Cerebral venous thrombosis

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  1. Thrombosis of the venous sinuses and/or draining veins is an uncommon cause of cerebral infarct relative to arterial disease
  2. Etiology
    1. Infection (sinusitis, subdural empyema, bacterial meningitis). Multiple organisms are to be considered, Staphylococcus aureus being the most common. In chronic infections, gram-negative organisms and fungi such as Aspergillus species may be found.
    2. Trauma( minor head trauma, neurosurgical procedures such as dural taps and infusions into the internal jugular vein)
    3. Medical conditions [inflammatory bowel disese, sarcoidosis, hypercoagulable states (antiphospholipid antibody syndrome, protein S and C deficiencies, antithrombin III deficiency, lupus anticoagulant, and the Leiden factor V mutation, prothrombin mutation), collagen -vascular diseases (systemic lupus erythematosus, Wegener granulomatosis, Beh├žet syndrome), hematologic conditions (thrombotic thrombocytopenic purpura, heparin induced thrombocytopenia, sickle cell disease, nocturnal paroxysmal hemoglobinuria, polycytemia) malignancies, nephrotic syndrome, dehydration, hepatic cirrhosis, and medication (oral contraceptives, corticosteroids, epsilon-aminocaproic acid, L-asparaginase, etc)
    4. Pregnancy and puerperium
      1. cavernous sinus is most frequently involved in septic thrombosis (common organisms staph aureus, streptococcus, pneumococcus and Gram negative bacilli)
      2. transverse sinus is associated with chronic otitis media and mastoiditis
      3. superior sagittal sinus thrombosis is most frequently associated with meningitis
  3. Clinical presentation is variable: headache, nausea, vomiting, seizures, decreased level of consciousness are common.
  4. Focal neurological deficits depend on the area involved
    1. hemiparesis, unilateral or bilateral lower extremity weakness, aphasia, hemianopsia, cranial nerve deficts are all possible
  5. Brain imaging
    1. CT is often the first imaging study obtained - may show a delta sign, venous infarction, a sinus infection, a subdural epyema, and can rule out other conditions. CT venography is useful in identification of cerebral veins and dural sinuses.
    2. MRI shows the pattern of an infarct that does not follow the distribution of an expected arterial occlusion. It may show absence of flow void in the normal venous channels.

MRV is an excellent method of visualizing the dural venous sinuses and larger cerebral veins.

  1. Treatment
    1. Anticoagulation - heparin (associated with much better survival), followed by warfarin 3-6 months
    2. Thrombolysis- infusion of thrombolitics through a microcatheter into the sinus
    3. Mechanical thrombectomy- endovascular technique
    4. Adjuvant treatment : antibiotics, drainage of affected sinus or drilling out of the mastoid, neurosurgical evacuation of a subdural empyema, brain abscess
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