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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 164-166

Cerebral Sinovenous Thrombosis due to Hypernatremic Dehydration in a Neonate


1 Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Submission12-May-2018
Date of Decision20-Mar-2020
Date of Acceptance17-Apr-2020
Date of Web Publication24-Feb-2021

Correspondence Address:
Suresh Kumar Angurana
Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.310090

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 » Abstract 


Cerebral sinus venous thrombosis is an uncommon complication of hypernatremic dehydration in neonates. Non-improvement in neurological status even after correction of hypernatremia should lead to suspicion of intracranial complications due to hypernatremia or its overtreatment. Slow correction of hypernatremia, calculated fluid administration, and anticoagulation improve outcome in neonates with CSVT.


Keywords: Dehydration, hypernatremia, thrombosis
Key Message: Hypernatremic dehydration can lead to cerebral sinus venous thrombosis in neonates. The treatment include slow correction of hypernatremia and anticoagulation.


How to cite this article:
Bhattacharya D, Angurana SK, Sundaram V, Singh P. Cerebral Sinovenous Thrombosis due to Hypernatremic Dehydration in a Neonate. Neurol India 2021;69:164-6

How to cite this URL:
Bhattacharya D, Angurana SK, Sundaram V, Singh P. Cerebral Sinovenous Thrombosis due to Hypernatremic Dehydration in a Neonate. Neurol India [serial online] 2021 [cited 2021 Apr 23];69:164-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/1/164/310090




Cerebral sinovenous thrombosis (CSVT) is rare in Pediatric age group (0.67/1,00,000 children) with newborns accounting for >60% of cases.[1] Risk factors include perinatal asphyxia, dehydration, sepsis, cardiac disease, and thrombophilia.[2] There are only few case reports of CSVT due to hypernatremic dehydration in neonates.[3],[4],[5],[6],[7],[8] The management of CSVT due to hypernatremic dehydration includes calculated fluid administration, slow sodium correction, and anticoagulation. We present a term newborn with thrombosis of superior saggital sinus, bilateral transverse sinus, and right sigmoid sinus secondary to hypernatremic dehydration with favorable outcome.


 » Case Report Top


A 5-day-old term neonate presented with fever, poor feeding, and lethargy. The birth weight was 2.5 kg and perinatal transition was smooth. He was fed with diluted cow's milk. Examination revealed pulse rate 145/min, respiratory rate 46/min, well palpable pulses, capillary refill time 2 s, features of dehydration, 20% weight loss (from birth weight), and encephalopathy. Investigations revealed blood glucose 84 mg%, serum sodium 177 meq/L, potassium 5.6 meq/L, urea 214 mg%, creatinine 2.2 mg%, hemoglobin 14 gm%, total leukocyte count 7600/cumm, platelet count 1.4 lac/cumm, CRP 0.38 mg%, sterile blood culture, normal cerebrospinal fluid analysis, and normal cranial sonography.

He was given 10% dehydration correction with ringer's lactate and 150% of maintenance fluids (N/2 Saline with 5% dextrose).He was also started on ciprofloxacin and amikacin in view of suspected sepsis and stopped after sterile blood culture report. There was gradual fall in serum sodium over next 48 h [Figure 1]. There was also improvement in renal functions [Table 1]. On day five encephalopathy was persisting with bilateral lower limb hypertonia despite improvement in metabolic parameters. For suspected intracranial complications, he underwent magnetic resonance imaging (MRI) brain which revealed thrombosis of superior saggital sinus, bilateral transverse sinuses, and right sigmoid sinus with extension into right jugular bulb [Figure 2]. He was started on subcutaneous low molecular weight heparin (LMWH). There was improvement in encephalopathy and he started taking feed orally. He was discharged on LMWH. At three months of follow-up, he had age appropriate neurological status and LMWH was stopped.
Figure 1: Showing trend in fall in serum sodium in first 48 h

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Table 1: Biochemical investigations

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Figure 2: MRI brain (a and b) Axial T1 and T2 weighted image showing bilateral transverse sinus thrombosis (c) Saggital T1 weighted image showing thrombus in confluence of sinuses and saggital sinus

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 » Discussion Top


Hypernatremia usually indicates net water loss or gain of sodium, associated with hyperosmolarity. Symptomatic hypernatremia is seen only when serum sodium value crosses 160 meq/L. Hypernatremic dehydration in neonates is usually due to inadequate breast-feeding (lactation failure), poor feeding, high breast milk sodium, inappropriately prepared formula milk, environmental heat induced hypernatremia, or fever.[9]The incidence of hypernatremic dehydration in breast feed infants was documented to be 4.1% and 1.2% of them developed CSVT.[9]

Both hypernatremia as well as its overzealous treatment may lead to various intracranial complications.[9]Brain shrinkage in hypernatremia can result in hemorrhage whereas overtly rapid correction can result in cerebral edema or central pontine myelinosis. Correction of hypernatremia involves calculation of free water deficit [(free water deficit = Body water×( plasma sodium-140/140)], which has to be administered over 48 h. Rate of sodium correction has to be monitored very carefully and should never be >0.5 meq/L per h.

In addition, hypernatremia by virtue of its hypercoagulable state predisposes to thrombosis of both cerebral and systemic circulation. There are few reports of CSVT secondary to hypernatremic dehydration in literature.[3],[4],[5],[6],[7],[8] Gebara et al.[3] reported bilateral extensive thrombosis involving the superior saggital sinus, straight sinus, and transverse sinuses in a ten

day old breastfed baby secondary to hypernatremic dehydration who was treated with anticoagulation and thrombolysis with favorable outcome. Iglesias Fernandez et al.[4] reported an 8-day-old exclusively breast-fed baby with severe hypernatremic dehydration due to inadequate breast feeding who developed complete aortic and cerebral venous thrombosis with was managed with systemic anticoagulation and thrombolytic therapy leading to complete resolution thrombosis. Hbibi et al.[8] reported a 9-day-old male breastfed baby with thrombosis of superior saggital sinus and aorta associated with hypernatremic dehydration which resolved after 1 month of treatment with LMWH.

In index child, inappropriate formula feeding along with poor feeding might have led to hypernatremic dehydration and CSVT. Clinical features of CSVT in neonates include jitteriness, seizures, lethargy, poor feeding and focal neurological deficits. For diagnosis, MRI brain with MR venography is considered as the gold standard. Computed tomography (CT) and CT venography have less sensitivity (73%) and also pose radiation exposure. Anticoagulation is the recommended treatment with LMWH or unfractionated heparin for 6 weeks to 3 months.[10],[11]Supportive care in form of adequate hydration, anticonvulsants, and antibiotics for infection is also necessary. Associated venous infarction and refractory seizures can worsen the outcome, with long term neurological sequelae. Long term neurological outcome is unclear in neonatal CSVT and up to 20-30% neonates can have abnormal neurodevelopment.


 » Conclusion Top


Hypernatremic dehydration being a hypercoagulable state can lead to CSVT in neonates. One should ssuspects intracranial complications of hypernatremia or its overtreatment including CSVT when there is non-improvement in neurological status even after correction of hypernatremia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
deVeber G, Andrew M, Adams C, Bjornson B, Booth F, Buckley DJ, et al. Cerebral sinovenous thrombosis in children. N Engl J Med 2001;345:417-23.  Back to cited text no. 1
    
2.
Ichord RN, Benedict SL, Chan AK, Kirkham FJ, Nowak-Gottl U. Paediatric cerebral sinovenous thrombosis: Findings of the International paediatric stroke study. Arch Dis Child 2015;100:174-9.  Back to cited text no. 2
    
3.
Gebara BM, Everett KO. Dural sinus thrombosis complicating hypernatremic dehydration in a breastfed neonate. Clin Pediatr (Phila) 2001;40:45-8.  Back to cited text no. 3
    
4.
Iglesias Fernandez C, Chimenti Camacho P, Vazquez Lopez P, Guerrero Soler M, Blanco Bravo D. [Aortic and cerebral trombosis caused by hypernatremic dehydration in an exclusively breast-fed infant]. An Pediatr (Barc) 2006;65:381-3.  Back to cited text no. 4
    
5.
Karadag A, Uras N, Odemis E, Tunc B, Tatli MM. Superior sagittal sinus thrombosis: A rare but serious complication of hypernatremic dehydration in newborns. J Perinat Med 2007;35:82-3.  Back to cited text no. 5
    
6.
Duran R, Aladag N, Vatansever U, Temizoz O, Genchallac H, Acunas B. Cranial MR venography findings of severe hypernatremic dehydration in association with cerebral venous thrombosis in the neonatal period. Pediatr Hematol Oncol 2007;24:387-91.  Back to cited text no. 6
    
7.
Locke C, Depani S, Gray M. Extensive subclinical venous sinus thrombosis in the dehydrated infant. J Matern Fetal Neonatal Med 2010;23:463-4.  Back to cited text no. 7
    
8.
Hbibi M, Abourazzak S, Babakhouya A, Boubou M, Atmani S, Tizniti S, et al. Severe hypernatremic dehydration associated with cerebral venous and aortic thrombosis in the neonatal period. BMJ Case Rep 2012;2012:bcr0720114426.  Back to cited text no. 8
    
9.
Unal S, Arhan E, Kara N, Uncu N, Aliefendioglu D. Breast-feeding-associated hypernatremia: Retrospective analysis of 169 term newborns. Pediatr Int 2008;50:29-34.  Back to cited text no. 9
    
10.
Saposnik G, Barinagarrementeria F, Brown RD, Jr., Bushnell CD, Cucchiara B, Cushman M, et al. Diagnosis and management of cerebral venous thrombosis: A statement for healthcare professionals from the American heart association/American stroke association. Stroke 2011;42:1158-92.  Back to cited text no. 10
    
11.
Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Gottl U, et al. Antithrombotic therapy in neonates and children: Antithrombotic therapy and prevention of thrombosis, 9th ed. American college of chest physicians evidence-based clinical practice guidelines. Chest 2012;141(2 Suppl):e737S-801S.  Back to cited text no. 11
    


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