Cerebral venous sinus thrombosis Cerebral venous sinus thrombosis (CVST), cerebral venous and sinus thrombosis or cerebral venous thrombosis (CVT) Cerebral venous and sinus thrombosis, (superior) sagittal sinus thrombosis, dural sinus thrombosis, intracranial venous thrombosis, cerebral thrombophlebitis Contents 1 Signs and symptoms 2 Causes 3 Diagnosis 3.1 Imaging 3.2 D-dimer 3.3 Further tests 4 Pathogenesis 5 Treatment 6 Prognosis 7 Epidemiology

1. Amr Hassan MD,FEBN
Professor of Neurology - Cairo University
Cerebral Venous
Sinus Thrombosis

2. Agenda
Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

3. Agenda
Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

4. Introduction
• The presence of a blood clot in the dural venous
sinuses draining blood from the brain.
• Cerebral venous sinus thrombosis is
much less common than arterial thrombosis.
• Estimated incidence is estimated to be between 2
and 5 per million per year
.
Cerebral Venous Sinus Thrombosis

5. Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

6. Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

7. Populations at Risk

8. Agenda
Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

9. Anatomy of Venous Sinuses

10. Anatomy of Venous Sinuses

11. Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

12. Clinical Picture
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

13. Clinical Picture
Posterior 1/3
Middle 1/3
Anterior 1/3

14. Clinical Picture

15. Clinical Picture
RIGHT

16. Clinical Picture

17. DD
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

18. Specific Diagnostic Landmarks: Cavernous Sinus
Causes of exophthalmoses and congestion of orbit
:-
1. Orbital tumors.
2. Meningioma.
3. Sphenoid Tumors.
Slow
onset
4. AV Fistula → D.D. by
- orbital bruit
- Pulsating Exophthalmoses
- Decrease Exophth. On Carotid a. is occluded by digital pressure.

19. Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

20. • D-dimer level greater than 500 μg/L.
• Thrombophilia testing:
Protein C
Protein S
Antithrombin III
Antiphospholipid antibodies (lupus anticoagulant and
anticardiolipin antibodies); Genetic testing for factor V Leiden
and prothrombin G20210A mutations.
Labs

21. Radiological Picture
Multiple Territories
Non Arterial Vascular
Territories
Bilaterality

22. CONTINUUM: Lifelong Learning in Neurology 20(2):335-351, April 2014.

23. CT Findings

24. CTV versus MRV?
CTV can be used as An alternative to MRV
N.B. MRI has the advantage of showing the
thrombus itself and being more sensitive in
detecting parenchymal lesions

25. CTV Findings

26. MRI Findings

27. CONTINUUM: Lifelong Learning in Neurology 20(2):335-351, April 2014.

28. MRI Findings

29. MRV Findings

30. MRV Findings

31. MRV Findings

32. MRV Findings

33. -Can be useful in patients with
inconclusive CTV or MRV in whom a
clinical suspicion for CVT remains high
-Surgical thrombectomy
Catheter Cerebral Angiography
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

34. Cerebral Venous Sinus Thrombosis
• Introduction.
• Populations at Risk.
• Risk factors & Etiology
• Anatomy .
• Investigations
• Clinical features & Specific Diagnostic Landmarks.
• Treatment.

35. Treatment

36. Just Like Magic: Before & After!

37. -Weight-based LMWH FAVORED OVER
adjusted-dose UFH
-UFH: teratogenic
-Followed by vitamin K antagonists,
-Regardless of the presence of ICH
Initial Anticoagulation
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

38. -Low-molecular-weight heparin preferred
(does not cross the placenta)
-If no improvement:
-Fibrinolytic drug tissue plasminogen activator
(tPA), strep-tokinase (SK) or urokinase (UK), in
the dural sinus via a microcatheter
Initial Anticoagulation
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

39. -Acetazolamide.
-Brain dehydrating measures
-No evidence to use steroids except if
suspected underlying
autoimmune/inflammatory process
Increased Tension?
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

40. -Lumbar puncture, optic nerve
decompression, or shunts
Progressive Visual Loss?
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

41. -Diagnostic: may be used if high clinical
suspicion despite negative CTV/ MRV
-Therapeutic:
May be considered if:
-Deterioration occurs despite intensive
anticoagulation treatment
-If severe hemorrhage?
Endovascular Maneuvers
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

42. -Resistant to anti-coagulation therapy,
-Have worsening of symptoms,
-Not at risk for impending herniation
Endovascular Thrombolysis & Thrombectomy
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

43. -Neurological
deterioration due to
severe mass effect
-Intracranial hemorrhage
causing intractable
intracranial hypertension,
Decompressive Hemicraniectomy
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

44. Decompressive Hemicraniectomy

45. Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..
Decompressive Hemicraniectomy

46. -Suspected bacterial infection
+/-surgical drainage of purulent
collections of infectious
IV Antibiotics?
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

47. -(CVT+single seizure) : early initiation of
antiepileptic drugs for a defined duration
is probably recommended to prevent
further seizures
-CVT+ no seizures: prophylactyic
antiepileptic use is not recommended
Antiepileptics
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a statement
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

48. • Provoked CVT (associated with a transient risk factor): 3 to 6
months, INR (2 – 3)
• Unprovoked CVT, 6 to 12 months
• Venous thromboembolism after CVT: for life
• First CVT (provoked or unprovoked) with severe
thrombophilia: for life
• Recurrent CVST: for life
Secondary Prevention
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a
statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

49. Algorithm for the management of cerebral venous
thrombosis.
Saposnik, G., Barinagarrementeria, F., Brown Jr, R. D., Bushnell, C. D., Cucchiara, B., Cushman, M., ... & Tsai, F. Y. (2011). Diagnosis and management of cerebral venous thrombosis: a
statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(4), 1158-1192
Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20..

50. • Cerebral venous thrombosis is a cerebrovascular disease of the
young, primarily of women.
• Headache is the most common symptom of cerebral venous
thrombosis.
• The most common clinical syndromes in cerebral venous
thrombosis include (1) intracranial hypertension, (2) focal
neurologic deficits (eg, motor weakness, sensory deficit,
aphasia), (3) encephalopathy, and (4) seizure disorder.
• MRI/magnetic resonance venography is the recommended
imaging for the diagnosis of cerebral venous thrombosis.
Specific sequences (eg, T2* susceptibility-weighted imaging) are
useful to assist in the diagnosis of isolated cortical venous
thrombosis.
Key points

51. • Transient risk factors for cerebral venous thrombosis include
pregnancy/puerperium, CNS or ear/sinus/mouth/face infections,
exposure to drugs (eg, oral contraceptives, steroids, cancer
treatments), head trauma, or procedures (eg, lumbar puncture,
jugular catheter placement).
• Chronic triggers of cerebral venous thrombosis include
hereditary or acquired thrombophilias that are established
causes of venous thromboembolism.
• Anticoagulation is the main treatment for the acute management
of cerebral venous thrombosis.
• All available guidelines recommend anticoagulation therapy for
the acute management of cerebral venous thrombosis.
Key points

52. THANK YOU
amrhasanneuro@kasralainy.edu.eg