Cerebral Venous Sinus Thrombosis
Dr Rajiv Jha, MS
Senior Resident M Ch Neurosurgery
National Neurosurgical Referral Center
National Academy Of Medical Sciences
1. 1
Dr Rajiv Jha, MS
Senior Resident M Ch Neurosurgery
National Neurosurgical Referral Center
National Academy Of Medical Sciences
2. 2
A rare condition,3-4 cases / million./year
The first description -French physician Ribes in
1825.
Until the second half of the 20th century remained a
diagnosis generally made after death.
In the 1940s-Dr Charles Symonds et all.
3. 3
< 2% of all strokes
Predominantly affects young adults and children
Male: Uniform age distribution
75% of adult patients are women (ISCVT study)
Accounts for up to 50% of strokes during pregnancy and
puerperium
Most sensitive examination: MRI + MR Venography
Treatment usually with anticoagulation
4. 4
To describe the features of a series of patient
with CVST treated at National Neurosurgical
Referral Center and to find the risk factors,
presentation, and outcome of the disease
process.
5. 5
Retrospective study
September 2008 – September 2010
National Neurosurgical Referral Center,
National Academy of Medical Sciences, Bir
Hospital
Group assignment – all ages / sex
Outcome measured at 3 months
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0
2
4
6
8
10
12
0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 >60
1 1
11
8
3
2 2
Numberofcases
Age
18. 18
Internal and Emergency Medicine Volume 3, Number 3 / September,
2008
The action of PRL as a platelet aggregation co-activator is recognized;
previous studies suggested that increased PRL concentrations could
concur to the hypercoagulable state observed in pregnancy and the
puerperium or other hyperprolactinemic conditions
Dural sinus thrombosis is a rare but dangerous complication of
estroprogestin assumption; in this case the hyperprolactinemia
associated to the pituitary macroadenoma might have concurred to
the thrombophilic state
20. 20
• General: supportive, symptomatic
correct underlying abnormalities(antibiotic for infection)
Avoid steroids
Anticonvulsants to control seizure
Hydrate aggressively
• Anticoagulation with IV Heparin – 15 cases
loading dose of 50-100 units/kg of heparin
constant infusion of 15-25 units/kg/hr – next 24 hrs
Maintenance dose of 50-100 units/kg of heparin,
• LMWH(Fragmin) – 3 cases
5000 IU qd s/c for 5-10 days
• warfarin initiated on day 5 - minimum upto 6 months
21. 21
• No data comparing the effect of Unfractionated Heparin
with Low molecular weight heparin
• Tendency for venous infarcts to become haemorrhagic
• 40% of patients with sinus thrombosis – haemorrhagic infarct
prior to anticoagulation commencing
• Weak Evidence for anticoagulation
• BUT – anticoagulation is safe, even in the setting of ICH
• 3 small randomised clinical trials (NEJM 2005;352:1791-
8)/ ISCVT:
• All showed non-significant benefit of anticoagulation as
compared with placebo
• All included patients who had haemorrhagic infarcts prior to
treatment, no increased or new cerebral haemorrhages
developed after treatment with heparin
23. 23
The 2006 European Federation of Neurological
Societies guideline :
Thrombolysis is only used in patients who deteriorate despite
adequate treatment, and other causes of deterioration have been
eliminated.
It is unclear which drug and which mode of administration is the
most effective.
Bleeding into the brain and in other sites of the body is a major
concern in the use of thrombolysis.
American guidelines:
Makes no recommendation with regards to thrombolysis, stating
that more research is needed.
24. 24
When all measures fail…
Decompressive craniectomy /decompressive
lobectomy
Direct attack on clotted sinus
Direct surgical treatment (thrombectomy and sinus
reconstruction) – rarely indicated, “rethrombosis “is
common
Surgical technique for direct treatment of SSS
thrombosis
25. 25
Important prognostic factors for
death or dependence
Coma (GCS < 9)
Cerebral Haemorrhage
Malignancy
Male sex
Age > 37 years
Mental status disorder
Thrombosis of deep cerebral
venous system – straight sinus
CNS infection
ISCVT- death/dependency 13.4%
Complete recovery 79%
96%
4%
Favorable (27) Unfavorable(1)
26. CVST is not an uncommon disease, but
needs extreme degree of suspicion
26
