Cerebral venous thrombosis

Background

• 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

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
• Labs
  • D-Dimer has been proposed as a possible screening tool in low risk patients, but still needs further investigation

DDx

Headache DDX

Treatment

• Due to the low incidence of disease, evidence-based recommendations on treatment are lacking
• 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
• Seizure prophylaxis should be considered in patients with CVT presenting with seizures
• Supportive care and close monitoring for increased ICP with consideration of hemicraniectomy for acute decompensation
• Intravascular thrombolytics can be 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

Source

Rosen's

Uptodate