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  • Clinician

Cerebral venous thrombosis (Cerebral venous sinus thrombosis)

Summary

Cerebral venous thrombosis (CVT) is a thrombotic obstruction of the cerebral venous system that can lead to ischemic lesions (or hemorrhages) in the brain. The condition can occur at any age and is often associated with a hypercoagulable state, a trigger (e.g., delivery, head injury, CNS instrumentation) or an infection (i.e., as in septic CVT). Women are affected more frequently than men, possibly as a result of the additional risk factors of pregnancy and oral contraceptive use. Cavernous sinus thrombosis is a rare subset of CVT that is most often due to infections in the paranasal region. Headache is the most common symptom of CVT and, depending on the size and location of the clot, may be accompanied by visual impairment, focal neurological deficits, seizures, or signs of raised intracranial pressure. Neuroimaging (MRI or CT venography) of the cerebral veins and dural sinus is used to establish the diagnosis. The mainstay of management is anticoagulation alongside the treatment of any potential underlying cause (e.g., antibiotics for septic CVT). Surgical intervention (e.g., endovascular thrombolysis or decompressive craniectomy) may be necessary in patients with significant symptoms who do not respond to anticoagulation.

Definition

Epidemiology

  • Sex: > ; 3:1 [2][3][4]
  • Age: any age group (average age ∼ 40 years)
  • Incidence: 3–4 cases per million in adults; approx. 7 cases per million in children [1]

References:[5][3][1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Noninfectious [5][6][7][2]

Infectious [7][2][8]

References:[5][6][7][2][8]

Pathophysiology

  • Thrombogenesis occurs in the cerebral venous system, including the dural sinuses ↓ cerebral drainageintracranial pressure → clinical features; ; (see below) [5][7]
  • Additionally, thrombus formation → congestion within the venous system of the brain → blood stasis → ↓ oxygenated blood in brain tissue → cerebral edema and/or infarcts/stroke [7]

Clinical features

Symptoms vary depending on the size and location of the thrombosis. They are often nonspecific and may be masked by the underlying disorder(s), necessitating a high degree of clinical suspicion. Patients may have any symptoms of increased ICP or cerebral ischemia. [2][9][10]

Since the thrombus develops gradually, clinical symptoms usually appear progressively and vary in magnitude.

Diagnostics

Diagnosis of CVT is based on neuroimaging with venography. Laboratory studies can help identify underlying conditions (e.g., infections) and to assess baseline organ function prior to therapy. [11]

Neuroimaging [11][13][14]

  • Preferred modalities
    • MRI head with MR venography (MRV): modality of choice (highest sensitivity) [15][16]
    • CT head with CT venography (CTV): if MRI is unavailable or is contraindicated
    • Findings: Typically similar in CTV and MRV
  • Additional modalities
    • Direct cerebral venography: if MRV/CTV are inconclusive or for procedural planning. Findings include filling defects and venous congestion
    • Noncontrast head CT

Additional evaluation [11][13][9]

Treatment

Initial management consists of general stabilization procedures (control of seizures, administration of fluids, treatment of intracranial hypertension) and treatment of the underlying cause. All patients require anticoagulation, and those with underlying infection require antimicrobial therapy; . Surgical intervention should be considered if there is no improvement with medical therapy.

Medical management [11][13]

Invasive procedures [11][13]

Acute management checklist

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last updated 11/18/2020
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