Cerebral venous thrombosis
Revision as of 18:36, 20 October 2014 by Rossdonaldson1 (talk | contribs)
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 the 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
DDx
Treatment
- Due to the low incidence of disease, evidence-based recommendations on treatment are lacking
- Currently accepted that treatment of choice is anticoagulation with heparin or low molecular weight heparin, with eventual transition to oral anticoagulation for a 3-6 month duration
- Seizure prophylaxis should be considered in patients with CVT presenting with seizures
- Supportive care and close monitoring for increased ICP with consideration of hemicraniectomy for acute decompensation
- Intravascular thrombolytics can be considered in patients who acutely decompensate, have symptoms of increased ICP, or decreased level of consciousness
Disposition
- All patients with confirmed CVT should be admitted to a level of care capable of frequent neurologic monitoring
- Patients should be started on anticoagulation if there are no contraindications, and transitioned to oral therapy and continued for 3-6 months
See Also
Source
- Rosen's
- Uptodate