Drowsiness, mental changes, confusion, or coma 30%
Multiple cranial nerve palsies 12%
Cerebellar incoordiantion 3%
Hearing loss 2%
Bilateral or alternating cortical signs 3%
Hypercoagulable states :
- Antiphospholipid syndrome
- protein S and C deficiencies
- antithrombin III deficiency
- lupus anticoagulant
- the Leiden factor V mutation
- Pregnancy and puerperium
Collagen-vascular diseases :SLE, Wegner granulomatosis and Behcet’s
Hematologic conditions :PNH, TTP, sickle cell disease and Polycythemia.
Hyperhomocysteinemia is a strong and independent risk factor for CVT.
Nephrotic syndrome, dehydration, spontaneous intracranial hypotension, high altitude, hepatic cirrhosis, sarcoidosis and malignancy.
Drugs:, steroids, epsilon-aminocaproic acid, thalidomide, tamoxifen, erythropoieten, phytoestrogens and L-asparaginase.
Heparin therapy has been reported to produce thrombotic thrombocytopenia with associated venous sinus thrombosis.
Sinus involvement Predisposing Condition Clinical features 1.SSS Thrombosis Meningitis Headache, fever, vomiting, confusion, seizure,weakness of both LL with bilateral babinski sign 2. Cavernous sinus Thrombosis Face, ethmoid and sphenoid Cranial Nerve 3,4,V1 and V2 invovlement 3. Transverse sinus Mastoid Headache, earache and Gradinego’s syndrome 4. Sigmoid sinus and IJV Thrombosis Neck pain
Three clinical presentation
1.superficial thrombosis of Cortical Veins:
-partial seizures and superficial hgc. Infarct
2.dural sinus thrombosis :
-SSS ,Lateral sinus and Cavernous sinus thrombosis
3.Deep cerebral vein thrombosis:occlusion of vein of Galen and intracerebral veins.rare entity;often presented with neuropsychological features
Infarction in nonarterial distribution (often hemorrhagic)
Empty delta sign
Dense triangle sign
Direct sign :
i. Cord sign :on plain CT, represents the spontaneous visualization of a thrombosed cortical vein; it’s rare .
ii. Dense triangle sign :reflects spontaneous SSS opacification by freshly clotted blood
iii. Empty delta sign : after contrast, it reflects the contrast between the opacified collateral veins in the SSS wall and non opacification of the clot inside the sinus.MC direct sign and seen approximately 35% of the cases.
To rule out other conditions, such as arterial stroke, abscess, tumors and SAH on emergency basis.
In a minority of cases, CT scanning shows the direct pathog. Signs of CVT
Combination of non contrast MRI and MRA and MRV : best method for the diagnosis and follow up of CVT .
MRI/V -Early: absence of flow void & isointense on T1 for occluded vessel; Hypo intense on T2
Late: hyper intense thrombus on T1 & T2
I.V.Heparin-bolus of 80U/kg followed by 18u/kg/hr continous infusion with control APTT 2.5times the control.followed by
Warfarin (INR=2-3) for 3-6 months
If underlying hypercoagulable state, life long anticoagulation.
Others : anti edema measures and antibiotics if suppurative thrombophlebitis
Ferro et al(2001) Bousser (2001) No. of pts 142 200 Full recovery 68 % 77 % Minor sequelae 22 % 11 % Major sequelae 4 % 9 % Death 6 % 3 %