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\begin{document}

\title{Cerebral venous sinus thrombosis in patient of Immune thrombocytopenic
purpura managed with mechanical thrombectomy: an anecdotal endovascular
experience from Lower middle income country}



\author[1]{Sagun Ghimire}%
\author[2]{Shikher Shrestha}%
\author[1]{Dinuj shrestha}%
\author[1]{suman bhattarai}%
\author[1]{kajan ranabhat}%
\author[2]{Ananta Maharjan}%
\author[1]{prabin chaudhary}%
\author[1]{Bibek  Jaiswal}%
\affil[1]{B \& B Hospital}%
\affil[2]{B\&B Hospital}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\emph{Cerebral venous sinus thrombosis in patient of Immune
thrombocytopenic purpura managed with mechanical thrombectomy: an
anecdotal endovascular experience from Lower middle income country}

Corresponding author:

Sagun Ghimire, MBBS,Department of Neurosurgery , B and B hospital,
Gwarko, Lalitpur, Nepal, +977 9846709636, sagunghimire01@gmail.com

Author list :

\textsuperscript{1}Sagun ghimire,MBBS,Department of Neurosurgery, B and
B hospital,Gwarko, Lalitpur, Nepal

\textsuperscript{1}Shikher Shrestha,MBBS,FCPS, Department of
Neurosurgery, B and B hospital, Gwarko,Lalitpur,Nepal

\textsuperscript{1}Dinuj Shrestha,MBBS,FCPS, Department of Neurosurgery,
B and B hospital, Gwarko,Lalitpur,Nepal

\textsuperscript{1}Kajan Ranabhat,MBBS,MD, Department of Radiology, B
and B hospital, Gwarko, Lalitpur,Nepal

\textsuperscript{1}Suman Bhattarai,MBBS,MD,Department of neuroscience, B
and B hospital, Gwarko, Lalitpur,Nepal

\textsuperscript{1}Ananta maharjan, MBBS,MS,Department of Neurosurgey,B
and B hospital, Gwarko,Lalitpur,Nepal

\textsuperscript{2}Bibek Jaiswal,MBBS,Department of Neurosurgery ,B and
B hospital, Gwarko,Lalitpur, Nepal

\textsuperscript{2}Prabin chaudhary,MBBS,Department of Neurosurgery,B
and B hospital, Gwarko, Lalitpur, Nepal

Abstract:

Key Clinical Message

The concurrent association of cerebral venous sinus thrombosis and
immune thrombocytopenic purpura is one of the rarest occurrences. There
exist very scarce evidence based medical literature regarding
pathophysiology resulting cerebral venous sinus thrombosis in patients
of immune thrombocytopenic purpura hence there lacks standard guidelines
guiding prompt management in such cases.

Keywords: Cerebral venous sinus thrombosis, Immune thrombocytopenic
purpura, Mechanical thrombectomy

\textbf{INTRODUCTION:}

Among the cerebrovascular diseases cerebral venous thrombosis is
considered one of the uncommon disease which can present in any age
group and accounts for only 0.5\% of all stroke cases.(1) Majority of
risk factors that are associated with cerebral venous sinus thrombosis
mostly have a common pathophysiological ground of prothrombotic state
either transient or permanent and immune thrombocytopenic purpura also
falls under that category .(2) Among the several causes of isolated
thrombocytopenia immune thrombocytopenic purpura ( ITP) is an autoimmune
disorder resulting from either increased destruction or decreased
production of platelets associated with antibodies against platelets
surface glycoproteins.(3)(4)The concurrent association of cerebral venou
sinus thrombosis in patient of ITP is scarcely reported in medical
literature along with it there is not any robust studied mechanism that
explains the cause of CVST in patients of ITP. As far as from available
evidences platelets microparticles (PMPs) which are tiny vesicles
measuring less than 0.5 micrometer and stems from platelets membranes
which further supports the formation of thrombus hence the chances of
CVST. Studies have shown that the levels of PMPs are found to be in
higher ranges in patient of ITP compared to other healthy
individuals.(5)Regarding the management mostly the pharmacological
modality such as IVIG, steroid therapy, platelet rich growth factors,
anti coagulants and treatment of underlying cause are some of the major
treatment means.(6)(7)There exist some studies (8)where mechanical
thrombectomy have been done in CVST patients however in such rare cases
where CVST resulted from ITP, the management from endovascular
intervention have not been not noted well.This case has been written in
accordance with SCARE guidelines .(9)

\textbf{CASE SUMMARY} :

A 25-year-old Asian Male was admitted to neuroscience department for
headache. His past medical history was suggestive of diagnosed case of
immuno thrombocytopenic purpura (ITP) under pharmacological treatment of
Tab Dexamethasone 20 mg 4 days per week every alternate week since five
months.Patient was also a known case of systemic hypertension but was
not under regular anti hypertensive medications. Other medical and
surgical history was unremarkable. . At arrival patient complaints of
severe headache since 2 days, headache was diffuse in nature and more
severe over bilateral frontal region, continuous, persisting, not
relieved on taking over the counter medications and associated with
sever bilateral periorbital pain. Vitals at the presentation were within
normal range. There was no other history of dizziness, nausea,vomiting,
weakness of limbs, abnormal body movement, slurring of speech, deviation
of angle of mouth, bowel and bladder incontinence and trauma. On further
examination neurologically GCS of the patient was 15/15, pupils were
bilateral reactive to light and no other significant systemic findings.
On Laboratory tests for full blood count, coagulation profile, and
C-reactive protein, D-dimer remained normal limits except his platelets
count was 67,500 .Patient still complained of persisting headache hence
was initially managed conservatively with IV analgesics. On further
investigation magnetic resonance venography (MRV) showed features
suggestive of extensive dural sinus venous thrombosis i.e complete
occlusion of superior saggital sinus, right transverse sinus, right
straight sinus and right jugular vein . Furthermore venous congestion
was also present along with venous drainage from bilateral superficial
middle cerebral vein to cavernous sinus to inferior petrosal sinus to
left jugular vein. A total body CECT was not done to rule out venous
thrombosis in other sites however no symptoms suggesting thrombosis of
other organs were apparent. Due to the clinical suspect of CVST ,
dexamethasone (40~mg i.v. daily for 4~days), and INJ Enoxaparin 60 mg
subcutaneously twice day was started . A subsequent brain MR imaging
further confirmed the diffuse cerebral venous thrombosis . The
neuroradiologist suggested a neuroendovascular treatment and after a
collegial discussion, we decided to proceed after platelet transfusion.
Thrombectomy was performed both with aspiration using large bore
aspiration catheter and with multiple embricated stent-retrievers. At
the beginning of the procedure 6 vessel angio run off was done which was
followed by thromobaspiration with cat-6 under 10 F guiding. After many
passages, superior saggital sinus was completely opened, right
transverse sinus, right straight sinus was also completely
opened.Trolard and labbe vein appear draining to superior saggital sinus
and right transverse sinus. Straight sinus was partly opened.At the end
of the procedure, day 0, the patient was admitted in ICU where he stayed
for 2 days. Screening tests for congenital and acquired thrombophilia
was suggested to the patient. In the subsequent days his platelet levels
fluctuated between 70,000 to 80,000.Symptomatically the severity of
headache was on decreasing trend. CT head was repeated at the time of
discharge which do not showed any features of hemorrhage, infarction.
Patient was discharged from our center after complete free of headache
and without any neurological and motor deficits.

.

\textbf{DISCUSSION:}

Thrombocytopenia, one of the major blood disorders can be defined as the
level of platelets less than 1, 50,000 microliter in the blood. The
cause behind such decrease in platelet count from blood can be
categorized as either from decrease in production due to factors such as
as viral infections, vitamin deficiencies, aplastic anemia, drugs or
increase in destruction of platelets resulting from heparin-induced
thrombocytopenia, idiopathic , pregnancy, immune system. Along with it
sequestration due to splenomegaly, neonatal, gestational or pregnancy
related sequestrations are the major culprits. (10)Associated with
body's immune system, immune thrombocytopenic purpura (ITP) is an
autoimmune disorder resulting from antibodies directed against the
platelets surface glycoprotein such as GPIIb/IIIa,GP Ib/IX complexes
along with certain role of T cell mediated cytotoxicity.(3),(4)Cerebral
venous sinus thrombosis is one the rarest entity causing cerebral
ischemia and is not mostly associated with blood disorders such as ITP.
Based upon what minimal evidence that exist in the medical literature
the cause behind the concurrent association of CVST in patient of ITP
could be due to platelet microparticles, a nano vesicle causing
increased thrombin formation,patient treated with IVIGs resulting in
increased blood viscosity and increased levels of von willebrand factor
antigen are some of the few studied fields.(11),(12)Regarding the
certain group of risk factors that could potentially result in CVST are
genetic thrombophilia, such as antithrombin deficiency, protein C
deficiency, or protein S deficiency, factor V Leiden mutation,
homocysteinemia, or acquired conditions like pregnancy and puerperium,
oral contraceptive pills, malignancy, or infections.(2)In terms of
patient presentation in cases of ITP , the patient usually presents with
~bleeding diathesis ~from~low platelet count such as~petechiae ,~purpura
, and bleeding per~mucosa along with platelet count less than
30~\selectlanguage{ngerman}×~10\textsuperscript{9}/liter can result in fatal life threatening
bleedings.(13)In cases of CVST patient usually presents with headache of
various severity, nausea, vomiting, visual disturbances and in most
cases also the optic disc changes have been seen.(14)

The diagnosis of ITP is considered after exclusion of all other possible
secondary causes whereas the diagnosis of CVST is straightforward and
radiological imaging mostly magnetic resonance venography (MRV) and MR
imaging of the brain is the standard modality of diagnosis. Regarding
the management of ITP the primary goal is to maintain adequate level of
platelets and control the bleeding tendency. ~Prednisolone,
dexamethasone, and~methylprednisolone is considered the baseline
management whereas in case of an emergency setting, intravenous
immunoglobulin and anti-D plays vital role in acutely raising the
platelets level and prevent patient deterioration.(15)Furthermore
American Society of Hematology recommends thrombopoetion receptor
agonist(TPO-RA) either romiplostim or eltrombopag as the second-line
therapy for people suffering from ITP who are corticosteroid-dependent
or resistant to corticosteroids for at least 3 months.(15)In case of
CVST systemic anticoagulation with~low molecular weight heparin ~and
unfractionated heparin is considered standard modality of management
which can bring about good prognosis in symptomatic improvement and
drastic recanalization.(16),(17)In recent decade there has been rise in
the cases of venous thrombotic events such as CVST but very less number
of reports have talked about CVST in diagnosed cases of
ITP.(14),(18),(19),(20) In majority of such cases where CVST and ITP
co-exist pharmacological treatment has been prioritized but endovascular
intervention such as mechanical thrombectomy in selected patients can
also bring about fruitful prognosis.Furthermore a ~systematic review~of
CVST described emergency mechanical thrombectomy as an effective~salvage
therapy ~with a ratio of favorable outcomes (modified Rankin Scale
scores 0--2) of almost 80\%.(21)There exist several endovascular
techniques for MT such as catheter thrombolysis, balloon-assisted
thrombectomy, stent retrievers and penumbra aspiration system with no as
such intervention guiding standard protocols to ascertain the
superiority of the different endovascular interventions. Our patient was
treated with a combination of stent retriever and direct aspiration
thrombectomy known as ``Solumbra'' technique.(22),(23) Patient selection
for such endovascular intervention is also a major dilemma and some of
the established indicators are failure of systemic anticoagulation,
extensive clot burden, cerebral edema, elevated intracranial pressure,
altered mental status and progressive worsening of neurological
symptoms.(21)In our case the major indicator was extensive clot burden
over multiple site and severe persisting headache. With appropriate
patient selection and timely intervention the desired prognosis was
achieved in our case.

\textbf{CONCLUSION:}

There exist a draught in terms of clinical reported cases where ITP and
CVST have co-existed and furthermore scarce are the endovascular
intervention done in such rare concurrent cases .The aim of medical
management in CVST is early recanalization of the thrombosed sinuses and
thereby preventing complications. Anticoagulants are considered the
standard therapy but considering the low complication rate and the
clinical and radiological success, our study provides evidence
supporting the efficacy and safety of MT in selected cases. More
multicenter academic trials with a large sample size are needed to
perform multivariable regression analyses on such low incidence rare
cases with large pathophysiological heterogeneity, in order to provide
reliable data on efficacy and safety of MT to guide prompt clinical
decision.

\textbf{Consent to participant}

Written informed consent was obtained from the participant.

\textbf{Consent to publish}

The participant has consented to the submission of the case report to
the journal.

\textbf{Ethical approval}

Not applicable.

\textbf{Funding}

No funding was received to assist with the preparation of this
manuscript.

\textbf{Declaration of Competing Interest}

The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to
influence the work reported in this paper.

\textbf{REFERRENCES} :

1 . Bousser, M. G., \& Ferro, J. M. (2007). Cerebral venous thrombosis:
an update.~\emph{The Lancet. Neurology} ,~\emph{6} (2), 162--170.
https://doi.org/10.1016/s1474-4422(07)70029-7 {[}PUBMED{]}

2 . Boulware, R., \& Refaai, M. A. (2020). Why do patients with immune
thrombocytopenia (ITP) experience lower bleeding events despite
thrombocytopenia?.~\emph{Thrombosis research} ,~\emph{187} , 154--158.
https://doi.org/10.1016/j.thromres.2020.01.020 {[}PUBMED{]}

3 . Provan, D., Stasi, R., Newland, A. C., Blanchette, V. S.,
Bolton-Maggs, P., Bussel, J. B., Chong, B. H., Cines, D. B.,
Gernsheimer, T. B., Godeau, B., Grainger, J., Greer, I., Hunt, B. J.,
Imbach, P. A., Lyons, G., McMillan, R., Rodeghiero, F., Sanz, M. A.,
Tarantino, M., Watson, S., \ldots{} Kuter, D. J. (2010). International
consensus report on the investigation and management of primary immune
thrombocytopenia.~\emph{Blood} ,~\emph{115} (2), 168--186.
https://doi.org/10.1182/blood-2009-06-225565 {[}PUBMED{]}

4 . Yassin M, El-Ayyoubi H, Muhammed H, Kamzoul R, Al-Badri M, Al-Sabbah
A. Efficacy and safety of six doses of rituximab (375mg/m²) in treatment
of chronic refractory immune thrombocytopenia an experience from Qatar.
Haematologica. 2011;96:648-9. {[}GOOGLE SCHOLAR{]}

5 . Sewify, E. M., Sayed, D., Abdel Aal, R. F., Ahmad, H. M., \& Abdou,
M. A. (2013). Increased circulating red cell microparticles (RMP) and
platelet microparticles (PMP) in immune thrombocytopenic
purpura.~\emph{Thrombosis research} ,~\emph{131} (2), e59--e63.
https://doi.org/10.1016/j.thromres.2012.11.021 {[}PUBMED{]}

6 . Ntantos D, Karantali E, Prevezianou A, Angelopoulos P,
Bostantjopoulou S. Spontaneous epidural hematomas due to cerebral venous
thrombosis in a patient with immune thrombocytopenic purpura. Journal of
Stroke and Cerebrovascular Diseases. 2020 Nov 1;29(11):105244.{[}GOOGLE
SCHOLAR{]}

7 . Wong R, Yava\selectlanguage{polish}ş\selectlanguage{english}o\selectlanguage{polish}ğ\selectlanguage{english}lu I, Yassin MA, Tarkun P, Yoon SS, Samra MA,
Angchaisuksiri P, Pilipovic V, Jang JH. Pf701 assessment of eltrombopag
in patients with chronic immune thrombocytopenia under routine clinical
practice in the middle east, Turkey, Asia, and Australia. HemaSphere.
2019 Jun;3:305. https://doi.org/10.1097/01.HS9.0000561088.53023.c9
{[}GOOGLE SCHOLAR{]}

8 . Jedi F, Dethlefs G, Hauser TK, Hennersdorf F, Mengel A, Ernemann U,
Bender B. Mechanical Thrombectomy in Cerebral Venous Sinus Thrombosis:
Reports of a Retrospective Single-Center Study. J Clin Med. 2022 Oct
28;11(21):6381. https://doi.org/10.3390\%2Fjcm11216381 {[}PUBMED{]}

9 . Sohrabi C, Mathew G, Maria N, Kerwan A, Franchi T, Agha RA. The
SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE)
guidelines. Int J Surg Lond Engl. 2023;109(5):1136.

10 . Rodeghiero, F., Stasi, R., Gernsheimer, T., Michel, M., Provan, D.,
Arnold, D. M., Bussel, J. B., Cines, D. B., Chong, B. H., Cooper, N.,
Godeau, B., Lechner, K., Mazzucconi, M. G., McMillan, R., Sanz, M. A.,
Imbach, P., Blanchette, V., K\selectlanguage{ngerman}ühne, T., Ruggeri, M., \& George, J. N.
(2009). Standardization of terminology, definitions and outcome criteria
in immune thrombocytopenic purpura of adults and children: report from
an international working group.~\emph{Blood} ,~\emph{113} (11),
2386--2393. https://doi.org/10.1182/blood-2008-07-162503 {[}PUBMED{]}

11 . Gordon DL. The diagnosis and management of cerebral venous
thrombosis. InHandbook of Cerebrovascular Diseases, Revised and Expanded
2004 Oct 29 (pp. 625-656). CRC Press. {[}GOOGLE SCHOLAR{]}

12 . Kim WH, Park JB, Jung CW, Kim GS. Rebalanced hemostasis in patients
with idiopathic thrombocytopenic purpura. Platelets. 2015 Jan
2;26(1):38-42. https://doi.org/10.1097/01.HS9.0000561088.53023.c9
{[}GOOGLE SCHOLAR{]}

13 . Schifferli A, Cavalli F, Godeau B, Liebman HA, Recher M, Imbach P,
Kühne T. Understanding immune thrombocytopenia: looking out of the box.
Frontiers in Medicine. 2021 Jun 24;8:613192.{[}GOOGLE SCHOLAR{]}

14 . Chutithep Teekaput, Angkana Nadsasarn, Surat Tanprawate, Atiwat
Soontornpun, Kitti Thiankhaw, Chayasak Wantaneeyawong, Kanokkarn
Teekaput, Chatree Chai-Adisaksopha,Cerebral venous sinus thrombosis in
immune thrombocytopenia patients treated with thrombopoietin receptor
agonist: Case reports and literature review,Annals of Medicine and
Surgery,Volume 79,2022,104116,ISSN 2049-0801.
https://doi.org/10.1016/j.amsu.2022.104116 {[}FULL TEXT{]}

15 . Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N,
Cuker A, Despotovic JM, George JN, Grace RF, Kühne T. American Society
of Hematology 2019 guidelines for immune thrombocytopenia. Blood
advances. 2019 Dec 10;3(23):3829-66.{[}GOOGLE SCHOLAR{]}

16 . Einhäupl K, Stam J, Bousser MG, De Bruijn SF, Ferro JM, Martinelli
I, Masuhr F. EFNS guideline on the treatment of cerebral venous and
sinus thrombosis in adult patients. European journal of neurology. 2010
Oct;17(10):1229-35. {[}GOOGLE SCHOLAR{]}

17 . Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F.
Prognosis of cerebral vein and dural sinus thrombosis: results of the
International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT).
Stroke. 2004 Mar 1;35(3):664-70.{[}GOOGLE SCHOLAR{]}

18 . Maimoonah A. Rasheed,~Arwa E. Alsaud,~Sania Razzaq,~Afraa
Fadul,~Mohamed A. Yassin; Cerebral Venous Thrombosis in a Patient with
Immune Thrombocytopenia, an Apparent Paradox.~\emph{Case Rep Oncol} ~22
September 2020; 13 (2): 588--594. https://doi.org/10.1159/000507389
{[}FULL TEXT{]}

19 . Bahadorizadeh, L., Emamikhah, M., Pour Mohammad, A.~\emph{et al.}
~Simultaneous Occurrence of Cerebral Venous Sinus Thrombosis and Immune
Thrombocytopenic Purpura in a Patient with a History of COVID-19
Infection.~\emph{Neurol Ther} ~\textbf{11} , 491--497 (2022).
https://doi.org/10.1007/s40120-021-00294-9 {[}FULL TEXT{]}

20 . Zhang, Xin; Zhang, Kai\textsuperscript{1}; Li, Feifei.~Cerebral
venous sinus thrombosis in a young patient with idiopathic
thrombocytopenic purpura: A case report. Indian Journal of Ophthalmology
- Case Reports 3(4):p 1076-1079, Oct--Dec 2023. DOI:
10.4103/IJO.IJO\_85\_23 .{[}FULL TEXT{]}

21 . Ilyas A, Chen CJ, Raper DM, Ding D, Buell T, Mastorakos P, Liu KC.
Endovascular mechanical thrombectomy for cerebral venous sinus
thrombosis: a systematic review. Journal of neurointerventional surgery.
2017 Sep 11. {[}GOOGLE SCHOLAR{]}

\textbf{22 . Ferro, J. M., Bousser, M. G., Canhão, P., Coutinho, J. M.,
Crassard, I., Dentali, F., di Minno, M., Maino, A., Martinelli, I.,
Masuhr, F., Aguiar de Sousa, D., Stam, J., \& European Stroke
Organization (2017). European Stroke Organization guideline for the
diagnosis and treatment of cerebral venous thrombosis - endorsed by the
European Academy of Neurology.~\emph{European journal of
neurology},~\emph{24}(10), 1203--1213. https://doi.org/10.1111/ene.13381
{[}PUBMED{]}}

23 . Saposnik, G., Barinagarrementeria, F., Brown, R. D., Jr, Bushnell,
C. D., Cucchiara, B., Cushman, M., deVeber, G., Ferro, J. M., Tsai, F.
Y., \& American Heart Association Stroke Council and the Council on
Epidemiology and Prevention (2011). Diagnosis and management of cerebral
venous thrombosis: a statement for healthcare professionals from the
American Heart Association/American Stroke Association.~\emph{Stroke}
,~\emph{42} (4), 1158--1192.
https://doi.org/10.1161/str.0b013e31820a8364 {[}PUBMED{]}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure A: MRI brain saggital veiw showing loss of T2 flow void, single
arrow suggestive of superior saggital sinus thrombosis, double arrow
suggestive of transverse sinus thrombosis.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure B : MRV brain showing drainage from secondary channels, superior
saggital sinus draining into superior middle cerebral vein which
draining into cavernous sinus then to inferior petrosal sinus then to
jugular vein\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure C: Pre procedure venous run off showing thrombosed superior
saggital vein, inferior saggital vein, transverse vein and drainage
through secondary channels as depicted in figure D\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Figure D: Pre procedure venous run off shows absent superior saggital
sinus, transverse sinus and drainage from secondary venous channels ,
superior middle cerebral vein draining into cavernous sinus then to
inferior petrosal sinus then to inferior jugular vein. Visible venous
strain indicative of parenchymal venous congestion.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

Figure E: Post mechanical thrombectomy lateral view venous run off
showing opened up superior saggital sinus, transverse sinus, sigmoid
sinus,torcula, patent vein of trolard and labbe and drainage to interior
jugular vein.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

Figure F : Post mechanical thrombectomy AP view venous run off showing
patent superior saggital sinus, transverse sinus,sigmoid sinus and
internal jugular vein.

\selectlanguage{english}
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