Development and Validation of a Clinical-Based Severity Scale for Patients with Cerebral Venous Thrombosis

Figures & data

Table 1 Severity Scale for Cerebral Venous Thrombosis

Items
1A	Level of Consciousness	0 = Alert; keenly responsive. 1 = Not alert, but arousable by minor stimulation to obey, answer or respond. 2 = Not alert, requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements. 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, areflexic.
1B	Level of Consciousness Questions	0 = Answer both questions correctly. 1 = Answer one question correctly. 2 = Answer neither question correctly.
1C	Level of Consciousness Commands	0 = Perform both tasks correctly. 1 = Perform one task correctly. 2 = Perform neither task correctly.
2	Best Gaze	0 = Normal. 1 = Partial gaze palsy. 2 = Forced deviation, total gaze paresis not overcome by the oculocephalic maneuver.
3	Visual Field	0 = No visual loss. 1 = Partial hemianopia. 2 = Complete hemianopia. 3 = Bilateral hemianopia, blindness.
4	Face Palsy	0 = Normal symmetrical movement. 1 = minor paralysis; flattened nasolabial fold, asymmetry on smiling. 2 = partial paralysis; total or near total paralysis of lower face. 3 = complete paralysis of one or both sides; absence of facial movement in the upper and lower face.
5A	Motor Left Arm	0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 3 = No effort against gravity; limb falls. 4 = No movement.
5B	Motor Right Arm	0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 3 = No effort against gravity; limb falls. 4 = No movement.
6A	Motor Left Leg	0 = No drift; leg holds 30 degrees for full 5 seconds. 1 = Drift; leg falls by the end of the 5 second period, but does not hit bed. 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. 3 = No effort against gravity; leg falls to bed immediately. 4 = No movement.
6B	Motor Right Leg	0 = No drift; leg holds 30 degrees for full 5 seconds. 1 = Drift; leg falls by the end of the 5 second period, but does not hit bed. 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. 3 = No effort against gravity; leg falls to bed immediately. 4 = No movement.
7	Limb Ataxia	0 = Absent. 1 = Present in one limb. 2 = Present in two limbs.
8	Sensory	0 = Normal; no sensory loss. 1 = Mild to moderate sensory loss; patient feels pinprick is less sharp or dull on the affected side, or there is a loss of superficial pain with pinprick but patient is aware of being touched. 2 = Severe or total sensory loss; patient is not aware of being touched in the face, arm and leg.
9	Best Language	0 = Normal; no aphasia. 1 = Mild to moderate aphasia; some obvious loss of fluency or facility of comprehension without significant limitation on ideas expressed or form of expression, reduction of speech and/or comprehension makes conversation about provided material difficult or impossible. 2 = Severe aphasia; all communication is through fragmentary expression, great need for inference, questioning and guessing by the listener, range of information that can be exchanged is limited, listeners carries burden of communication, examiner cannot identify materials provided from patient response. 3 = Mute or global aphasia; no usable speech or auditory comprehension.
10	Dysarthria	0 = Normal; no dysarthria. 1 = Mild to moderate dysarthria; patient slurs at least some words and at worst can be understood with some difficulty. 2 = Severe dysarthria; patient’s speech is so blurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute.
11	Extinction and Inattention	0 = Normal. 1 = Visual, tactile, auditory, spatial or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 2 = Profound hemi-inattention or hemi-inattention to more than one modality, does not recognize own hand or orients to only one side of space.
12	Epilepsy	0 = Normal. 1 = Focal epilepsy. 2 = Generalized epilepsy. 3 = Status epilepticus.
13	Headache	0 = Normal. 1 = Mild; intermittent, bearable. 2 = Moderate headache; persistent, bearable, concomitant with nausea and/or vomiting. 3 = Severe headache; persistent, unbearable, concomitant with nausea and/or projectile vomiting.
14	Tinnitus	0 = Normal. 1 = Mild tinnitus; intermittent. 2 = Moderate tinnitus; persistent, can only be heard in quiet environment. 3 = Severe tinnitus; persistent, can be heard in noisy environment, concomitant with vertigo or hearing loss.
15	Papilledema	0 = Normal. 1 = C-shaped halo with a temporal gap. 2 = Circumferential halo. 3 = Loss of major vessels on the optic disc. 4 = Obscuration of all vessels on the optic disc.
16	Ophthalmoplegia	0 = Normal. 1 = Unilateral ophthalmoplegia. 2 = Bilateral ophthalmoplegia.
17	Mental disorders	0 = Normal. 1 = mild; can be persuaded. 2 = severe; cannot be persuaded.
18	Neck discomfort	0 = Normal. 1 = Pain, but no stiff neck. 2 = Stiff neck.

Table 2 Baseline Characteristics and Clinical Manifestations of Patients with Cerebral Venous Thrombosis

Characteristics	CVT Patients (N = 170)
Age	35.7±1.0
Gender (male)	75 (44.1%)
Clinical manifestations
Decreased level of consciousness	15 (8.8%)
Gaze palsy	2 (1.2%)
Visual field defect	3 (1.8%)
Facial Palsy	20 (11.8%)
Arm weakness	44 (25.6%)
Leg weakness	44 (25.6%)
Limb ataxia	3 (1.8%)
Sensory loss	16 (9.4)
Aphasia	17 (10.0%)
Dysarthria	5 (2.9%)
Extinction and Inattention	4 (2.4%)
Epilepsy	45 (26.5%)
Headache	158 (92.9%)
Nausea	95 (55.9%)
Vomiting	82 (48.2%)
Papilledema	77 (45.3%)
Decreased visual acuity	68 (40%)
Tinnitus	14 (8.2%)
Vertigo	3 (1.8%)
Hearing decline	2 (1.2%)
Ophthalmoplegia	17(10%)
Mental disorders	5 (2.9%)
Neck discomfort	22 (12.9%)

Table 3 Rotated Factor Loadings for the Severity Scale

Items	Factor 1 (Focal Neurological Deficits)	Factor 2 (Diffuse Encephalopathy)	Factor 3 (Intracranial Hypertension)	Factor 4 (Cavernous Sinus Syndrome)
Level of consciousness	0.856
Gaze palsy	0.815
Visual field	0.764
Facial Palsy	0.856
Motor arm	0.881
Motor leg	0.894
Limb ataxia	0.583
Sensory	0.872
Best language	0.886
Dysarthria	0.893
Extinction and Inattention	0.844
Epilepsy	0.424
Headache			0.445
Tinnitus			0.443
Papilledema			0.735	0.356
Ophthalmoplegia				0.796
Mental disorders		0.532
Neck discomfort		0.572

Figure 1 The CVT severity scale is positively correlated with ICP, NIHSS and mRS (A–C), and negatively correlated with GCS (D) at baseline.

Abbreviations: CVT, cerebral venous thrombosis; ICP, intracranial pressure; NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin scale; GCS, Glasgow Coma Scale.

Figure 2 ROC curve showed that the CVT severity scale > 3.5 indicated IH (A). Further analysis revealed that patients with CVT severity scale > 3 suffered from higher ICP compared with those with CVT severity scale ≤ 3 (B). Factor 3 (IH) > 2.5 also indicated IH (C). Further analysis revealed that patients with factor > 2 suffered from higher ICP compared with those with factor ≤ 2 (D). * p < 0.05.

Abbreviations: ROC, receiver operating characteristic; CVT, cerebral venous thrombosis; IH, intracranial hypertension; ICP, intracranial pressure.

Figure 3 ROC curve showed that the CVT severity scale > 10.5 indicated mRS > 2 at 6 months of follow-up (A). mRS in patients with CVT severity scale > 10 is significantly lower than those with CVT severity scale ≤ 10 (B). * p < 0.05.

Abbreviations: ROC, receiver operating characteristic; CVT, cerebral venous thrombosis; mRS, modified Rankin Scale.