Review of Cerebral Venous Sinus Thrombosis

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A brief overview of the presentation, diagnosis, and treatment of cerebral venous sinus thrombosis, a rare neurovascular condition.

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CeREBRAL Venous Sinus Thrombosis: 

CeREBRAL Venous Sinus Thrombosis Pranay Sinha Neurosuregery Clerkship Presentation pranay@virginia.edu

A Plumbing Issue: 

A Plumbing Issue Courtesy: Uptodate.com

Common choke points: 

Common choke points Courtesy: Saponsik et al. (2011)

Mechanisms of injury: 

Mechanisms of injury CVST Increased venous pressure Decreased absorption of CSF from Arachnoid granulations Increased ICP Increased Capillary pressure Decreased Cerebral Perfusion Parenchymal damage due to failure of energetic mechanisms Parenchymal hemorrhage Disruption of BBB Vasogenic edema

Risk Factors: 

Infections Drugs Prothrombotic States Malignancy Inflammatory diseases Trauma Risk Factors

A rare problem: 

Incidence varies from 0.22/100,000 to 1.23/100,000 11.6/100,000 among pregnant ladies More common in women than men (3:1) Diagnosis is frequently delayed A rare problem

Pregnancy and thrombosis: 

Hypercoagulability in pregnancy might be an evolutionary mechanism to protect against post partum hemorrhage Increased Fibrinogen (~3x) Increased Thrombin Decreased Protein S Increased Plasminogen Activator Inhibitor-I Venous stasis due to increased compliance of vessel walls Pregnancy and thrombosis

Clinical Presentation: 

Three Major groups of symptoms Intracranial hypertension Focal deficits Encephalopathy Clinical Presentation

Intracranial hypertension: 

Most Common Symptom: headache Can be the only symptom and precede others by weeks or days Location does not correlate with that of thrombosis Variable in onset Papilledema, N/V, visual symptoms may or may not be present Intracranial hypertension

Focal deficits: 

Usually hemiparesis Rarely sensation and vision loss Focal seizures Focal deficits

Encephalopathy: 

Delirium Apathy Frontal lobe signs Stupor Seizures Multifocal deficits Encephalopathy

Imaging: 

MRI (T2) and MRV are best 1 st week( deoxyHb ) : T1- iso ; T2- hypointense 2 nd week ( methHb ): Hyper in both modalities If MRI is unavailable, try CT and CTV CVT appears as hyperdensity in CT Cerebral angiography if MRV and CTV are inconclusive Imaging

MRV imaging: 

MRV imaging 2 days s/p acute onset 1 year f/u with oral anticoagulant therapy Courtesy: Saponsik et al. (2011)

PowerPoint Presentation: 

Acute Non contrast CT: Hyperdensity in cortical vein Non contrast CT: Hyperdensity in torculae and the straight sinus– dense triangle sign Contrast CT: Unfilled confluence of sinuses after contrast injection– the empty delta sign Courtesy: Uptodate.com

CTV: 

CTV Courtesy: Saponsik et al. (2011)

Cerebral angiography: 

Cerebral angiography Courtesy: Saponsik et al. (2011)

Lab studies: 

Test for risky drugs Test for Prothrombotic conditions -Factor V leiden , Antithrombin III, Protein C, Protein S levels, G20210 Prothrombin mutation D-dimer levels are controversial. ?99.6% NPV; 55.1% PPV Lab studies

Treatment: 

Treatment Central Venous Thrombosis Recanalization of occluded veins Prevent the propagation of the thrombus Treat the underlying thrombophilia Stop offending drugs such as oral hormones AHA, ACCP, EFNS all support anticoagulation with LMWH or Unfractionated Heparin In severe cases, can also try mechanical thrombolysis or intra-sinus delivery of rtPA or urokinase using a catheter

Other acute stuff: 

Management of Intracranial pressure Fenestration of optic nerve sheath to treat ICP induced visual loss Management, not necessarily prophylaxis, of seizure Other acute stuff

Short term Prognosis: 

Predictors of mortality at 30 days Altered mental status Thrombosis of deep veins Posterior fossa lesions Short term Prognosis

Long term Prognosis: 

CNS infection Malignancy Thrombosis of deep veins Hemorrhage GCS<9 Age>37 Male gender Long term Prognosis

Bibliography: 

Etiology, Clinical Features, and Diagnosis of Cerebral Venous Sinus Thrombosis. UptoDate . Retrieved 6/26/2012 Treatment and prognosis of Cerebral Venous Sinus Thrombosis. UpToDate . Retrieved 6/26/2012. Einhaupl K et al.: EFNS guidelines for the management of cerebral v enous and sinus t hrombosis in adults. European Journal of Neurology. 1229-1235, 2010 Stam J, Lensing AWA, Vermeulen M, Tijssen JGP: Heparin treatment for cerebral venous and sinus throm - bosis . Lancet. 338: 1154, 1991 De Bruijn SFTM, Stam J, for the Cerebral Venous Sinus Thrombosis Study Group. Randomized, placebo- controlled trial of anticoagulant treatment with low- molecular-weight heparin for cerebral sinus thrombosis. Stroke 30: 484– 488, 1999 Cantu C, Barinagarrementeria F. Cerebral venous thrombosis associated with pregnancy and puerperium . Review of 67 cases. Stroke 24: 1880– 1884, 1993 Saposinik G et al: Diagnosis and Management of Cerebral Venous Sinus Thrombosis. Stroke. 42:1158-1192, 2011 Maiello M et al.: Hypercoagulability during pregnancy: evidences for a thrombophillic state. Minerva Ginecol . 58(5): 417-422, 2006 Bibliography