const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Cerebral Sinus Venous Thrombosis (CSVT)";
pres.author = "Medical Education";

// ─── Design Tokens ───────────────────────────────────────────────────────────
const C = {
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  blueLight:"EAF2FA",
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  red:      "C0392B",
  redLight: "FDECEA",
  amber:    "D4840A",
  amberLight:"FEF6E4",
  black:    "1A1A1A",
};

// ─── Helper: slide header bar ────────────────────────────────────────────────
function addHeader(slide, title, sub) {
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    x: 0.28, y: 0.95, w: 9.4, h: 0,
    line: { color: C.greyMid, width: 1 }
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}

// ─── Helper: bullet list (content slides) ───────────────────────────────────
function bullets(items) {
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    options: { bullet: { type: "bullet" }, breakLine: i < items.length - 1,
               fontSize: 14, color: C.black, fontFace: "Calibri",
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  }));
}

// ─── Helper: info box ────────────────────────────────────────────────────────
function infoBox(slide, x, y, w, h, title, body, bg, accent) {
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    x, y, w, h, rectRadius: 0.08,
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    valign: "top", wrap: true
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
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    x: 0, y: 0, w: "100%", h: "100%",
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    fill: { color: C.darkNavy }, line: { color: C.darkNavy }
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  // Acronym big
  s.addText("CSVT", {
    x: 0.5, y: 0.9, w: 9, h: 1.5,
    fontSize: 80, bold: true, color: C.darkNavy,
    fontFace: "Calibri", align: "center", charSpacing: 10
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  // Full title
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    x: 0.5, y: 2.35, w: 9, h: 0.6,
    fontSize: 26, bold: false, color: C.teal,
    fontFace: "Calibri", align: "center"
  });
  // Subtitle
  s.addText("Pathophysiology · Diagnosis · Management · Prognosis", {
    x: 0.5, y: 2.95, w: 9, h: 0.4,
    fontSize: 14, color: C.grey,
    fontFace: "Calibri", align: "center", italic: true
  });
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  s.addShape(pres.ShapeType.line, {
    x: 2.5, y: 3.5, w: 5, h: 0,
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  });
  s.addText("Neurology Grand Rounds  |  2026", {
    x: 0.5, y: 3.65, w: 9, h: 0.35,
    fontSize: 12, color: C.grey, fontFace: "Calibri", align: "center"
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — OUTLINE
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: "100%",
    fill: { color: C.white }, line: { color: C.white }
  });
  addHeader(s, "Presentation Outline");

  const topics = [
    ["01", "Definition & Overview"],
    ["02", "Epidemiology"],
    ["03", "Anatomy of the Venous Sinuses"],
    ["04", "Etiology & Risk Factors"],
    ["05", "Pathophysiology"],
    ["06", "Clinical Presentation"],
    ["07", "Specific Sinus Syndromes"],
    ["08", "Investigations — Lab & LP"],
    ["09", "Neuroimaging — CT & MRI"],
    ["10", "Neuroimaging — MRV & Angiography"],
    ["11", "Diagnosis & Differential"],
    ["12", "Management — Anticoagulation"],
    ["13", "Management — Endovascular & Surgical"],
    ["14", "ICP Management & Seizures"],
    ["15", "Special Populations — Pregnancy"],
    ["16", "Special Populations — Pediatric / Neonatal"],
    ["17", "COVID-19 & Vaccine-Induced VITT"],
    ["18", "Complications"],
    ["19", "Prognosis & Outcomes"],
    ["20", "Key Take-Home Points"],
  ];

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  const col2 = topics.slice(10);

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    });
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      align: "center", valign: "middle"
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      x: 5.2, y: 1.05 + i * 0.42, w: 0.4, h: 0.3, rectRadius: 0.04,
      fill: { color: C.navy }, line: { color: C.navy }
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    s.addText(num, {
      x: 5.2, y: 1.05 + i * 0.42, w: 0.4, h: 0.3,
      fontSize: 9, bold: true, color: C.white, fontFace: "Calibri",
      align: "center", valign: "middle"
    });
    s.addText(title, {
      x: 5.68, y: 1.05 + i * 0.42, w: 4.1, h: 0.3,
      fontSize: 11, color: C.black, fontFace: "Calibri", valign: "middle"
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — DEFINITION & OVERVIEW
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Definition & Overview", "What is CSVT?");

  infoBox(s, 0.28, 1.08, 9.44, 1.05,
    "Definition",
    "Cerebral Sinus Venous Thrombosis (CSVT) is thrombotic occlusion of the dural venous sinuses and/or cerebral veins, impairing venous drainage of the brain and leading to venous hypertension, cerebral edema, and potentially hemorrhagic infarction.",
    C.blueLight, C.navy
  );

  infoBox(s, 0.28, 2.25, 4.6, 1.2,
    "Key Facts",
    "• Rare but potentially life-threatening\n• Incidence: ~5 per million/year\n• Mean age ~39 years\n• More common in women (3:1 ratio)\n• Accounts for 0.5–1% of all strokes",
    C.tealLight, C.teal
  );

  infoBox(s, 5.04, 2.25, 4.68, 1.2,
    "Why It Matters",
    "• Frequently misdiagnosed (mimics migraine, meningitis, IIH)\n• Potentially reversible with early treatment\n• Mortality 5–10% in modern series\n• Good outcome in ~80% with treatment\n• Recurrence rate ~2–4%",
    C.amberLight, C.amber
  );

  s.addText("Sources: Tintinalli's Emergency Medicine | Adams & Victor's Neurology | Rosen's Emergency Medicine", {
    x: 0.28, y: 5.2, w: 9.44, h: 0.25,
    fontSize: 8, color: C.grey, fontFace: "Calibri", italic: true
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Epidemiology", "Who gets CSVT?");

  const stats = [
    ["~5/million/year", "Incidence", C.teal],
    ["39 years", "Mean Age at Onset", C.navy],
    ["75%", "Female Predominance", C.blue],
    ["~30%", "Develop Hemorrhage", C.red],
  ];

  stats.forEach(([val, label, color], i) => {
    const x = 0.28 + i * 2.4;
    s.addShape(pres.ShapeType.roundRect, {
      x, y: 1.1, w: 2.2, h: 1.5, rectRadius: 0.1,
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      x, y: 1.2, w: 2.2, h: 0.7,
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    s.addText(label, {
      x, y: 1.9, w: 2.2, h: 0.55,
      fontSize: 11, color: C.grey, fontFace: "Calibri", align: "center", wrap: true
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  s.addText("Demographic Patterns", {
    x: 0.28, y: 2.8, w: 9.44, h: 0.35,
    fontSize: 14, bold: true, color: C.darkNavy, fontFace: "Calibri"
  });
  s.addText([
    { text: "• Female predominance driven by oral contraceptive use and pregnancy (peripartum period is highest risk window)\n", options: {} },
    { text: "• Bimodal distribution: young women (reproductive age) and older adults with prothrombotic conditions\n", options: {} },
    { text: "• Neonatal CSVT: separate entity — perinatal asphyxia, dehydration, sepsis, and birth trauma are key drivers\n", options: {} },
    { text: "• Geographic variation: higher incidence in developing countries (dehydration, infections, anemia)\n", options: {} },
    { text: "• COVID-19 pandemic: recognized VITT-associated CSVT following adenoviral vector vaccines", options: {} },
  ], {
    x: 0.28, y: 3.15, w: 9.44, h: 2.1,
    fontSize: 12, color: C.black, fontFace: "Calibri", valign: "top"
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — ANATOMY
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Anatomy of the Dural Venous Sinuses", "Key structures involved in CSVT");

  const sinuses = [
    ["Superior Sagittal Sinus (SSS)", "Most commonly thrombosed. Runs along midline, drains superficial cortex. Occlusion causes bilateral parasagittal hemorrhagic infarcts and raised ICP."],
    ["Transverse Sinuses", "Right usually dominant. Thrombosis can mimic otomastoiditis. Causes temporal lobe infarction with edema."],
    ["Sigmoid Sinus", "Continuation of transverse sinus → internal jugular vein. Associated with otitis media / mastoiditis."],
    ["Straight Sinus", "Drains deep veins (vein of Galen, internal cerebral veins). Thrombosis causes bithalamic infarction."],
    ["Cavernous Sinus", "Surrounds sella. Often thrombosed in facial / orbital infections. Presents with proptosis, chemosis, CN palsies."],
    ["Cortical Veins", "Isolated cortical vein thrombosis: focal deficits, seizures, superficial hemorrhagic infarct."],
  ];

  sinuses.forEach(([title, text], i) => {
    const col = i < 3 ? 0 : 1;
    const row = i % 3;
    const x = col === 0 ? 0.28 : 5.1;
    const y = 1.08 + row * 1.45;
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.65, h: 1.3,
      fill: { color: i % 2 === 0 ? C.greyLight : C.blueLight },
      line: { color: C.greyMid, width: 1 }
    });
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 0.07, h: 1.3,
      fill: { color: C.teal }, line: { color: C.teal }
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      x: x + 0.14, y: y + 0.05, w: 4.4, h: 0.3,
      fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri"
    });
    s.addText(text, {
      x: x + 0.14, y: y + 0.35, w: 4.4, h: 0.88,
      fontSize: 10, color: C.black, fontFace: "Calibri", wrap: true, valign: "top"
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — ETIOLOGY & RISK FACTORS
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Etiology & Risk Factors", "Hypercoagulable, hormonal, infectious, and structural causes");

  const categories = [
    { title: "Thrombophilic / Hematologic", color: C.navy, items: [
      "Factor V Leiden mutation (homozygous >> heterozygous)",
      "Protein C or Protein S deficiency",
      "Antithrombin III deficiency",
      "Antiphospholipid antibody syndrome",
      "Polycythemia vera, thrombocythemia, paroxysmal nocturnal hemoglobinuria",
    ]},
    { title: "Hormonal / Iatrogenic", color: C.teal, items: [
      "Oral contraceptive pills (OCP) — most common modifiable risk factor",
      "Pregnancy and puerperium (peripartum period)",
      "Hormone replacement therapy",
      "L-Asparaginase therapy",
      "Glucocorticoids",
    ]},
    { title: "Infectious", color: C.red, items: [
      "Otitis media / mastoiditis → sigmoid/transverse sinus",
      "Sinusitis (frontal/ethmoidal) → SSS",
      "Orbital cellulitis → cavernous sinus",
      "Meningitis, encephalitis, brain abscess",
      "HIV, CMV, aspergillosis (immunocompromised)",
    ]},
    { title: "Structural / Other", color: C.amber, items: [
      "Head trauma, neurosurgical procedures",
      "Behçet disease, inflammatory bowel disease",
      "Nephrotic syndrome (protein loss → prothrombotic)",
      "Malignancy (marantic endocarditis, direct invasion)",
      "Dehydration (especially neonates / elderly)",
    ]},
  ];

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    const y = i % 2 === 0 ? 1.05 : 3.25;
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      x, y, w: 4.65, h: 2.1,
      fill: { color: C.white }, line: { color: color, width: 1.5 }
    });
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.65, h: 0.32,
      fill: { color: color }, line: { color: color }
    });
    s.addText(title, {
      x: x + 0.1, y, w: 4.45, h: 0.32,
      fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    s.addText(items.map(t => "• " + t).join("\n"), {
      x: x + 0.1, y: y + 0.37, w: 4.45, h: 1.65,
      fontSize: 9.5, color: C.black, fontFace: "Calibri", valign: "top", wrap: true
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Pathophysiology", "Two overlapping mechanisms of injury");

  // Mechanism 1
  infoBox(s, 0.28, 1.08, 4.65, 2.1,
    "Mechanism 1 — Venous Hypertension",
    "Venous sinus occlusion → impaired CSF absorption at arachnoid granulations → ↑ intracranial pressure (ICP)\n\nVenous hypertension → impaired cerebral perfusion pressure\n\nResult: Diffuse cerebral edema, bilateral headache, papilledema, visual loss",
    C.blueLight, C.blue
  );

  // Mechanism 2
  infoBox(s, 5.1, 1.08, 4.62, 2.1,
    "Mechanism 2 — Venous Infarction",
    "Cortical vein occlusion → stagnation of blood → local venous congestion\n\nCytotoxic AND vasogenic edema develop (unlike arterial strokes — mixed pattern)\n\nHemorrhagic transformation very common (~30–40%) due to blood-brain barrier disruption",
    C.tealLight, C.teal
  );

  // Flow diagram: simplified
  s.addText("Pathophysiologic Cascade", {
    x: 0.28, y: 3.28, w: 9.44, h: 0.32,
    fontSize: 13, bold: true, color: C.darkNavy, fontFace: "Calibri"
  });

  const steps = [
    "Venous / sinus thrombosis",
    "↓ Venous outflow",
    "↑ Venous pressure",
    "Edema + Hemorrhage",
    "Neuronal injury",
  ];
  const stepW = 1.7;
  const stepY = 3.68;
  steps.forEach((txt, i) => {
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    s.addShape(pres.ShapeType.roundRect, {
      x: bx, y: stepY, w: stepW, h: 0.58, rectRadius: 0.06,
      fill: { color: i === 0 ? C.darkNavy : i === 4 ? C.red : C.navy },
      line: { color: C.darkNavy }
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      x: bx, y: stepY, w: stepW, h: 0.58,
      fontSize: 10, bold: false, color: C.white, fontFace: "Calibri",
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      s.addText("▶", {
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        fontSize: 14, color: C.greyMid, fontFace: "Calibri", align: "center"
      });
    }
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  s.addText("Key difference from arterial stroke: mixed cytotoxic + vasogenic edema; partial or full reversibility possible with recanalization", {
    x: 0.28, y: 4.45, w: 9.44, h: 0.5,
    fontSize: 11, color: C.grey, fontFace: "Calibri", italic: true
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — CLINICAL PRESENTATION
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Clinical Presentation", "Highly variable — key pitfall: symptom onset over days to weeks");

  s.addText("Symptoms by Frequency", {
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    fontSize: 13, bold: true, color: C.darkNavy, fontFace: "Calibri"
  });

  const symps = [
    ["Headache", "~90%", C.navy],
    ["Seizures", "~40%", C.teal],
    ["Focal neurological deficit", "~40%", C.blue],
    ["Altered consciousness / coma", "~14%", C.red],
    ["Visual symptoms (papilledema)", "~30%", C.amber],
    ["Nausea / vomiting", "Common", C.grey],
  ];

  symps.forEach(([s2, pct, color], i) => {
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    s.addShape(pres.ShapeType.rect, {
      x: 0.28, y, w: 4.6, h: 0.4,
      fill: { color: i % 2 === 0 ? C.greyLight : C.white },
      line: { color: C.greyMid }
    });
    s.addText(s2, {
      x: 0.38, y, w: 3.2, h: 0.4,
      fontSize: 12, color: C.black, fontFace: "Calibri", valign: "middle"
    });
    s.addShape(pres.ShapeType.roundRect, {
      x: 3.7, y: y + 0.08, w: 1.0, h: 0.25, rectRadius: 0.04,
      fill: { color: color }, line: { color: color }
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    s.addText(pct, {
      x: 3.7, y: y + 0.08, w: 1.0, h: 0.25,
      fontSize: 10, bold: true, color: C.white, fontFace: "Calibri",
      align: "center", valign: "middle"
    });
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  s.addText("Clinical Patterns", {
    x: 5.1, y: 1.08, w: 4.62, h: 0.32,
    fontSize: 13, bold: true, color: C.darkNavy, fontFace: "Calibri"
  });

  const patterns = [
    { title: "Isolated ↑ICP Syndrome", body: "Headache + papilledema, no focal deficit. Mimics idiopathic intracranial hypertension (IIH). LP shows elevated opening pressure." },
    { title: "Focal Deficit / Seizure", body: "Cortical vein thrombosis presenting as focal motor/sensory deficit or seizures. May fluctuate over hours to days." },
    { title: "Thunderclap Headache", body: "Sudden severe headache at onset. Must exclude SAH first. CSVT can present acutely like this." },
    { title: "Encephalopathy / Coma", body: "Deep vein or bilateral sinus involvement. Bithalamic infarction from straight sinus/vein of Galen thrombosis. Poor prognosis." },
  ];

  patterns.forEach(({ title, body }, i) => {
    const y = 1.48 + i * 1.0;
    s.addShape(pres.ShapeType.rect, {
      x: 5.1, y, w: 4.62, h: 0.88,
      fill: { color: C.blueLight }, line: { color: C.greyMid }
    });
    s.addText(title, {
      x: 5.2, y: y + 0.05, w: 4.42, h: 0.25,
      fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri"
    });
    s.addText(body, {
      x: 5.2, y: y + 0.28, w: 4.42, h: 0.54,
      fontSize: 10, color: C.black, fontFace: "Calibri", wrap: true, valign: "top"
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — SPECIFIC SINUS SYNDROMES
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Specific Sinus Thrombosis Syndromes", "Location determines clinical phenotype");

  const rows = [
    ["Sinus / Vein", "Classic Presentation", "Key Imaging Finding"],
    ["Superior Sagittal Sinus", "Bilateral parasagittal deficits, ↑ICP, paraparesis, seizures, papilledema", "Bilateral parasagittal hemorrhagic infarcts; 'empty delta' sign on contrast CT"],
    ["Transverse Sinus", "↑ICP, temporal headache, unilateral — often asymptomatic if non-dominant", "Hemorrhagic infarction of temporal lobe convexity"],
    ["Sigmoid Sinus", "Otogenic headache, fever, mastoid tenderness, pulsatile tinnitus", "Filling defect adjacent to mastoid on MRV"],
    ["Cavernous Sinus", "Proptosis, chemosis, periorbital edema, CN III/IV/VI palsies, fever", "Bilateral involvement common; CT shows cavernous sinus filling defect"],
    ["Straight Sinus / Deep Veins", "Akinetic mutism, amnesia, bithalamic edema, coma", "Bilateral thalamic T2 hyperintensity; 'hockey stick' sign"],
    ["Cortical Veins (isolated)", "Focal seizures, focal deficit (hemiparesis, aphasia), superficial hemorrhage", "Cortical vein hyperdensity on CT; cortical vein thrombosis on MRI"],
  ];

  rows.forEach((cells, ri) => {
    const y = 1.05 + ri * 0.61;
    const widths = [2.5, 3.8, 3.1];
    const xs = [0.28, 2.88, 6.78];
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      const isHeader = ri === 0;
      s.addShape(pres.ShapeType.rect, {
        x: xs[ci], y, w: widths[ci] - 0.04, h: 0.58,
        fill: { color: isHeader ? C.darkNavy : (ri % 2 === 0 ? C.white : C.greyLight) },
        line: { color: C.greyMid }
      });
      s.addText(cell, {
        x: xs[ci] + 0.06, y, w: widths[ci] - 0.14, h: 0.58,
        fontSize: isHeader ? 11 : 9.5,
        bold: isHeader,
        color: isHeader ? C.white : C.black,
        fontFace: "Calibri", valign: "middle", wrap: true
      });
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — INVESTIGATIONS
// ════════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Investigations — Laboratory & Lumbar Puncture", "Initial workup and supporting investigations");

  infoBox(s, 0.28, 1.08, 4.65, 2.0,
    "Blood Tests",
    "CBC with differential (polycythemia, thrombocytopenia in VITT)\nCoagulation screen: PT, aPTT, fibrinogen\nD-dimer — often elevated but non-specific\nThrombophilia screen: protein C/S, antithrombin III, APS antibodies, factor V Leiden, prothrombin mutation\nANCA, ANA, anti-dsDNA (vasculitis)\nPregnancy test in reproductive-age women\nHIV testing if clinically indicated",
    C.blueLight, C.navy
  );

  infoBox(s, 5.1, 1.08, 4.62, 2.0,
    "D-Dimer in CSVT",
    "D-dimer < 500 ng/mL has moderate sensitivity for exclusion in low-probability cases but CANNOT safely rule out CSVT alone.\n\nA normal D-dimer does not exclude CSVT — imaging is always required when clinical suspicion is present.\n\nHigh D-dimer supports the diagnosis but is non-specific.",
    C.amberLight, C.amber
  );

  infoBox(s, 0.28, 3.2, 9.44, 1.65,
    "Lumbar Puncture (LP)",
    "LP is safe in CSVT (no mass lesion herniation risk from venous hypertension alone).\n\nElevated opening pressure (> 20 cmH₂O) in ~80% — key clue when CT/MRI appears normal.\nCSF may show xanthochromia or mild pleocytosis/elevated protein in hemorrhagic cases.\nNormal CSF does not exclude CSVT.\n\nIndication: especially valuable when CT is normal and clinical picture suggests CSVT or IIH — an elevated pressure should prompt MRV.",
    C.tealLight, C.teal
  );
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — NEUROIMAGING CT & MRI
// ════════════════════════════════════════════════════════════════════════════
{
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  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Neuroimaging — CT & MRI Findings", "Recognizing direct and indirect signs");

  s.addText("CT Findings", {
    x: 0.28, y: 1.05, w: 4.65, h: 0.32,
    fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri"
  });

  const ctFindings = [
    { sign: "Hyperdense sinus (cord sign)", desc: "Acute thrombus appears hyperdense on plain CT. Seen in SSS or sigmoid sinus." },
    { sign: "Empty delta sign (on contrast CT)", desc: "Enhancement of collateral veins around non-enhancing thrombus in SSS — looks like 'empty triangle'." },
    { sign: "Bilateral parasagittal infarcts", desc: "Not in arterial territory — bilateral hemorrhagic infarcts near midline suggest SSS thrombosis." },
    { sign: "Normal CT", desc: "CT is normal in ~30% of CSVT cases — a normal CT does NOT exclude the diagnosis." },
  ];

  ctFindings.forEach(({ sign, desc }, i) => {
    const y = 1.45 + i * 0.94;
    s.addShape(pres.ShapeType.rect, {
      x: 0.28, y, w: 4.65, h: 0.85,
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      line: { color: C.greyMid }
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    s.addText(sign, {
      x: 0.38, y: y + 0.04, w: 4.45, h: 0.28,
      fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri"
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    s.addText(desc, {
      x: 0.38, y: y + 0.32, w: 4.45, h: 0.48,
      fontSize: 10, color: C.black, fontFace: "Calibri", wrap: true, valign: "top"
    });
  });

  s.addText("MRI Findings", {
    x: 5.1, y: 1.05, w: 4.62, h: 0.32,
    fontSize: 13, bold: true, color: C.teal, fontFace: "Calibri"
  });

  const mriFindings = [
    { sign: "T1: isointense / hyperintense sinus", desc: "Acute thrombus: isointense. Subacute: hyperintense (methemoglobin). Loss of normal flow void." },
    { sign: "T2 / FLAIR: sinus hyperintensity", desc: "High signal replaces the normal dark flow void in thrombosed sinuses." },
    { sign: "DWI: mixed restriction", desc: "Unlike arterial stroke — mixed cytotoxic + vasogenic edema. Partial DWI restriction in venous territory." },
    { sign: "T2*/ SWI (best for clot)", desc: "Susceptibility-weighted imaging — most sensitive for detecting thrombus (blooming artifact) and cortical vein thrombosis." },
  ];

  mriFindings.forEach(({ sign, desc }, i) => {
    const y = 1.45 + i * 0.94;
    s.addShape(pres.ShapeType.rect, {
      x: 5.1, y, w: 4.62, h: 0.85,
      fill: { color: i % 2 === 0 ? C.tealLight : C.white },
      line: { color: C.greyMid }
    });
    s.addText(sign, {
      x: 5.2, y: y + 0.04, w: 4.42, h: 0.28,
      fontSize: 11, bold: true, color: C.teal, fontFace: "Calibri"
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    s.addText(desc, {
      x: 5.2, y: y + 0.32, w: 4.42, h: 0.48,
      fontSize: 10, color: C.black, fontFace: "Calibri", wrap: true, valign: "top"
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — MRV & ANGIOGRAPHY
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Neuroimaging — MRV & Angiography", "Gold-standard and adjunct imaging modalities");

  infoBox(s, 0.28, 1.08, 4.65, 2.2,
    "MRI + MR Venography (MRV) — Gold Standard",
    "MRV directly visualizes absence of flow in thrombosed sinuses.\n\nCoronal and sagittal MRV shows the complete venous anatomy — identifies extent and location of thrombosis.\n\nNote: Normal anatomical variants (e.g., hypoplastic transverse sinus) can mimic thrombosis — correlation with MRI signal changes is required.\n\nMRV without gadolinium: time-of-flight technique; MRV with gadolinium: more sensitive for slow-flow states.",
    C.blueLight, C.navy
  );

  infoBox(s, 5.1, 1.08, 4.62, 2.2,
    "CT Venography (CTV)",
    "Alternative when MRI is unavailable or contraindicated.\n\nSensitivity comparable to MRV for major dural sinuses.\n\nAdvantages: widely available, fast, excellent spatial resolution.\n\nLimitations: iodinated contrast, radiation, inferior to MRV for cortical vein thrombosis.\n\nUseful in emergency settings — especially if CT already performed.",
    C.tealLight, C.teal
  );

  infoBox(s, 0.28, 3.42, 4.65, 1.7,
    "Conventional Catheter Angiography",
    "Reserved for equivocal MRV/CTV or planned endovascular therapy.\n\nVenous phase of DSA is definitive — but invasive.\n\nRarely needed for primary diagnosis in modern practice.",
    C.amberLight, C.amber
  );

  infoBox(s, 5.1, 3.42, 4.62, 1.7,
    "Imaging Algorithm Summary",
    "1. Non-contrast CT (exclude hemorrhage, mass)\n2. MRI brain + MRV (gold standard)\n3. If MRI unavailable → CT with CTV\n4. LP if imaging normal but high suspicion\n5. Catheter angiography only if equivocal or intervention planned",
    C.greyLight, C.grey
  );
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — DIAGNOSIS & DIFFERENTIAL
// ════════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Diagnosis & Differential Diagnosis", "Red flags that should prompt imaging");

  infoBox(s, 0.28, 1.08, 9.44, 0.95,
    "When to Suspect CSVT",
    "New headache (especially progressive over days-weeks) + any: pregnancy/puerperium, OCP use, hypercoagulable state, recent infection/surgery, seizures without prior epilepsy, focal deficit not in arterial territory, papilledema, elevated LP opening pressure",
    C.redLight, C.red
  );

  s.addText("Differential Diagnosis", {
    x: 0.28, y: 2.16, w: 9.44, h: 0.32,
    fontSize: 13, bold: true, color: C.darkNavy, fontFace: "Calibri"
  });

  const diffs = [
    { dx: "Idiopathic Intracranial Hypertension (IIH / Pseudotumor Cerebri)", how: "Presents identically with headache, papilledema, elevated LP pressure. CSVT must be excluded with MRV before diagnosing IIH." },
    { dx: "Bacterial/Viral Meningitis", how: "Fever, neck stiffness, photophobia. CSF findings differentiate. CSVT can coexist with meningitis (septic thrombophlebitis)." },
    { dx: "Subarachnoid Hemorrhage (SAH)", how: "Thunderclap headache. CT head shows subarachnoid blood. LP shows xanthochromia. CSVT may cause SAH-like hemorrhage." },
    { dx: "Arterial Ischemic Stroke", how: "Acute onset, arterial territory. DWI restriction. No venous occlusion on MRV." },
    { dx: "Brain Tumor / Abscess", how: "Mass effect, ring enhancement. CT/MRI differentiate. Venous occlusion may be secondary to tumor." },
    { dx: "PRES (Posterior Reversible Encephalopathy Syndrome)", how: "Seizures + hypertension + posterior T2 changes. No venous occlusion. Associated with eclampsia." },
  ];

  diffs.forEach(({ dx, how }, i) => {
    const y = 2.55 + i * 0.49;
    s.addShape(pres.ShapeType.rect, {
      x: 0.28, y, w: 9.44, h: 0.42,
      fill: { color: i % 2 === 0 ? C.white : C.greyLight },
      line: { color: C.greyMid }
    });
    s.addText(dx, {
      x: 0.38, y, w: 3.5, h: 0.42,
      fontSize: 10, bold: true, color: C.navy, fontFace: "Calibri", valign: "middle"
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    s.addText(how, {
      x: 3.96, y, w: 5.68, h: 0.42,
      fontSize: 10, color: C.black, fontFace: "Calibri", valign: "middle", wrap: true
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — MANAGEMENT: ANTICOAGULATION
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Management — Anticoagulation", "First-line treatment even in the presence of hemorrhage");

  infoBox(s, 0.28, 1.08, 9.44, 0.85,
    "Key Principle",
    "Anticoagulation is recommended EVEN when intracranial hemorrhage is present — the mechanism is venous, and treatment prevents propagation. Evidence: ISCVT study + European Stroke Organization Guidelines.",
    C.redLight, C.red
  );

  const acsections = [
    {
      title: "Acute Phase — Inpatient",
      color: C.navy,
      items: [
        "Low Molecular Weight Heparin (LMWH): preferred over UFH (RCT evidence, easier monitoring)",
        "Unfractionated Heparin (UFH): use if rapid reversal may be needed (e.g., severe hemorrhage, need for procedure)",
        "Target: therapeutic anticoagulation (anti-Xa monitoring for LMWH)",
        "Begin immediately after confirmed diagnosis",
      ]
    },
    {
      title: "Transition — Subacute",
      color: C.teal,
      items: [
        "Overlap to oral anticoagulation after clinical stabilization",
        "Direct Oral Anticoagulants (DOACs): dabigatran, rivaroxaban — being used increasingly (RE-SPECT CVT trial: dabigatran non-inferior to warfarin)",
        "Warfarin (target INR 2–3): traditional option, requires monitoring",
        "Duration: typically 3–6 months for provoked CSVT; 6–12 months for unprovoked; lifelong for recurrent or permanent thrombophilia",
      ]
    },
  ];

  acsections.forEach(({ title, color, items }, i) => {
    const y = 2.05 + i * 1.65;
    s.addShape(pres.ShapeType.rect, {
      x: 0.28, y, w: 9.44, h: 1.55,
      fill: { color: i === 0 ? C.blueLight : C.tealLight },
      line: { color: color, width: 1.5 }
    });
    s.addText(title, {
      x: 0.38, y: y + 0.05, w: 9.24, h: 0.3,
      fontSize: 12, bold: true, color, fontFace: "Calibri"
    });
    s.addText(items.map((t,ii) => `${ii+1}. ${t}`).join("\n"), {
      x: 0.38, y: y + 0.35, w: 9.24, h: 1.12,
      fontSize: 10.5, color: C.black, fontFace: "Calibri", valign: "top", wrap: true
    });
  });

  s.addText("RE-SPECT CVT Trial (2019): Dabigatran 150 mg BD non-inferior to warfarin for extended anticoagulation in CVT", {
    x: 0.28, y: 5.25, w: 9.44, h: 0.25,
    fontSize: 9, color: C.grey, fontFace: "Calibri", italic: true
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 15 — ENDOVASCULAR & SURGICAL
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Management — Endovascular & Surgical Interventions", "Reserved for refractory or deteriorating cases");

  const interventions = [
    {
      title: "Catheter-Directed Thrombolysis (CDT)",
      color: C.navy,
      content: "Intra-sinus infusion of tPA or urokinase via catheter placed in thrombosed sinus.\nIndications: clinical deterioration despite therapeutic anticoagulation, coma, rapidly worsening ICP.\nEvidence: small series and retrospective data — no randomized trials. Reserved for extreme cases (stupor/coma + greatly elevated CSF pressure — Adams & Victor).\nRisks: intracranial hemorrhage extension.",
    },
    {
      title: "Mechanical Thrombectomy",
      color: C.teal,
      content: "Aspiration thrombectomy or stent-retriever devices used in venous sinuses.\nSystematic review (Ilyas et al.): technical success 87%; clinical improvement in ~75% of selected cases.\nConsidered in severe cases with failed anticoagulation or CDT.\nRequires specialized neurointerventional center.",
    },
    {
      title: "Decompressive Craniectomy",
      color: C.red,
      content: "Indicated for large, space-occupying venous infarcts with herniation risk.\nLifesaving in selected patients with malignant venous infarction.\nMay be combined with hematoma evacuation.\nReported good functional outcomes in survivors despite severity at presentation.",
    },
    {
      title: "CSF Diversion (VP Shunt / LP)",
      color: C.amber,
      content: "For refractory intracranial hypertension causing visual loss.\nSerial therapeutic lumbar punctures can be used acutely.\nVentriculoperitoneal or lumboperitoneal shunt for chronic ICP elevation.\nLimited role compared to primary anticoagulation.",
    },
  ];

  interventions.forEach(({ title, color, content }, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.28 : 5.1;
    const y = 1.08 + row * 2.2;
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.65, h: 2.05,
      fill: { color: C.white }, line: { color: color, width: 1.5 }
    });
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.65, h: 0.32,
      fill: { color: color }, line: { color: color }
    });
    s.addText(title, {
      x: x + 0.08, y, w: 4.5, h: 0.32,
      fontSize: 10.5, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    s.addText(content, {
      x: x + 0.08, y: y + 0.38, w: 4.5, h: 1.6,
      fontSize: 10, color: C.black, fontFace: "Calibri", wrap: true, valign: "top"
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 16 — ICP MANAGEMENT & SEIZURES
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "ICP Management & Seizure Control", "Supportive care alongside anticoagulation");

  infoBox(s, 0.28, 1.08, 4.65, 4.2,
    "Raised ICP Management",
    "Head elevation 30 degrees\nAvoid hypotonic fluids — prefer isotonic or hypertonic saline\nOsmotherapy: mannitol or hypertonic saline for acute herniation\nAcetazolamide: reduces CSF production — useful for chronic ICP elevation (especially in ICP-predominant syndrome)\nSerial lumbar punctures: therapeutic drainage if LP OP markedly elevated\nAvoid hypercapnia (causes cerebral vasodilation)\nSteroids: NOT routinely recommended for CSVT-related edema — may worsen thrombosis risk\nDecompressive craniectomy: for malignant edema with herniation",
    C.blueLight, C.navy
  );

  infoBox(s, 5.1, 1.08, 4.62, 2.0,
    "Seizure Management",
    "Seizures occur in ~40% of CSVT patients.\nAcute symptomatic seizures: treat with IV antiepileptics (levetiracetam preferred — fewer drug interactions, no enzyme induction affecting anticoagulation).\nProphylactic AEDs: recommended in patients with cortical lesions or hemorrhagic infarcts (high seizure risk).\nDuration: typically maintained for 1 year, then reassessed.",
    C.tealLight, C.teal
  );

  infoBox(s, 5.1, 3.2, 4.62, 2.08,
    "Headache Management",
    "Headache often severe and refractory.\nSimple analgesia (paracetamol, NSAIDs with caution) for mild headache.\nOpioids for severe headache acutely.\nLPO/acetazolamide to reduce CSF pressure component.\nNote: headache may take weeks to resolve even with effective anticoagulation and recanalization.",
    C.amberLight, C.amber
  );
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 17 — PREGNANCY
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Special Populations — Pregnancy & Puerperium", "Highest risk period for CSVT in women");

  infoBox(s, 0.28, 1.08, 9.44, 0.85,
    "Epidemiology",
    "Peripartum CSVT accounts for a significant proportion of all CSVT cases in women. Risk is highest in the puerperium (first 4 weeks postpartum) due to hypercoagulable state, dehydration, infection, and venous stasis. Incidence estimated at ~12 per 100,000 deliveries.",
    C.blueLight, C.navy
  );

  const pregSections = [
    { title: "Risk Factors in Pregnancy", color: C.navy, items: [
      "Physiological hypercoagulability of pregnancy (↑ fibrinogen, ↑ VWF, ↓ protein S)",
      "Peripartum blood loss and dehydration",
      "Operative delivery (cesarean section, instrumental delivery)",
      "Preeclampsia / HELLP syndrome",
      "Underlying thrombophilia amplified by pregnancy",
      "Postpartum infection / endometritis",
    ]},
    { title: "Management in Pregnancy", color: C.teal, items: [
      "LMWH is the anticoagulant of choice in pregnancy (does not cross placenta)",
      "Warfarin: teratogenic in first trimester — avoid",
      "DOACs: contraindicated in pregnancy (teratogenicity, neonatal hemorrhage)",
      "Continue LMWH throughout pregnancy and for minimum 6 weeks postpartum",
      "Thrombophilia workup after delivery (protein S levels unreliable in pregnancy)",
      "Subsequent pregnancies: low-dose aspirin + thromboprophylaxis with LMWH",
    ]},
  ];

  pregSections.forEach(({ title, color, items }, i) => {
    const x = i === 0 ? 0.28 : 5.1;
    const y = 2.05;
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.65, h: 3.1,
      fill: { color: C.white }, line: { color: color, width: 1.5 }
    });
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.65, h: 0.32,
      fill: { color: color }, line: { color: color }
    });
    s.addText(title, {
      x: x + 0.08, y, w: 4.5, h: 0.32,
      fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    s.addText(items.map(t => "• " + t).join("\n"), {
      x: x + 0.1, y: y + 0.38, w: 4.45, h: 2.66,
      fontSize: 10.5, color: C.black, fontFace: "Calibri", valign: "top", wrap: true
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 18 — PEDIATRIC / NEONATAL
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:"100%",h:"100%", fill:{color:C.white}, line:{color:C.white} });
  addHeader(s, "Special Populations — Pediatric & Neonatal CSVT", "Distinct risk factors, presentation, and management");

  infoBox(s, 0.28, 1.08, 4.65, 4.4,
    "Neonatal CSVT",
    "Perinatal CSVT is increasingly recognized but still less common than perinatal arterial ischemic stroke.\n\nMost commonly affected sinuses: superior sagittal sinus, transverse sinuses, deep sinuses.\n\nPresentation: seizures with preceding or accompanying encephalopathy (vs. arterial stroke: focal seizures after 12h). IVH often present.\n\nRisk factors: chorioamnionitis, meconium-stained fluid, emergency delivery, low Apgar scores, dehydration, sepsis, polycythemia.\n\nImaging: MRI/MRV preferred. Head US with Doppler, CTV also options.\n\nManagement: No consensus. Anticoagulation associated with reduced propagation without increased hemorrhage extension (non-randomized data).\n\nPrognosis: Depends on extent of infarct and hemorrhage. Similar range to perinatal arterial stroke.",
    C.blueLight, C.navy
  );

  infoBox(s, 5.1, 1.08, 4.62, 4.4,
    "Childhood CSVT",
    "Incidence: ~0.67 per 100,000 children/year.\n\nRisk factors differ from adults:\n• Head/neck infections (otitis media, mastoiditis, sinusitis)\n• Dehydration (gastroenteritis)\n• Iron deficiency anemia\n• Congenital heart disease\n• Leukemia / L-asparaginase therapy\n• Nephrotic syndrome\n• Thrombophilia (more significant in pediatric CSVT)\n\nPresentation: headache, seizures, focal deficits, altered consciousness, papilledema.\n\nManagement:\n• LMWH or UFH initially\n• Transition to warfarin (DOACs: limited pediatric data)\n• Duration: 3–6 months\n\nPrognosis: Generally good; ~80% achieve complete or near-complete recovery.",
    C.tealLight, C.teal
  );
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 19 — COVID-19 & VITT
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  addHeader(s, "COVID-19 & Vaccine-Induced Immune Thrombocytopenia and Thrombosis (VITT)", "Emerging cause of CSVT — unique mechanism and management");

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    "Background",
    "VITT was first recognized in 2021 following adenoviral vector COVID-19 vaccines (AstraZeneca/ChAdOx1, Johnson & Johnson/Ad26.COV2.S). CSVT was the most common thrombotic manifestation, often combined with thrombocytopenia — similar to autoimmune heparin-induced thrombocytopenia (HIT).",
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    "Mechanism",
    "Platelet-activating antibodies directed against Platelet Factor 4 (PF4) develop after vaccination.\nThese antibodies activate platelets (similar to autoimmune HIT), causing simultaneous thrombosis and thrombocytopenia.\nClinical syndrome: CSVT + low platelets + elevated D-dimer + anti-PF4 antibodies.",
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    "Clinical Features",
    "Onset: 4–28 days post-vaccination.\nClinical triad: thrombosis (CSVT most common) + thrombocytopenia + anti-PF4 antibodies.\nLab: Low platelets, elevated D-dimer, elevated fibrinogen or fibrin degradation products.\nHigh mortality if untreated.",
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    "Management — KEY DIFFERENCES from usual CSVT",
    "AVOID heparin (UFH or LMWH) — worsens platelet activation!\nTreatment: Non-heparin anticoagulants — fondaparinux, argatroban, or bivalirudin acutely.\nTransition to rivaroxaban or dabigatran (long-term).\nIVIG: high-dose (1 g/kg/day x 2 days) to neutralize anti-PF4 antibodies.\nAvoid platelet transfusion (worsens thrombosis).",
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    "COVID-19 Infection Itself",
    "COVID-19 infection is independently associated with CSVT due to:\n• Hypercoagulable state\n• Endothelial injury\n• ACE2-mediated pathology\nManagement: standard anticoagulation (LMWH/DOAC). No special contraindications unless concurrent VITT.",
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}

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// SLIDE 20 — PROGNOSIS & OUTCOMES
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    ["~10%", "Persistent Neurological Deficit", C.navy],
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    { text: "Young age, female sex, isolated ↑ICP presentation, early treatment\n", options: {} },
    { text: "Unfavorable: ", options: { bold: true } },
    { text: "Coma at onset, bilateral hemorrhagic infarcts, deep vein involvement, malignancy, CNS infection\n", options: {} },
    { text: "Note: ", options: { bold: true, italic: true } },
    { text: "Coma and multiple cerebral hemorrhages are associated with high mortality (Adams & Victor)", options: { italic: true } },
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  const keyPoints = [
    "Think CSVT in any unexplained headache with risk factors (pregnancy, OCP, thrombophilia)",
    "CT brain can be NORMAL — MRI + MRV is gold standard",
    "Anticoagulate even if hemorrhage present — venous mechanism",
    "LMWH preferred over UFH acutely; DOACs for long-term",
    "In VITT: AVOID heparin — use fondaparinux/argatroban + IVIG",
    "Prognosis is good with early treatment — ~80% recover fully",
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  s.addText("Cerebral Sinus Venous Thrombosis (CSVT)  |  Neurology Education  |  2026  |  Sources: Bradley & Daroff's Neurology, Adams & Victor's Neurology, Tintinalli's, Rosen's Emergency Medicine", {
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// WRITE FILE
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