Accidente cerebrovascular pedi&#225;trico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cerebral venous thrombosis &#40;CVT&#41; is an uncommon and clinically heterogeneous cerebrovascular particularly in children&#44; only a few published case series focused in the pediatric population&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective single-center observational and analytical study of consecutive pediatric patients admitted in a level II Portuguese hospital with a confirmed diagnosis of CVT&#44; from 2003 to 2021&#46; Clinical presentation&#44; neuroimaging findings&#44; prothrombotic factors&#44; treatment strategies&#44; outcome and recanalization were documented&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twelve children were included &#40;58&#37; female&#41;&#46; Mean age was 7&#46;3 years&#46; The most frequent symptoms were vomiting&#44; headache and behavioral alterations&#46; Infection was the triggering factor in 50&#37; of the cases&#46; The diagnosis of CVT was made based on imaging evidence of thrombosis through magnetic imaging resonance &#40;MRI&#41; with venography and&#47;or computed tomography &#40;CT&#41; with venography&#46; In 67&#37; of cases there were multiples sinuses involved&#59; the transverse sinus was the most affected&#44; followed by the sigmoid sinus&#46; In 83&#37; of cases anticoagulant therapy was initiated with low molecular weight heparin &#40;LMWH&#41; and associated prothrombotic factors were investigated&#44; with no major prothrombotic factors identified&#46; No deaths occurred&#44; but 30&#37; had long-term neurological sequelae&#46; One patient recurred 18 years later&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The results of this study are consistent with data from other published studies&#46; MRI is the preferred imaging method for diagnosis in children by avoiding ionizing radiation and allowing identification of subjacent causes&#46; Anticoagulation with LMWH is recommended and important to reduce mortality and sequelae&#46; Infectious diseases are the most common trigger for CVT and can also be the cause for high morbidity and poor outcomes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La trombosis venosa cerebral &#40;TVC&#41; es una enfermedad cerebrovascular poco com&#250;n y cl&#237;nicamente heterog&#233;nea&#44; especialmente en ni&#241;os&#44; con pocas series de casos publicadas centradas en la poblaci&#243;n pedi&#225;trica&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pacientes y m&#233;todos Estudio observacional y anal&#237;tico&#44; retrospectivo&#44; unic&#233;ntrico&#44; de pacientes pedi&#225;tricos consecutivos ingresados de 2003 a 2021 en un hospital portugu&#233;s de nivel II con diagn&#243;stico confirmado de TVC&#46; Se document&#243;&#58; presentaci&#243;n cl&#237;nica&#44; hallazgos de neuroimagen&#44; factores protromb&#243;ticos&#44; estrategias de tratamiento&#44; evoluci&#243;n y recanalizaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 12 ni&#241;os &#40;58&#37; mujeres&#41;&#46; La edad media fue de 7&#44;3 a&#241;os&#46; Los s&#237;ntomas m&#225;s frecuentes fueron v&#243;mitos&#44; dolor de cabeza y alteraciones del comportamiento&#46; La infecci&#243;n fue el factor desencadenante en el 50&#37; de los casos&#46; El diagn&#243;stico de TVC se realiz&#243; con base en la evidencia de im&#225;genes de trombosis mediante resonancia magn&#233;tica con venograf&#237;a y&#47;o tomograf&#237;a computarizada &#40;TC&#41; con venograf&#237;a&#46; En el 67&#37; de los casos hubo m&#250;ltiples senos afectados&#59; el seno transverso fue el m&#225;s afectado&#44; seguido del seno sigmoideo&#46; En el 83&#37; de los casos se inici&#243; tratamiento anticoagulante con heparina de bajo peso molecular &#40;HBPM&#41; y se investigaron los factores protromb&#243;ticos asociados&#44; sin identificar factores protromb&#243;ticos importantes&#46; No se produjeron muertes&#44; pero el 30&#37; tuvieron secuelas neurol&#243;gicas a largo plazo&#46; Un paciente recidiv&#243; 18 a&#241;os despu&#233;s&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los resultados de este estudio son consistentes con los datos de otros estudios publicados&#46; La resonancia magn&#233;tica es el m&#233;todo de im&#225;genes preferido para el diagn&#243;stico en ni&#241;os al evitar la radiaci&#243;n ionizante y permitir la identificaci&#243;n de las causas subyacentes&#46; Se recomienda la anticoagulaci&#243;n con HBPM&#44; que es importante para reducir la mortalidad y las secuelas&#46; Las enfermedades infecciosas son el desencadenante m&#225;s com&#250;n de TVC y tambi&#233;n pueden ser la causa de una alta morbilidad y de malos resultados&#46;</p></span>"
        "secciones" => array:3 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Resultados"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1092
            "Ancho" => 2091
            "Tamanyo" => 106016
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Age distribution by year of diagnosis&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 489
            "Ancho" => 1255
            "Tamanyo" => 76584
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Coronal T2 demonstrates absent flow void in the right transverse sinus &#40;yellow arrow&#41;&#59; &#40;B&#41; MRV &#40;3D reconstruction&#41;&#44; exhibits absent flow signal in the right transverse and sigmoid sinuses as well as ipsilateral jugular vein &#40;red arrows&#41;&#59; &#40;C&#41; Axial T1post-GAD showing diffuse pachymeningeal and leptomeningeal enhancement &#40;blue arrows&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 427
            "Ancho" => 1255
            "Tamanyo" => 62946
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Axial depicts SWI&#44; hypointensity &#40;&#8220;blooming effect&#8221;&#41; along a cortical vein located in the high convexity &#40;green arrow&#41; indicating the presence of thrombus and sub-arachnoid hemorrhage &#40;blue arrows&#41;&#59; &#40;B&#41; axial T1WI reveals spontaneous hyperintensity in a cortical vein located in the high convexity on the right &#8211; endoluminal thrombus&#59; &#40;C&#41; MRV &#40;3D reconstruction&#41;&#44; poor visualization of the cortical veins draining into the superior sagittal sinus&#44; which is itself patent&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 625
            "Ancho" => 1005
            "Tamanyo" => 67563
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Axial brain CT without contrast administration obtained 18 years after the primary event shows a left frontal cortico-subcortical vascular sequela &#40;yellow arrow&#41; as well as hyperdensity within the superior sagittal sinus &#40;red arrows&#41; and cortical veins in the high convexity &#40;blue arrows&#41; in keeping with recurrent cerebral venous thrombosis&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 513
            "Ancho" => 1255
            "Tamanyo" => 83218
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Axia CTV &#40;A and B&#41; showing a filling defect in the left transverse and sigmoid sinuses &#40;blue arrows&#41;&#59; &#40;C&#41; MRV &#40;3D reconstruction&#41; obtained 7 months later in the same patient shows subtotal recanalization of the previously thrombosed sinuses &#40;red arrow&#41;&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequelae&#46; New CVT 06&#47;2021 &#8211; unknown cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequelae after 12 years &#40;until 2018&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequelae after 8 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequelae after 8 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Right hemiparesis and attention deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Global development delay &#40;&#43;speech&#41; and epilepsy &#40;resolved&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Severe global development delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequalae after 4 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequelae after 3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No sequelae after 2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">As previous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intellectual disability previously to the event&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recanalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No imaging control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Etiological cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nephrotic syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral acute mastoiditis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nephrotic syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meningoradiculitis due to herpes-7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bacterial meningitis to <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bacterial meningitis due to <span class="elsevierStyleItalic">E&#46; coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute mastoiditis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deep neck abscess&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown &#40;Down syndrome&#44; obesity and hypothyroidism&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>warfarin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH and corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH and antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH&#44; antibiotic and corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH&#44; antiviral&#44; antibiotic and corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH and antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH and antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>warfarin and antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH&#44; antiviral and antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LWMH<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>warfarin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Localization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Straight sinus&#44; galen and cerebral veins and right thalamic stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral transverse and superior sagittal sinuses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right transverse and bilateral sigmoid sinuses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right transverse and sigmoid sinuses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right transverse and superior sagittal and confluence of sinuses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right transverse sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cortical veins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right sigmoid sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left transverse sinus and cortical veins with hemorrhagic venous thrombosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left transverse&#44; sigmoid sinuses and internal jugular vein&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right transverse&#44; straight and sigmoid sinuses and internal jugular vein&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right transverse and sigmoid and superior sagittal sinuses and cortical veins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; vomiting and prostration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; vomiting and prostration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomiting and nystagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; vomiting and prostration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right hemiparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever and irritability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Septic chock&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever and ear pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; sore throat and torticollis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; vomiting&#44; fever and irritability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache and vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&#44; age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 11-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9794;&#44; 3-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9794;&#44; 5-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 5-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 7-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9794;&#44; 2-months-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 6-days-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9794;&#44; 8-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9794;&#44; 1-day-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 16-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 16-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#9792;&#44; 16-year-old&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Complete demographic&#44; clinical presentation&#44; localization of affected sinuses&#44; treatment in the acute phase&#44; etiological cause&#44; recanalization and clinical outcome at last time follow-up of all twelve patients engaged in this study&#46; CVT &#8211; cerebral venous thrombosis&#59; LWMH &#8211; low weight molecular heparin&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&#47;12 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#47;12 &#40;75&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#47;12 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#47;12 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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          "identificador" => "bibs0015"
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            0 => array:3 [
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                          "etal" => false
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                  "host" => array:1 [
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Article information
ISSN: 21735808
Original language: English
DOI:10.1016/j.nrleng.2024.09.002
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