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Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi

Year 2021, Volume: 2 Issue: 1, 25 - 32, 30.03.2021

Abstract

Giriş ve Amaç: Serebral ven trombozu (SVT) arteriyal inmeye oranla daha seyrek görülmekle birlikte her yaş grubunu etkileyebilmektedir. Başlangıç şekli ve seyri değişken olup genellikle iyi prognoza sahiptir. Erken gelişen koma ve intrakraniyal kanama ise kötü prognostik faktörlerdendir.
Gereç ve Yöntem: 01 Ocak 2006 – 1 Ekim 2011 tarihleri arasındaki 5 yıllık dönemde, SVT tanısı ile takip edilen 30 kadın 16 erkek toplam 46 hasta retrospektif olarak incelendi.
Bulgular: 46 olgunun 30’u kadın, 16’sı erkekti. Yaş ortalaması 39,3+12,29, yaş aralığı 13-69 olup 22’si subakut, 20’si akut, 4’ü kronik dönemde başvurdu. En sık yakınma başağrısı olup (%69,6) en sık tespit edilen bulgu papilla ödemiydi (%56,5). Çalışmaya alınan 15 hastada epileptik nöbet izlendi. Görüntüleme bulguları incelendiğinde 24’ünde parenkimal lezyon yokken, 13’ünde hemorajik infarkt, 6’sında iskemik infarkt, 2’sinde subaraknoid kanama, birinde epidural apse saptandı. 16 hastada tek bir dural sinüs trombozu izlenirken, 30 hastada birden fazla sinüs tutulumu mevcuttu. İzole ve izole olmayan sinüsler birlikte alındığında en sık transvers sinüs (n=37), trombozu saptandı. Hastaların 11’inde etyolojik neden saptanamazken, 18 hastada birden fazla etyoloji saptandı. Saptanan predispozan faktörler; infeksiyon (n=21), gebelik ve postpartum (n=5), oral kontraseptif ilaç (n=7), kalıtımsal trombofili (n=21), Behçet Hastalığı (n=2), ülseratif kolit (n=1), kafa travması (n=1) idi. Hastaların izleminde 38 hastada tam düzelme kaydedildi, 1 hasta vefat etti, 7 hastada defisit saptandı.
Sonuç: SVT yüksek klinik şüphecilik gerektiren bir durumdur. Erken tedavi; ölüm ve ağır dizabilite riskini azaltır. SVT özelikle sebebi bilinmeyen baş ağrıları olan hastalarda ayırıcı tanıda akla gelmelidir.

References

  • 1. Afşar N, Aktan S. Serebral Venöz Tromboz. İn: Balkans (editör), Serebrovasküler Hastalıklar (3. Basım) Güneş Tıp Kitapevi, Ankara 2009; 135-147.
  • 2. Silvis SM, de Sousa DA, Ferro JM, Coutinho JM. Cerebral venous thrombosis. Nat Rev Neurol. 2017;13(9):555-565.
  • 3. Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M, et al. American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Apr;42(4):1158-1192.
  • 4. Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol. 2007;6(2):162-170.
  • 5. Coutinho JM, Zuurbier SM, Aramideh M, Stam J. The incidence of cerebral venous thrombosis: a cross-sectional study. Stroke. 2012;43(12):3375-3377.
  • 6. Coutinho JM, Zuurbier SM, Stam J. Declining mortality in cerebral venous thrombosis: a systematic review. Stroke. 2014;45(5):1338-1341.
  • 7. Mehta A, Danesh J, Kuruvilla D. Cerebral Venous Thrombosis Headache. Curr Pain Headache Rep. 2019;23(7):47.
  • 8. Duman T, Uluduz D, Midi I, Bektas H, Kablan Y, Goksel BK, Milanlioglu A, Necioglu Orken D, Aluclu U; VENOST Study Group. A Multicenter Study of 1144 Patients with Cerebral Venous Thrombosis: The VENOST Study. J Stroke Cerebrovasc Dis. 2017 Aug;26(8):1848-1857.
  • 9. Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F; ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35(3):664-670.
  • 10. Kamışlı Ö, Arslan R, Altınkaya S, Kamışlı S, Kablan Y. Serebral venöz sinüs trombozu: Klinik değerlendirme. Journal of Turkish Cerebrovascular Diseases. 2009; 15: 2: 39-42.
  • 11. Cumurciuc R, Crassard I, Sarov M, Valade D, Bousser MG. Headache as the only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry. 2005;76(8):1084-1087.
  • 12. Damak M, Crassard I, Wolff V, Bousser MG. Isolated lateral sinus thrombosis: a series of 62 patients. Stroke. 2009;40(2):476-481.
  • 13. Agrawal K, Burger K, Rothrock JF. Cerebral Sinus Thrombosis. Headache. 2016;56(8):1380-1389.
  • 14. Behrouzi R, Punter M. Diagnosis and management of cerebral venous thrombosis [published correction appears in Clin Med (Lond). 2018 Mar;18(2):192]. Clin Med (Lond). 2018;18(1):75-79.
  • 15. Girot M, Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F, Leys D; ISCVT Investigators. Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke. 2007 Feb;38(2):337-342.
  • 16. Zubkov AY, McBane RD, Brown RD, Rabinstein AA. Brain lesions in cerebral venous sinus thrombosis. Stroke. 2009;40(4):1509-1511.
  • 17. Sahin N, Solak A, Genc B, Bilgic N. Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage: case report and literature review. Clin Imaging. 2014;38(4):373-379.
  • 18. Domaç F M, Mısırlı H, Adıgüzel T, Mestan E. Serebral venöz sinüs trombozunda klinik, etiyoloji ve prognoz. Türk Nöroloji Dergisi. 2008; 14 (1): 27-32.
  • 19. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005;352(17):1791-1798 .
  • 20. Girot M, Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F, Leys D; ISCVT Investigators. Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke. 2007 Feb;38(2):337-342. 
  • 21. Silvis SM, Lindgren E, Hiltunen S, Devasagayam S, Scheres LJ, Jood K, Zuurbier SM, Kleinig TJ, Silver FL, Mandell DM, Middeldorp S, Putaala J, Cannegieter SC, Tatlisumak T, Coutinho JM. Postpartum Period Is a Risk Factor for Cerebral Venous Thrombosis. Stroke. 2019 Feb;50(2):501-503.
  • 22. Mehraein S, Ortwein H, Busch M, Weih M, Einhäupl K, Masuhr F. Risk of recurrence of cerebral venous and sinus thrombosis during subsequent pregnancy and puerperium. J Neurol Neurosurg Psychiatry. 2003;74(6):814-816.
  • 23. de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in [correction of who are] carriers of hereditary prothrombotic conditions. The Cerebral Venous Sinus Thrombosis Study Group [published correction appears in BMJ 1998 Mar 14;316(7134):822]. BMJ. 1998;316(7131):589-592. 
  • 24. Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke. 2000;31(6):1274-1282.
  • 25. Khealani BA, Wasay M, Saadah M, Sultana E, Mustafa S, Khan FS, Kamal AK. Cerebral venous thrombosis: a descriptive multicenter study of patients in Pakistan and Middle East. Stroke. 2008 Oct;39(10):2707-2711. 26. Bugnicourt JM, Roussel B, Tramier B, Lamy C, Godefroy O. Cerebral venous thrombosis and plasma concentrations of factor VIII and von Willebrand factor: a case control study. J Neurol Neurosurg Psychiatry. 2007;78(7):699-701.
  • 27. Lee MK, Ng SC. Cerebral venous thrombosis associated with antithrombin III deficiency. Aust N Z J Med. 1991;21(5):772-773.
  • 28. Rahil AI, Errayes M, Salem KM. Cerebral venous thrombosis as the initial presentation of Behcet's disease. Chang Gung Med J. 2009;32(2):220-223.
  • 29. Uluduz D, Midi I, Duman T, Colakoglu S, Tüfekci A, Bakar M, Nazliel B, et al. Behçet's disease as a causative factor of cerebral venous sinus thrombosis: subgroup analysis of data from the VENOST study. Rheumatology (Oxford). 2019 Apr 1;58(4):600-608.
  • 30. Yesilot N, Bahar S, Yilmazer S, Mutlu M, Kurtuncu M, Tuncay R, Coban O, Akman-Demir G. Cerebral venous thrombosis in Behçet's disease compared to those associated with other etiologies. J Neurol. 2009 Jul;256(7):1134-1142. 
  • 31. Akman G, Yeşilot N, Serdaroğlu P. Behçet hastalığında nörolojik tutulum: Klinik özellikler, tanı ve tedaviye yaklaşım. Journal of Neurological Sciences (Turkish) 2006; 2: 3-7.
  • 32. Crimmins TJ, Rockswold GL, Yock DH Jr. Progressive posttraumatic superior sagittal sinus thrombosis complicated by pulmonary embolism. Case report. J Neurosurg. 1984;60(1):179-182.
  • 33. Ochagavia AR, Boque MC, Torre C, Alonso S, Sirvent JJ. Dural venous sinus thrombosis due to cranial trauma. Lancet. 1996;347(9014):1564.
  • 34. Umit H, Asil T, Celik Y, Tezel A, Dokmeci G, Tuncbilek N, Utku U, Soylu AR. Cerebral sinus thrombosis in patients with inflammatory bowel disease: a case report. World J Gastroenterol. 2005 Sep 14;11(34):5404-5407.
  • 35. Suda S, Katsura K, Okubo S, Abe A, Suzuki K, Suzuki M, Katayama Y. Successful treatment of cerebral venous thrombosis associated with ulcerative colitis. J Stroke Cerebrovasc Dis. 2013 Nov;22(8):e684-686.
  • 36. Canhão P, Ferro JM, Lindgren AG, Bousser MG, Stam J, Barinagarrementeria F; ISCVT Investigators. Causes and predictors of death in cerebral venous thrombosis. Stroke. 2005 Aug;36(8):1720-1725.
  • 37. Ferro JM, Aguiar de Sousa D. Cerebral Venous Thrombosis: an Update. Curr Neurol Neurosci Rep. 2019;19(10):74.

Etiological, topographic and clinical evaluation of patients with cerebral vein thrombosis

Year 2021, Volume: 2 Issue: 1, 25 - 32, 30.03.2021

Abstract

Objective: Cerebral venous thrombosis is seen more infrequent than arterial stroke and effects every age group. Onset and process is variable and usually a good prognosis occurs. Early devolopment of coma and intracranial hemorrhage are bad prognostic factors.
Methods: In our retrospective study, it’s aimed to investigate the neurological deficits, etiological factors, localisation and prognosis of the 46 patients who are hospitalized with the diagnosis of cerebral venous thrombosis.
Results: Of 46 patients, 30 were women, 16 were men. Mean age was 39+12,29 and age interval was 13-69. 22 patients in subacute, 20 patients in acute and 4 patients in chronic stage had admitted to our clinics. The most frequent symptom was headache (%69,6) and the most frequent neurological sign was papillaedema (%56,5). 15 patients had subarachnoid hemorrhage, 6 patients had venous ischemic infarct, 1 patient had epidural abscess. 16 patients had one dural sinus thrombosis, 30 patients had more than one dural sinus thrombosis. The most commonly affected sinus in isolated or combined sinus thrombosis is transverse sinus (n=37). We hadn’ t found any etiological factor in 11 patients; versus 18 patients had more than one etiological factor. The predisposing factors were infections (n=14), pregnancy and postpartum period (n=5), oral contraceptive pills (n=7), hereditary thrombophilia (n=21), Behçet Disease (n=2), ulcerative colitis (n=1) and head injury (n=1). In follow up, 37 patients had complete recovery, one patient died in the early period. 7 patients are disabled.
Conclusion: Cerebral venous thrombosis needs highly suspection in order to define the clinical signs. As the early treatment prevents exitus and severe disability, early diagnosis is very important. Cerebral venous thrombosis must be remembered in the differential diagnosis of headaches of unknown etiology.

References

  • 1. Afşar N, Aktan S. Serebral Venöz Tromboz. İn: Balkans (editör), Serebrovasküler Hastalıklar (3. Basım) Güneş Tıp Kitapevi, Ankara 2009; 135-147.
  • 2. Silvis SM, de Sousa DA, Ferro JM, Coutinho JM. Cerebral venous thrombosis. Nat Rev Neurol. 2017;13(9):555-565.
  • 3. Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M, et al. American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Apr;42(4):1158-1192.
  • 4. Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol. 2007;6(2):162-170.
  • 5. Coutinho JM, Zuurbier SM, Aramideh M, Stam J. The incidence of cerebral venous thrombosis: a cross-sectional study. Stroke. 2012;43(12):3375-3377.
  • 6. Coutinho JM, Zuurbier SM, Stam J. Declining mortality in cerebral venous thrombosis: a systematic review. Stroke. 2014;45(5):1338-1341.
  • 7. Mehta A, Danesh J, Kuruvilla D. Cerebral Venous Thrombosis Headache. Curr Pain Headache Rep. 2019;23(7):47.
  • 8. Duman T, Uluduz D, Midi I, Bektas H, Kablan Y, Goksel BK, Milanlioglu A, Necioglu Orken D, Aluclu U; VENOST Study Group. A Multicenter Study of 1144 Patients with Cerebral Venous Thrombosis: The VENOST Study. J Stroke Cerebrovasc Dis. 2017 Aug;26(8):1848-1857.
  • 9. Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F; ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35(3):664-670.
  • 10. Kamışlı Ö, Arslan R, Altınkaya S, Kamışlı S, Kablan Y. Serebral venöz sinüs trombozu: Klinik değerlendirme. Journal of Turkish Cerebrovascular Diseases. 2009; 15: 2: 39-42.
  • 11. Cumurciuc R, Crassard I, Sarov M, Valade D, Bousser MG. Headache as the only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry. 2005;76(8):1084-1087.
  • 12. Damak M, Crassard I, Wolff V, Bousser MG. Isolated lateral sinus thrombosis: a series of 62 patients. Stroke. 2009;40(2):476-481.
  • 13. Agrawal K, Burger K, Rothrock JF. Cerebral Sinus Thrombosis. Headache. 2016;56(8):1380-1389.
  • 14. Behrouzi R, Punter M. Diagnosis and management of cerebral venous thrombosis [published correction appears in Clin Med (Lond). 2018 Mar;18(2):192]. Clin Med (Lond). 2018;18(1):75-79.
  • 15. Girot M, Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F, Leys D; ISCVT Investigators. Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke. 2007 Feb;38(2):337-342.
  • 16. Zubkov AY, McBane RD, Brown RD, Rabinstein AA. Brain lesions in cerebral venous sinus thrombosis. Stroke. 2009;40(4):1509-1511.
  • 17. Sahin N, Solak A, Genc B, Bilgic N. Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage: case report and literature review. Clin Imaging. 2014;38(4):373-379.
  • 18. Domaç F M, Mısırlı H, Adıgüzel T, Mestan E. Serebral venöz sinüs trombozunda klinik, etiyoloji ve prognoz. Türk Nöroloji Dergisi. 2008; 14 (1): 27-32.
  • 19. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005;352(17):1791-1798 .
  • 20. Girot M, Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F, Leys D; ISCVT Investigators. Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke. 2007 Feb;38(2):337-342. 
  • 21. Silvis SM, Lindgren E, Hiltunen S, Devasagayam S, Scheres LJ, Jood K, Zuurbier SM, Kleinig TJ, Silver FL, Mandell DM, Middeldorp S, Putaala J, Cannegieter SC, Tatlisumak T, Coutinho JM. Postpartum Period Is a Risk Factor for Cerebral Venous Thrombosis. Stroke. 2019 Feb;50(2):501-503.
  • 22. Mehraein S, Ortwein H, Busch M, Weih M, Einhäupl K, Masuhr F. Risk of recurrence of cerebral venous and sinus thrombosis during subsequent pregnancy and puerperium. J Neurol Neurosurg Psychiatry. 2003;74(6):814-816.
  • 23. de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in [correction of who are] carriers of hereditary prothrombotic conditions. The Cerebral Venous Sinus Thrombosis Study Group [published correction appears in BMJ 1998 Mar 14;316(7134):822]. BMJ. 1998;316(7131):589-592. 
  • 24. Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke. 2000;31(6):1274-1282.
  • 25. Khealani BA, Wasay M, Saadah M, Sultana E, Mustafa S, Khan FS, Kamal AK. Cerebral venous thrombosis: a descriptive multicenter study of patients in Pakistan and Middle East. Stroke. 2008 Oct;39(10):2707-2711. 26. Bugnicourt JM, Roussel B, Tramier B, Lamy C, Godefroy O. Cerebral venous thrombosis and plasma concentrations of factor VIII and von Willebrand factor: a case control study. J Neurol Neurosurg Psychiatry. 2007;78(7):699-701.
  • 27. Lee MK, Ng SC. Cerebral venous thrombosis associated with antithrombin III deficiency. Aust N Z J Med. 1991;21(5):772-773.
  • 28. Rahil AI, Errayes M, Salem KM. Cerebral venous thrombosis as the initial presentation of Behcet's disease. Chang Gung Med J. 2009;32(2):220-223.
  • 29. Uluduz D, Midi I, Duman T, Colakoglu S, Tüfekci A, Bakar M, Nazliel B, et al. Behçet's disease as a causative factor of cerebral venous sinus thrombosis: subgroup analysis of data from the VENOST study. Rheumatology (Oxford). 2019 Apr 1;58(4):600-608.
  • 30. Yesilot N, Bahar S, Yilmazer S, Mutlu M, Kurtuncu M, Tuncay R, Coban O, Akman-Demir G. Cerebral venous thrombosis in Behçet's disease compared to those associated with other etiologies. J Neurol. 2009 Jul;256(7):1134-1142. 
  • 31. Akman G, Yeşilot N, Serdaroğlu P. Behçet hastalığında nörolojik tutulum: Klinik özellikler, tanı ve tedaviye yaklaşım. Journal of Neurological Sciences (Turkish) 2006; 2: 3-7.
  • 32. Crimmins TJ, Rockswold GL, Yock DH Jr. Progressive posttraumatic superior sagittal sinus thrombosis complicated by pulmonary embolism. Case report. J Neurosurg. 1984;60(1):179-182.
  • 33. Ochagavia AR, Boque MC, Torre C, Alonso S, Sirvent JJ. Dural venous sinus thrombosis due to cranial trauma. Lancet. 1996;347(9014):1564.
  • 34. Umit H, Asil T, Celik Y, Tezel A, Dokmeci G, Tuncbilek N, Utku U, Soylu AR. Cerebral sinus thrombosis in patients with inflammatory bowel disease: a case report. World J Gastroenterol. 2005 Sep 14;11(34):5404-5407.
  • 35. Suda S, Katsura K, Okubo S, Abe A, Suzuki K, Suzuki M, Katayama Y. Successful treatment of cerebral venous thrombosis associated with ulcerative colitis. J Stroke Cerebrovasc Dis. 2013 Nov;22(8):e684-686.
  • 36. Canhão P, Ferro JM, Lindgren AG, Bousser MG, Stam J, Barinagarrementeria F; ISCVT Investigators. Causes and predictors of death in cerebral venous thrombosis. Stroke. 2005 Aug;36(8):1720-1725.
  • 37. Ferro JM, Aguiar de Sousa D. Cerebral Venous Thrombosis: an Update. Curr Neurol Neurosci Rep. 2019;19(10):74.
There are 36 citations in total.

Details

Primary Language Turkish
Subjects Health Care Administration
Journal Section Articles
Authors

Suna Aşkın Turan

Şule Deveci

Canan Bolcu Emir 0000-0002-5418-930X

Cihat Örken

Publication Date March 30, 2021
Submission Date January 19, 2021
Published in Issue Year 2021 Volume: 2 Issue: 1

Cite

APA Aşkın Turan, S., Deveci, Ş., Bolcu Emir, C., Örken, C. (2021). Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi. Troia Medical Journal, 2(1), 25-32.
AMA Aşkın Turan S, Deveci Ş, Bolcu Emir C, Örken C. Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi. Troia Med J. March 2021;2(1):25-32.
Chicago Aşkın Turan, Suna, Şule Deveci, Canan Bolcu Emir, and Cihat Örken. “Serebral Ven Trombozlu hastaların Etiyolojik, Topografik Ve Klinik değerlendirilmesi”. Troia Medical Journal 2, no. 1 (March 2021): 25-32.
EndNote Aşkın Turan S, Deveci Ş, Bolcu Emir C, Örken C (March 1, 2021) Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi. Troia Medical Journal 2 1 25–32.
IEEE S. Aşkın Turan, Ş. Deveci, C. Bolcu Emir, and C. Örken, “Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi”, Troia Med J, vol. 2, no. 1, pp. 25–32, 2021.
ISNAD Aşkın Turan, Suna et al. “Serebral Ven Trombozlu hastaların Etiyolojik, Topografik Ve Klinik değerlendirilmesi”. Troia Medical Journal 2/1 (March 2021), 25-32.
JAMA Aşkın Turan S, Deveci Ş, Bolcu Emir C, Örken C. Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi. Troia Med J. 2021;2:25–32.
MLA Aşkın Turan, Suna et al. “Serebral Ven Trombozlu hastaların Etiyolojik, Topografik Ve Klinik değerlendirilmesi”. Troia Medical Journal, vol. 2, no. 1, 2021, pp. 25-32.
Vancouver Aşkın Turan S, Deveci Ş, Bolcu Emir C, Örken C. Serebral ven trombozlu hastaların etiyolojik, topografik ve klinik değerlendirilmesi. Troia Med J. 2021;2(1):25-32.