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EDUCATION AND TRAININGLondon & New York: RutledgeFarmer.11. Simon, Y. R. (1983). Pursuit ofHappiness and Lust for Power inTechnological Society, C. Mitcham& R. Mackey (eds.), Philosophy andTechnology, New York: Free Press.12. Skinner, B. f. (Spring 1954).The Science of Learning and the Artof Teaching, Harvard EducationalReview: 24, pp. 86-97; TeachingMachines & Science: 128 (October24, 1978). Why We Need TeachingMachines, Harvard EducationalReview: 31 (Fall 1961).13. Valcke, M. (1999). EducationalRedesign of Courses to supportLarge Groups of University Studentsby Building Upon the Potential ofICT, In Information Technology forTeaching and Training, The Journalof the Integrated Study of ArtificialIntelligence Cognitive Science andApplied Epistemology: 16.14. Waldse, Jilbert (2005).Instructional Television’s ChangingRole in the Classroom, April 2009.15. www.falsafe-godfather.blogfa.com16. www.festival.roshd.ir (Magazine)17. www.irandoc.ac.ir18. www.rahavi.ir19. www.science-dept.talif.sch.ir-20. www.visual.merriam-webster.com38MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10
CASE REPORTCerebral venous sinus thrombosis in a child with Idiopathicnephrotic syndromeAlexander SMAl-Enezi FahadVictor AOwaidha MPaediatric Department,Al-Jahra Hospital, KuwaitCorrespondence:Dr Fahad H AlaneziAljahra Hospital, KuwaitTel: 96599846919Fax: 96524572123Email: fdh529@hotmail.comAbstractCerebral venous sinus thrombosis(CVST) is an uncommon complicationof Nephrotic syndrome(NS). CVST occurring in a childwith steroid sensitive nephroticsyndrome is described in thisarticle. He presented initiallywith non specific symptoms ofheadache, lethargy and intermittentvomiting after 4 weeks ofinitiating steroid therapy. Thesewere initially attributed to steroidtherapy. Initial CT brain andMRI of the brain were normal. Hedeveloped intermittent convergentsquint. At this time CVSTwas strongly suspected and MRangiography and MR venographywas done which confirmed theCVST. Anticoagulation therapywas initiated with heparin andafter three weeks changed to oralwarfarin. He made slow but completeneurological and radiologicalrecovery.Key words: Cerebral VenousSinus Thrombosis (CVST), NephroticSyndrome (NS), Anticoagulation,Magnetic ResonanceAngiography (MRA), MagneticResonance Venography (MRV).IntroductionHypercoagulable state is a well recognized complication of nephroticsyndrome [1, 2]. Clinically significant thromboembolic complication is wellknown to occur in nephrotics [3,4,5,6,7,8,9,10,11,12,13,14,15,16]. Theseare more common in adults than in children [9]. Both arterial and venousthrombosis have been seen [8, 9]. Among the venous thrombosis,renal vein thrombosis is the most common type. Cerebral venous sinusthrombosis in children with NS is a well known but rare complication [5,17]. CVST can present with non specific symptoms [18, 19]. It can alsobe missed by conventional diagnostic methods. It carries significantsequelae in the form of either neurological deficit or death in nearly halfof the cases [3]. Hence early diagnosis and initiation of anticoagulanttherapy is of critical importance. This case report describes a child withthis rare complication.Case ReportA four year old boy, a known case of idiopathic nephrotic syndrome, wasadmitted with history of headache, lethargy and intermittent vomitingof 4 days duration. He was diagnosed to have nephrotic syndrome amonth earlier and had been started on oral prednisolone (2mg/kg/day).Proteinuria had improved and he had been discharged on oral steroidsafter 1 week in the hospital. There was no history of seizures, psychosisor focal neurological deficits. His urine output was good. At the time ofadmission, physical examination revealed an alert and cooperative childwith cushingoid appearance. He was hypertensive (BP 134/90mmHg).His face was puffy, but he had no ascites or pedal oedema. Hisneurological examination was normal.Figure 1MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 39
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