Difference between revisions of "Cerebral venous thrombosis"

(Supportive care)
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===Supportive care===
===Supportive care===
*Frequent neurologic checks and clinical monitoring for [[increased ICP]]
*Frequent neurologic checks and clinical monitoring for [[increased ICP]]
*Neurology or neurosurgical consultation depending on institutional resources
===Acute Decompensation===
===Acute Decompensation===

Revision as of 08:42, 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.


Cerebral Veins
  • 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
Sinus thrombosis.jpg


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






Aseptic Meningitis


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


  • 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]


  • 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



  • 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
  • Neurology or neurosurgical consultation depending on institutional resources

Acute Decompensation

  • Consider
    • Hemicraniectomy
  • Intravascular thrombolytics


  • Admission
    • To a level of care capable of frequent neurologic monitoring

See Also


  1. Piazza G. Cerebral venous thrombosis. Circulation 2012;125:1704-1709.
  2. 2.0 2.1 2.2 Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007; 6:162-70.
  3. 3.0 3.1 Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791–8.
  4. 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.
  5. Lee Emil J. Y. “The Empty Delta Sign.” Radiology. 224(3). 2002. 788-789.
  6. 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.