Cerebral venous thrombosis
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.
Background
- Occlusion of venous sinus (most commonly superior sagittal and lateral sinuses) by thrombus or compression from mass
- 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
- 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:
- 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
- May see "Delta sign" dense triangle in superior sagittal sinus
- Labs
- D-Dimer has been proposed as a possible screening tool in low risk patients, but still needs further investigation
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Treatment
- Anticoagulation
- Heparin or low molecular weight heparin
- Eventual transition to oral anticoagulation for a 3-6 month duration
- Seizure prophylaxis
- If present with seizures
- Supportive care
- Monitoring for increased ICP
Acute Decompensation
- Consider
- Hemicraniectomy
- Intravascular thrombolytics
Disposition
- Admission
- To a level of care capable of frequent neurologic monitoring
See Also
Source
- Rosen's
- Uptodate