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.
- Occlusion of venous sinus (most commonly superior sagittal and lateral sinuses) by thrombus
- 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.
- Median Age ~ 37 years
- Female:Male ratio 3:1
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
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- Carbon monoxide poisoning
- Basilar artery dissection
- Cerebral venous thrombosis
- Hypertensive emergency
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Suspect in patients with headache, signs of increased ICP, or focal neurologic deficits, especially if any of above predisposing factors are present
- MRI and MRV are considered diagnostic study of choice
- CT venography is a reasonable alternative if there is a contraindication to MRV and may have a similar sensitivity to MRV in recent studies
- May see "Empty delta sign" dense triangle in superior sagittal sinus
- 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.
- 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.
- Non contrast CT possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion
- May see "dense delta sign" (hyperattenuation consistent with thrombus in the posterior sagittal sinus)
- 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.
- 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
- Prophylaxis with antiepileptic is NOT required if the patient has a single seizure with no signs of supratentorial cerebral lesion.
- Frequent neurologic checks and clinical monitoring for increased ICP
- Neurology or neurosurgical consultation depending on institutional resources
- To a level of care capable of frequent neurologic monitoring. Inpatient, the patient should also have a evaluation for a coagulopathy.
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