1. Cerebral venous sinus thrombosis
Hammad ghanchi

2. Anatomy - Sinuses
Venous collection of blood between the periosteal and meningeal layers of the Dura, lined with endothelium
Lack typical vessel layers & valves
Drain:
Blood
CSF
Ultimately drain into Internal Jugular Vein

3. Anatomy

5. Cerebral Venous Sinus Thrombosis
Thrombosis within the venous system of the Brain ~ “DVT in the Brain”
3 types
Dural Sinus Thrombosis
Cortical Venous Thrombosis
Deep Venous Thrombosis

6. Pathophysiology Closed vascular system
Restriction of blood flow into brain due to the clot in the cerebral sinus blocking outflow (venous congestion)
Cerebral Edema and Increased intracranial pressure
Decreased inflow of oxygenated blood
Infarction (termed ‘venous infarction’)

7. etiology Infection Pregnancy/Puerperium Oral Contraceptive Pills
Dehydration
Iatrogenic (post-cranictomy, transvenous pacemaker placement)
Trauma
Malignancy
Inherited Thrombophilias
Diabetes Mellitus
Homocystinuria
Behcet’s Syndrome
Lumbar Punctures (rarely)

8. Saposnik G et al. Stroke. 2011;42:1158-1192

9. Age and sex distribution of cerebral venous and sinus thrombosis (CVT) in adults.
Age and sex distribution of cerebral venous and sinus thrombosis (CVT) in adults. Bars represent the number of patients with CVT for the specific age/sex category. Data provided by Dr Jose Ferro from the International Study on Cerebral Venous and Dural Sinuses Thrombosis.
Saposnik G et al. Stroke. 2011;42:

10. Magnetic resonance venogram showing the cerebral venous system and most frequent (%) location of cerebral venous and sinus thrombosis, as reported in the International Study on Cerebral Venous and Dural Sinuses Thrombosis (n=624).44.
Magnetic resonance venogram showing the cerebral venous system and most frequent (%) location of cerebral venous and sinus thrombosis, as reported in the International Study on Cerebral Venous and Dural Sinuses Thrombosis (n=624).44
Saposnik G et al. Stroke. 2011;42:

11. Clinical presentation - history
Headache (>90%) – no association between location and site of thrombosis
Throbbing (9%)
Band-like (20%)
Thunderclap (5%)
Other (pounding, exploding, stabbing, etc) (20%)
Abnormal Vision
Nausea/Vomiting
Seizure
Altered mental status
Stroke-like symptoms (hemiplegia, hemiparesis, aphasia,etc)
Ataxia
Dizziness/Vertigo
Wasay M et all, Headache in Cerebral Venous Thrombosis: incidence, pattern, and location in 200 consecutive patients. J Headache Pain. Apr 2010; 11(2):137-9

12. Clinical presentation – physical exam
Mental Status Changes variable (no change to coma)
Papilledema
Cranial Nerve Deficits
Cavernous sinus thrombosis -> extraocular motor dysfunction
Thrombosis extending into jugular vein may develop jugular foramen syndrome (CN 9, 10, 11)
Hemiparesis with Superior Sagittal Sinus involvement

13. Workup Non-Contrast Head CT – normal in 10-20 % of cases
Hyperdense sinuses and veins; cord sign (right) is pathognomic
Flame hemorrhages
Small ventricles
White matter edema

14. Workup Contrast-Enhanced Head CT Dura may enhance Gyral enhancement
Dense deep white matter veins (collateral flow)
Tentorial enhancement
Empty Delta Sign (Right)
Filling defect of superior sagittal sinus (pathognomonic)

15. Workup Head MRI Clot is acutely isointese on T1 and hypointense on T2
Subacute becomes hyperintense in T1 and T2
Late (>10 days) becomes black from flow void
CT findings present on MRI

16. WorkUp Magnetic Resonance Venogram (MRV)
Will demonstrate lack of blood flow
Magnetic resonance venography confirmed thrombosis (black arrows) of right transverse and sigmoid sinuses and jugular vein.
Saposnik G et al. Stroke. 2011;42:1158-c1192

17. Magnetic resonance venogram showing thrombosis (black arrows) of the superior sagittal sinus and sigmoid sinuses.
Magnetic resonance venogram showing thrombosis (black arrows) of the superior sagittal sinus and sigmoid sinuses. A, 2 days after symptom onset. B, 1 year follow-up after oral anticoagulation therapy (OAC).
Saposnik G et al. Stroke. 2011;42:1158-c1192

18. Workup IV Digital Subtraction Angiography Gold standard for diagnosis
Rarely used due to invasive nature

19. Medical Management Correct underlying etiology Systemic Heparin
Remains best treatment, even in the presence of intracerebral hemorrhage
Avoid steroids (reduces fibrinolysis, increases coagulation)
Control HTN
Anticonvulsants if seizures present
Hydrate aggressively as ICP tolerates

20. Anticoagulation First reported use in 1942 by Stansfield
Supported by a small clinical trial of 20 patients
0 patients died on Heparin vs 3 deaths on placebo
Trial terminated after 3 weeks
Repeated again on 59 patients in 1999
Low molecular weight heparin vs placebo (for 3 weeks followed by oral warfarin for 3 months vs nothing)
Favorable outcomes but not statistically significant
Recent study compared Unfractionated Heparin vs Low Molecular Weight Heparin (2010)
Showed better functionality at 6 months and decreased incidence of intracerebal hemorrhage with LMW Heparin
No difference in complete recovery or mortality
Randomized, placebo-controlled trial of anticoagulant treatment with low-molecular-weight heparin for cerebral sinus thrombosis.
Stroke Mar;30(3): PMID:
Anticoagulation for cerebral venous sinus thrombosis.
Cochrane Database Syst Rev Aug 10;(8):CD doi: / CD pub2. PMID:
Unfractionated or low-molecular weight heparin for the treatment of cerebral venous thrombosis.
Coutinho JM
Stroke Nov;41(11): doi: /STROKEAHA Epub 2010 Oct 7. PMID

21. Surgical intervention
Monitor ICP if patient continues to deteriorate
Ventriculostomy
Thrombolytic therapy, sometimes directly into the sinus
TPA
Urokinase
Streptokinase
Decompressive craniectomy
Decreases ICP but no proven improvement in outcome

22. Interventional Neuroradiology
Penumbra system – sucks out the clot in small amounts
MERCI retriever – corkscrew-shaped wire that pulls out clot
Angiojet – efficacious for venous clots, but not arterial clots
experimental . Used in severe cases as a last resort
Penumbra -
MERCI Retreiver -
Angiojet -

23. Follow-up/prognosis
Visual loss with papilledema may be treated with optic nerve fenestrations
Long term treatment after resolution of acute phase with heparin and/or warfarin for 3-12 months
No clear guidelines
Indicators of poor prognosis:
Deep sinus involvement
Extension into cortical veins
Presenting Low GCS (Coma)
Rapid deterioration (no time for collateral compensation)
10-day delay in diagnosis
Hemorrhage on CT
Papilledema

24. References Handbook of Neurosurgery 7th Edition, Mark S. Greenburg
Wasay M et al, Headache in Cerebral Venous Thrombosis: incidence, pattern, and location in 200 consecutive patients. J Headache Pain. Apr 2010; 11(2):137-9
Denise, M. Lemke, Loffti. Cerebral Venous Sinus Thrombosis. Journal of Neuroscience Nursing (5) p
Layon, J et al. Textbook of Neurointensive Care 1st edition. December p
Saposnik G et al.Diagnosis and Management of Cerebral Venous Thrombosis. Stroke. 2011;42: