This document summarizes cerebral venous and sinus thrombosis. It discusses the pathogenesis, which can involve thrombosis in cerebral veins leading to venous hypertension and hypoxia. Risk factors include trauma, hypercoagulable states, infections, oral contraceptive use, and idiopathic causes. Clinical findings often include headache, seizures, neurological deficits, and features depending on the site of thrombosis. Diagnosis involves CT, MRI, MRA and MRV to detect thrombus. Treatment involves anticoagulants like heparin and warfarin, thrombolytics through interventional radiology, and occasionally surgery for complications. Outcomes depend on factors like coma, site of thrombosis, and degree of intracranial pressure.

1. Cerebral venous
and sinus thrombosis
Youmans Chapter 357
Kenneth C. Liu
Bronwyn E. Hamilton
Stanley L. Barnwell

2. Outline
• Pathogenesis
• Incidence
• Clinical findings
• Diagnostic evaluation
• Treatment

3. Pathogenesis
• Thrombosis in cerebral vein  venous hypertension 
hypoxia of the brain  neurolonal ischemia
• Cerebral edema, massive hemorrhage, bilateral cerebral
infarction
• Mechanism
– alteration in the physical activity of dural sinuses and
vein
– chemical properties of blood
– hemodynamic properties of blood flow

4. Pathogenesis
• Vascular injury from trauma  local endothelial damage
and altered hemodynamic
• Abnormality of blood coagulation factor : dysfunction of
protein C,protein S, antithrombin III, plasminogen 
hypercoagulable states
• Risk factor :Factor V, prothrombin gene mutation, lupus
anticoagulant, anti-phospholipid,anticardiolipin antibodies

5. Pathogenesis
• Infection : alter coagulation cascade and inducible
hypercoagulable state
– Cavernous sinus thrombosis, transverse sinus
thrombosis : sinusitis, otitis, mastoiditis
– Staphylococcus aureus,gram negative rod,
Aspergillus
• More common in young women, puerperium, oral
contraceptive
• Idiopathic

6. Incidence
• Rare disease
• All age group
• Both sex, women 20-40 years old

7. Clinical finding
• Most common : headache(earliest symptoms) and
Seizure
• Nausea, vomiting, visual change, Papilledema from
increase intracranial pressure
• Confusion, agitation, mental status change
• Focal neurological deficit from venous hypertension and
cerebral infarction
• Aphasia, hemianopia, hemisensory
• Acute mimic acute ischemic stroke, subacute are more
common
• Fluctuating or progressive

8. Clinical finding
• Clinical feature to the site
– Superior saggital sinus or transverse sinus : isolated
intracranial hypertension
– Extend to cortical vein : focal deficit, seizure
– Bilateral deficit : late sign of superior saggital sinus
– Transverse sinus CVT may associated with otalgia,
otorrhea, cervical tenderness and lymphadenopathy

9. Clinical finding
• Clinical feature to site
– Cavernous sinus CVT : eyelid edema, chemosis,
retroorbital pain and exophthalmos, paralysis of CN
III,IV, V1,V2,VI
– Involve deep venous system : akinetic mutism, coma,
decerebration
– Memory disturnance, minor confusion
– Cerebellar vein thrombosis : extremely rare and often
lethal

10. Diagnostic evaluation
• Key diagnostic because clinical highly variables
• CT
– Dense vein
– Cord sign : hyperdense on NC CT
– Dense triangle sign(delta sign) : specific to SSS on Contrast CT
– First 1-2 wk after thrombosis
– False positive : neonate, dehydrate, elevated hemoglobin
– False negative is high

11. Diagnostic evaluation
• MRI
– MRA, MRV : best method
– Thrombus, edema, hemorrhagic infaction
– False positive : sinus congenital absent or hypoplastic
– False negative : methemoglobin mimic flowing blood, pt not
cooperate, poor technic

13. • Peripheral dural leaf
enhancement along with
nonopacified thrombus

14. A : axial,NC : 59 yrs old woman c headache, wedge-shaped, Hemorrhagic
mass-like at lt.fronto-parietal area
Ddx : hemorrhagic stroke, vascular malformation, tumour, cortical vein
thrombosis
B : angiogram : filling defect in superior saggital sinus but no dominant superior
cortical vein of Trolard identified  hemorrhagic stroke

15. • A : Man 41 Yrs old : new-onset headache and seizure, Lt frontal mass c
internal hemorrhagic, surgical explore was performed for suspected cavernous
malformation, Finding : anterior third of SSS and the associated cortical vein
was thrombosed
• B : CTA in same PT : delta sign
• C : lateral venous-phase angiography : lack of contrast enhancement in SSS
• D : lateral venous-phase angiography : venous collateral

16. • A : vasogenic edema, superimposed hemorrhage, R/O
vein of Labbe occlusion
• B : MRV transverse sinus thrombosis
• C : source image

17. Treatement
• Cause
• Symptoms from increase ICP
• Seizure or focal deficit

18. Antithrombotics
• Heparin
– Early stage(< 7 days)
– PTT 2-2.5 upper normal limit
– Condition stabilize, add warfarin
– Keep INR 2-3
– No underlying cause : 6 Mo
– Hypercoaguable state : lifelong
• Complication : intracerebral hemorrhage

19. Systemic thrombolytics
• Streptokinase, urokinase, tissue plasminogen activator
(t-PA)
• Complication
• GI bleeding
• ICH
• Contraindication
• Recent child birth
• History of a bleeding diathesis
• Recent major surgery
• Recent major trauma
• Active GI bleeding
• Inflammatory bowel disease
• No strong data support

20. Interventional Neuroradiology
• Direct mechanical manipulation and remove clot
• Local infusion of thrombolytics
• Route : transfemoral, transjugular
• Endovascular local thrombolysis and mechanical
thrombectomy are generally safe and effective in
opening venous occlusion
• Pt had better outcome

21. Urokinase

22. Urokinase

23. rt-PA
• Urokinase not available in USA
• Advantage
– Shorter half-life (5 vs 15 min)
– Better clot lysis

25. Surgery
• Indicaiton
– Malignant intracranial hypertension
– Acute visual loss
– Intracranial hemorrhage
• Ventriculostomy
– Diversion of CSF
– Monitoring of intracranial pressure
• Craniotomy with direct puncture of the dural sinuses and
thrombectomy

26. Outcome
• Mortality rate 30-80 %
• Prognosis
– Coma
– Extreme age : infant, elderly
– Site of thrombosis : deep venous system,cerebellar system
– Severe intracranial pressure
– Underlysis : sepsis, malignancy

27. Thank you