Difference between revisions of "Cerebral venous thrombosis"

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== Treatment ==
 
== Treatment ==
*Due to the low incidence of disease, evidence-based recommendations on treatment are lacking
+
*Anticoagulation
*Currently accepted that treatment of choice is anticoagulation with heparin or low molecular weight heparin, with eventual transition to oral anticoagulation for a 3-6 month duration
+
**[[Heparin]] or [[low molecular weight heparin]]
*Seizure prophylaxis should be considered in patients with CVT presenting with seizures
+
**Eventual transition to oral anticoagulation for a 3-6 month duration
*Supportive care and close monitoring for increased ICP with consideration of hemicraniectomy for acute decompensation
+
*Seizure prophylaxis
*Intravascular thrombolytics can be considered in patients who acutely decompensate, have symptoms of increased ICP, or decreased level of consciousness
+
**If present with seizures
 +
*Supportive care  
 +
*Monitoring for increased ICP
 +
**Hemicraniectomy for acute decompensation
 +
*Intravascular thrombolytics
 +
**Considered in patients who acutely decompensate, have symptoms of [[increased ICP]], or decreased level of consciousness
  
 
== Disposition ==
 
== Disposition ==

Revision as of 18:43, 20 October 2014

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.

Background

  • Occlusion of venous sinus (most commonly superior sagittal and lateral sinuses) by thrombus or compression from mass
  • No precise prevalence or incidence established due to rarity of condition
  • Median Age ~ 37 years
  • Female:Male ratio 3:1
  • 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:
      • Headache 74-92%
      • Seizures 35-50%
      • Papilledema 28-45%
      • Focal Neurologic sequelae (seizures, dizziness) 25-71%
      • Encephalopathy

Diagnosis

  • Suspect in patients presenting with headache, signs of increased ICP, or focal neurologic deficits in setting of any of above predisposing factors

Work-Up

  • Imaging
    • MRI/MRV considered diagnostic study of choice, now considered gold standard
    • CT venography is a reasonable alternative
      • Has been found to have similar sensitivity to MRV in recent studies
    • Non contrast CT possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion
      • May see "Delta sign" dense triangle in superior sagittal sinus
  • Labs
    • D-Dimer has been proposed as a possible screening tool in low risk patients, but still needs further investigation

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Treatment

  • Anticoagulation
  • Seizure prophylaxis
    • If present with seizures
  • Supportive care
  • Monitoring for increased ICP
    • Hemicraniectomy for acute decompensation
  • Intravascular thrombolytics
    • Considered in patients who acutely decompensate, have symptoms of increased ICP, or decreased level of consciousness

Disposition

  • All patients with confirmed CVT should be admitted to a level of care capable of frequent neurologic monitoring
  • Patients should be started on anticoagulation if there are no contraindications, and transitioned to oral therapy and continued for 3-6 months

See Also

Source

  • Rosen's
  • Uptodate