Cerebral Sinus Thrombosis

8/11/2019 Cerebral Sinus Thrombosis

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CEREBRAL VENOUS

SINUS THROMBOSIS

Pranay Sinha

Neurosuregery Clerkship Presentation

[email protected]


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A PLUMBINGISSUE

Courtesy: Uptodate.com


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COMMON

CHOKE

POINTS

Courtesy: Saponsik et al. (2011)


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MECHANISMS

OF INJURYCVST

Increased venous pressure

Decreased absorption of CSFfrom Arachnoid granulations

Increased ICP

Increased Capillarypressure

Decreased CerebralPerfusion

Parenchymal damage

due to failure ofenergetic mechanisms

Parenchymalhemorrhage

Disruption of BBB

Vasogenic edema


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Infections

Drugs

Prothrombotic States

Malignancy

Inflammatory diseases

Trauma

RISK FACTORS


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Incidence varies from 0.22/100,000 to1.23/100,000

11.6/100,000 among pregnant ladies

More common in women than men (3:1)

Diagnosis is frequently delayed

A RARE

PROBLEM


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Hypercoagulability in pregnancy mightbe an evolutionary mechanism toprotect against post partumhemorrhage

(i) Increased Fibrinogen (~3x)

(ii) Increased Thrombin(iii) Decreased Protein S

(iv) Increased Plasminogen ActivatorInhibitor-I

(v) Venous stasis due to increased

compliance of vessel walls

PREGNANCY

AND

THROMBOSIS


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Three Major groups of symptoms

(i) Intracranial hypertension

(ii) Focal deficits

(iii) Encephalopathy

CLINICAL

PRESENTATION


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Most Common Symptom: headache

Can be the only symptom and precedeothers by weeks or days

Location does not correlate with that ofthrombosis

Variable in onset Papilledema, N/V, visual symptoms may

or may not be present

INTRACRANIAL

HYPERTENSION


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Usually hemiparesis

Rarely sensation and vision loss

Focal seizures

FOCAL

DEFICITS


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Delirium

Apathy

Frontal lobe signs

Stupor

Seizures

Multifocal deficits

ENCEPHALOPATHY


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MRI (T2) and MRV are best

1st week( deoxyHb): T1- iso; T2-hypointense

2ndweek (methHb): Hyper in bothmodalities

If MRI is unavailable, try CT and CTV CVT appears as hyperdensity in CT

Cerebral angiography if MRV and CTVare inconclusive

IMAGING


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MRV IMAGING

2 days s/p acute onset 1 year f/u with oral anticoagulanttherapy



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Acute Non contrast CT:Hyperdensity in corticalvein

Non contrast CT:Hyperdensity intorculae and thestraight sinusdensetriangle sign

Contrast CT: Unfilledconfluence of sinusesafter contrast injectionthe empty delta sign

Courtesy: Uptodate.com


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CTV



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CEREBRAL

ANGIOGRAPHY



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Test for risky drugs

Test for Prothrombotic conditions

-Factor V leiden, Antithrombin III, ProteinC, Protein S levels, G20210 Prothrombinmutation

D-dimer levels are controversial.?99.6% NPV; 55.1% PPV

LAB STUDIES


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TREATMENT

Central Venous Thrombosis

Recanalization ofoccluded veins

Prevent the propagationof the thrombus

Treat the underlyingthrombophilia

Stop offending drugs such as oral hormones

AHA, ACCP, EFNS all support anticoagulation with LMWH orUnfractionated Heparin

In severe cases, can also try mechanical thrombolysis or intra-sinus delivery of rtPA or urokinase using a catheter


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Management of Intracranial pressure

Fenestration of optic nerve sheath totreat ICP induced visual loss

Management, not necessarilyprophylaxis, of seizure

OTHER ACUTE

STUFF


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Predictors of mortality at 30 days

Altered mental status

Thrombosis of deep veins

Posterior fossa lesions

SHORT TERM

PROGNOSIS


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CNS infection

Malignancy

Thrombosis of deep veins

Hemorrhage

GCS37

Male gender

LONG TERM

PROGNOSIS


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Etiology, Clinical Features, and Diagnosis of Cerebral Venous SinusThrombosis. 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 venousand sinus thrombosis in adults. European Journal of Neurology. 1229-1235, 2010

Stam J, Lensing AWA, Vermeulen M, Tijssen JGP: Heparin treatment forcerebral venous and sinus thrombosis. Lancet. 338: 1154, 1991

De Bruijn SFTM, Stam J, for the Cerebral Venous Sinus Thrombosis Study

Group. Randomized, placebo- controlled trial of anticoagulant treatmentwith low- molecular-weight heparin for cerebral sinus thrombosis.Stroke 30: 484488, 1999

Cantu C, Barinagarrementeria F. Cerebral venous thrombosis associatedwith pregnancy and puerperium. Review of 67 cases. Stroke 24: 18801884, 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 athrombophillic state. Minerva Ginecol. 58(5): 417-422, 2006

BIBLIOGRAPHY

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Cerebral Sinus Thrombosis