Cerebral venous thrombosis

The cavernous sinus is one of the several cerebral veins and cavernous sinus thrombosis is a specific type of cerebral venous (sinus) thrombosis. See that article for a discussion of that specific clinical entity.

Background
Cerebral Veins
  • Occlusion of venous sinus (most commonly superior sagittal and lateral sinuses) by thrombus[1]
  • No precise prevalence or incidence established due to rarity of condition. However the disease is more prevalent in patients with thrombophilia, oral contraceptive use, and during pregnancy.[2]
  • Median Age ~ 37 years[2]
  • Female:Male ratio 3:1[2]

Predisposing factors

Clinical Features

Clinical presentation varies depending on location, acuity, and severity of thrombosis. More gradual onset of symptoms or thrombosis allows for compensatory collateral venous system to develop

Common Symptoms

Symptoms are variable and may not all be present[3]

Neurodefecits

Although presentation can be highly variable, neurodefecits can be correlated with the location of the occlusion[3]

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation
Sagital sinus thrombosis on CT

Suspect in patients with headache, signs of increased ICP, or focal neurologic deficits, especially if any of above predisposing factors are present

Imaging
  • MRI and MRV are considered diagnostic study of choice[4]
  • CT venography is a reasonable alternative if there is a contraindication to MRV and may have a similar sensitivity to MRV in recent studies[4][5]
    • May see "Empty delta sign" dense triangle in superior sagittal sinus[6]
    • Cord sign: thrombus in the cerebral sinus may appear as a hyperattenuated foci. It is homogenous in nature and appears linear or round based on the affected sinus. This is most commonly seen in the first week. [7]
    • Vein Sign: After two weeks, the thrombus becomes hypoattenuated. When the thrombus is located in the deep vein it is referred to as the vein sign. [8]
  • Non contrast CT possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion

Labs

Management

Anticoagulation
  • Heparin or low molecular weight heparin (Grade 1C)
    • Of note, heparin initial bolus is 3000-5000U, lower than the dosing for PE/DVT
  • Following the acute phase, patients should transition to oral anticoagulation for a 3-6 month duration
    • Warfarin is recommended as oral anticoagulation of choice
    • There is a controversy regarding the use of direct oral anticoagulants. However, findings from the RE-SPECT CVT trial which was published recently and compared warfarin to dabigatran, suggest that both agents have similar effectiveness and safety for preventing recurrent CVT.

Seizure prophylaxis
  • Recommended for patients with seizure at presentation PLUS focal cerebral lesion (edema, infarction or hemorrhage on CT/MRI) (Grade 1B)
  • Only required if the patient has a seizure[10]
  • Prophylaxis with antiepileptic is NOT required if the patient has a single seizure with no signs of supratentorial cerebral lesion.

Supportive care
  • Frequent neurologic checks and clinical monitoring for increased ICP
  • Neurology or neurosurgical consultation depending on institutional resources

Acute Decompensation
  • If persistent or severe elevated intracranial pressure a hemicraniectomy may be necessary
  • Intravascular thrombolytics (either catheter guided or systemic) in coordination with neurology may be required if the patient experiences rapidly progressing decompensation[11]

Disposition
  • Admission
    • To a level of care capable of frequent neurologic monitoring. Inpatient, the patient should also have a evaluation for a coagulopathy.

See Also

References
  1. Piazza G. Cerebral venous thrombosis. Circulation 2012;125:1704-1709.
  2. Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007; 6:162-70.
  3. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791–8.
  4. Khandelwal N et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol 2006;187:1637–1643.
  5. Rodallec MH, Krainik A, Feydy A et-al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics. 2006;26 Suppl 1 (suppl_1): S5-18.
  6. Lee Emil J. Y. “The Empty Delta Sign.” Radiology. 224(3). 2002. 788-789.
  7. Ram K. P. Vijay. "The Cord Sign."Radiology. 2006; 240:299-300.
  8. Linn J, Pfefferkorn T. "Noncontrast CT in Deep Cerebral Venous Thrombosis and Sinus Thrombosis: Comparison of Its Diagnostic Value for Both Entities."AJNR Am J Neuroradiology. 2010; 30: 728-735.
  9. Crassard I, Soria C, Tzourio C, Woimant F, Drouet L, Ducros A, Bousser MG. A negative D-dimer assay does not rule out cerebral venous thrombosis: a series of seventy-three patients. Stroke 2005;36:1716 –1719.
  10. Ferro JM et al. Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics. Stroke 2008;39:1152–1158.
  11. 38.Dentali F et al. Safety of thrombolysis in cerebral venous thrombosis: a systematic review of the literature. Thromb Haemost 2010;104:1055–1062.
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