Difference between revisions of "Cerebral venous thrombosis"
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[[File:Sagital sinus thrombus.JPG|thumbnail|Sagital sinus thrombosis on CT]] | [[File:Sagital sinus thrombus.JPG|thumbnail|Sagital sinus thrombosis on CT]] | ||
''Suspect in patients presenting with headache, signs of increased ICP, or focal neurologic deficits in setting of any of above predisposing factors'' | ''Suspect in patients presenting with headache, signs of increased ICP, or focal neurologic deficits in setting of any of above predisposing factors'' | ||
| − | + | ===Imaging=== | |
| − | + | *MRI and MRVis considered diagnostic study of choice<ref name="rads">Khandelwal N et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol 2006;187:1637–1643.</ref> | |
| − | + | *CT venography is a reasonable alternative if there is a contraindication to MRV and may have a similar sensitivity to MRV in recent studies<ref name="rads"></ref> | |
| − | |||
**Non contrast CT possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion | **Non contrast CT possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion | ||
| − | + | **May see "Empty delta sign" dense triangle in superior sagittal sinus<ref>Lee Emil J. Y. “The Empty Delta Sign.” Radiology. 224(3). 2002. 788-789.</ref> | |
| − | + | ===Labs=== | |
| − | + | *D-Dimer is not a reliable test to rule out a cerebral venous thrombosis<ref>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.</ref> | |
| + | *In patients with a concern for [[meningitis]] then pursue diagnosis via standard workup which includes a [[CT before lumbar puncture]] | ||
==Management== | ==Management== | ||
Revision as of 08:41, 11 October 2016
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.
Contents
Background
- 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 thrombilia, oral contraceptive use, and during pregnancy.[2]
- Median Age ~ 37 years[2]
- Female:Male ratio 3:1[2]
Predisposing factors
- Cancer
- Pregnancy
- Local infections (otitis media, sinusitis, cellulitis)
- Hypercoagulable states
- Trauma
- Drugs (ecstasy, androgens, OCPs)
- Compression of venous sinus (tumor, abscess)
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]
- Headache 74-92%
- Seizures 35-50%
- Papilledema 28-45%
- Focal Neurologic sequelae (seizures, dizziness) 25-71%
- Encephalopathy
Neurodefecits
Although presentation can be highly variable, neurodefecits can be correlated with the location of the occlusion[3]
- Superior Sagital sinus - motor deficits, seizures
- Left transverse sinus - aphasia
- Cavernous sinus - ocular pain, protosis, oculomotor palsies
- Deep venous sinus -thalamic related symptoms such as altered mental status
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- 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
Others
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Varicella
- Herpes
- Enterovirus
- West Nile
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
- Sarcoidosis
- Vasculitis
- Connective tissues disease
- Drug induced aseptic meningitis
Evaluation
Suspect in patients presenting with headache, signs of increased ICP, or focal neurologic deficits in setting of any of above predisposing factors
Imaging
- MRI and MRVis 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]
- Non contrast CT possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion
- May see "Empty delta sign" dense triangle in superior sagittal sinus[5]
Labs
- D-Dimer is not a reliable test to rule out a cerebral venous thrombosis[6]
- In patients with a concern for meningitis then pursue diagnosis via standard workup which includes a CT before lumbar puncture
Management
Anticoagulation
- Heparin or low molecular weight heparin
- Of note, heparin initial bolus is 3000-5000U, lower than the dosing for PE/DVT
- Eventual transition to oral anticoagulation for a 3-6 month duration
Seizure prophylaxis
- Only required if the patient has a seizures
Supportive care
- Frequent neurologic checks and clinical monitoring for increased ICP
Acute Decompensation
- Consider
- Hemicraniectomy
- Intravascular thrombolytics
Disposition
- Admission
- To a level of care capable of frequent neurologic monitoring
See Also
References
- ↑ Piazza G. Cerebral venous thrombosis. Circulation 2012;125:1704-1709.
- ↑ 2.0 2.1 2.2 Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007; 6:162-70.
- ↑ 3.0 3.1 Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791–8.
- ↑ 4.0 4.1 Khandelwal N et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol 2006;187:1637–1643.
- ↑ Lee Emil J. Y. “The Empty Delta Sign.” Radiology. 224(3). 2002. 788-789.
- ↑ 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.