Prediction of cerebral venous thrombosis with a new clinical score and D-dimer levels

Mirjam R Heldner; Susanna M Zuurbier; Bojun Li; Rascha Von Martial; Joost C M Meijers; Rebekka Zimmermann; Bastian Volbers; Simon Jung; Marwan El-Koussy; Urs Fischer; Hans P Kohler; Verena Schroeder; Jonathan M Coutinho; Marcel Arnold

doi:10.1212/WNL.0000000000009998

Prediction of cerebral venous thrombosis with a new clinical score and D-dimer levels

Neurology. 2020 Aug 18;95(7):e898-e909. doi: 10.1212/WNL.0000000000009998. Epub 2020 Jun 23.

Affiliations

¹ From the Department of Neurology (M.R.H., R.V.M., R.Z., B.V., S.J., U.F., M.A.), Inselspital, University Hospital and University of Bern, Switzerland; Department of Neurology (S.M.Z., J.M.C.), Amsterdam University Medical Centers, University of Amsterdam, the Netherlands; Department of Experimental Vascular Medicine (J.C.M.M.), Amsterdam University Medical Centers, University of Amsterdam, and Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands; and Institute of Diagnostic and Interventional Neuroradiology (M.E.-K.), Inselspital and Experimental Haemostasis Group (B.L., H.P.K., V.S.), Department for BioMedical Research, University of Bern, Switzerland. mirjam.heldner@insel.ch.
² From the Department of Neurology (M.R.H., R.V.M., R.Z., B.V., S.J., U.F., M.A.), Inselspital, University Hospital and University of Bern, Switzerland; Department of Neurology (S.M.Z., J.M.C.), Amsterdam University Medical Centers, University of Amsterdam, the Netherlands; Department of Experimental Vascular Medicine (J.C.M.M.), Amsterdam University Medical Centers, University of Amsterdam, and Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands; and Institute of Diagnostic and Interventional Neuroradiology (M.E.-K.), Inselspital and Experimental Haemostasis Group (B.L., H.P.K., V.S.), Department for BioMedical Research, University of Bern, Switzerland.

PMID: 32576633
DOI: 10.1212/WNL.0000000000009998

Abstract

Objective: To investigate prediction of cerebral venous thrombosis (CVT) by clinical variables and D-dimer levels.

Methods: This prospective multicenter study included consecutive patients with clinically possible CVT. On admission, patients underwent clinical examination, blood sampling for D-dimers measuring (ELISA test), and magnetic resonance/CT venography. Predictive value of clinical variables and D-dimers for CVT was calculated. A clinical score to stratify patients into groups with low, moderate, or high CVT risk was established with multivariate logistic regression.

Results: CVT was confirmed in 26.2% (94 of 359) of patients by neuroimaging. The optimal estimate of clinical probability was based on 6 variables: seizure(s) at presentation (4 points), known thrombophilia (4 points), oral contraception (2 points), duration of symptoms >6 days (2 points), worst headache ever (1 point), and focal neurologic deficit at presentation (1 point) (area under the curve [AUC] 0.889). We defined 0 to 2 points as low CVT probability (negative predictive value [NPV] 94.1%). Of the 186 (51.8%) patients who had a low probability score, 11 (5.9%) had CVT. The frequency of CVT was 28.3% (34 of 120) in patients with a moderate (3-5 points) and 92.5% (49 of 53) in patients with a high (6-12 points) probability score. All low CVT probability patients with CVT had D-dimers >500 μg/L. Predictive value of D-dimers for CVT for >675 μg/L (best cutoff) vs >500 μg/L was as follows: sensitivity 77.7%, specificity, 77%, NPV 90.7%, and accuracy 77.2% vs sensitivity 89.4%, specificity 66.4%, NPV 94.6%, and accuracy 72.4%, respectively. Adding the clinical score to D-dimers >500 μg/L resulted in the best CVT prediction score explored (at the cutoff ≥6 points: sensitivity 83%/specificity 86.8%/NPV 93.5%/accuracy 84.4%/AUC 0.937).

Conclusion: The proposed new clinical score in combination with D-dimers may be helpful for predicting CVT as a pretest score; none of the patients with CVT showed low clinical probability for CVT and D-dimers <500 μg/L.

Clinicaltrialsgov identifier: NCT00924859.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Computed Tomography Angiography / methods
Female
Fibrin Fibrinogen Degradation Products / metabolism*
Headache / diagnosis
Headache / metabolism
Humans
Intracranial Thrombosis / diagnosis*
Intracranial Thrombosis / metabolism
Male
Middle Aged
Predictive Value of Tests*
Venous Thrombosis / diagnosis*
Venous Thrombosis / metabolism
Young Adult

Substances

Fibrin Fibrinogen Degradation Products
fibrin fragment D

Associated data

ClinicalTrials.gov/NCT00924859