CEREBRAL VENOUS

SINUS THROMBOSIS
Pranay Sinha
Neurosuregery Clerkship Presentation
pranay@virginia.edu
A PLUMBING
ISSUE
Courtesy: Uptodate.com
COMMON
CHOKE
POINTS
Courtesy: Saponsik et al. (2011)
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
Infections
Drugs
Prothrombotic States
Malignancy
Inflammatory diseases
Trauma

RISK FACTORS
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
Hypercoagulability in pregnancy might
be an evolutionary mechanism to
protect against post partum
hemorrhage
(i) Increased Fibrinogen (~3x)
(ii) Increased Thrombin
(iii) Decreased Protein S
(iv) Increased Plasminogen Activator
Inhibitor-I
(v) Venous stasis due to increased
compliance of vessel walls


PREGNANCY
AND
THROMBOSIS
Three Major groups of symptoms
(i) Intracranial hypertension
(ii) Focal deficits
(iii) Encephalopathy
CLINICAL
PRESENTATION
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
Usually hemiparesis
Rarely sensation and vision loss
Focal seizures
FOCAL
DEFICITS
Delirium
Apathy
Frontal lobe signs
Stupor
Seizures
Multifocal deficits
ENCEPHALOPATHY
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
2 days s/p acute onset 1 year f/u with oral anticoagulant
therapy
Courtesy: Saponsik et al. (2011)
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
Courtesy: Saponsik et al. (2011)
CEREBRAL
ANGIOGRAPHY
Courtesy: Saponsik et al. (2011)
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
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
Management of Intracranial pressure
Fenestration of optic nerve sheath to
treat ICP induced visual loss
Management, not necessarily
prophylaxis, of seizure


OTHER ACUTE
STUFF
Predictors of mortality at 30 days
Altered mental status
Thrombosis of deep veins
Posterior fossa lesions
SHORT TERM
PROGNOSIS
CNS infection
Malignancy
Thrombosis of deep veins
Hemorrhage
GCS<9
Age>37
Male gender
LONG TERM
PROGNOSIS
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 venous
and sinus thrombosis 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: 484488, 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