cerebral vein thrombosis basic knowledge

4. Gustavo Saposnik. Stroke. Diagnosis and Management of Cerebral V
enous Thrombosis, Volume: 42, Issue: 4, Pages: 1158-1192, DOI: (10
.1161/STR.0b013e31820a8364) © 2011 American Heart Association, Inc.

6. Cerebral venous thrombosis (CVT) is uncommon, representing
ap-
proximately 0.5% of all cases of cerebrovascular disease world
wide.
Many factors, alone or combined, can cause CVT. It affects abo
ut 5 people in 1 million each year.
Although CVT can occur at any age, it most commonly affects n
eonates and young
adults. CVT is difficult to diagnose clinically because patients ca
n
present with a wide spectrum of nonspecific manifestations, the
most common of which are headache in 89%–91%, focal deficit
s
in 52%–68%, and seizures in 39%–44% of patients. Consequen
tly,
imaging is fundamental to its diagnosis. MRI is the most sensitiv
e
and specific technique for diagnosis of CVT. The different MRI

7. pathphysiology

10. CT
Unenhanced CT is usually the first imaging investigation performed given the
nonspecific clinical presentation in these cases. When not associated with ve
nous hemorrhage or infarction, it can be a subtle finding on CT images, relyin
g on hyperdensity of the sinus being identified. Potential findings include:
•cord sign
•dense vein sign
• a potential pitfall is interpreting the distal superior sagittal sinus as
being hyperdense near the torcula herophili; it is important to
appreciate that normal blood within the dural sinuses is usually of
slightly increased density relative to brain parenchyma and that true
hyperdensity is the key to recognizing thrombosis
• The walls at this location can be thick, measuring up to 2-3 mm
•cerebral/cortical edema: secondary to venous hypertension
•unilateral or bilateral cortical or peripheral venous hemorrhage
With contrast administration, especially with a CT venogram, a sinus filling def
ect is sought. Multiplanar reformatted CT venography has been reported with
a sensitivity of 95% for this diagnosis 4. Signs on contrast CT include:
•empty delta sign (specific to a superior sagittal sinus thrombosis)
•gyral enhancement
•prominent intramedullary vein

14. Differential diagnosis
•asymmetric anatomy: hypoplasia or atresia of the transverse sinus
• the right transverse sinus is larger than the left in most patients 5
• if the sinus is small or absent, then the ipsilateral sigmoid sinus and jugul
ar fossa should also be small 6
•arachnoid granulations:
• usually characterized as well-defined focal filling defects within the dural v
enous sinuses (measuring 2–9 mm in diameter) 4
• these are more common in the lateral aspects of the transverse sinuses a
nd should follow CSF signal intensity on all MRI sequences
•asymmetric flow in the transverse or sigmoid sinus can mimic a dural venous thr
ombosis

16. Differential Diagnosis
Headache
Common
•Migraine headache
•Tension headache
•Cluster headache
Killers
•Meningitis/encephalitis
•Retropharyngeal abscess
•Intracranial Hemorrhage (ICH)
• SAH / sentinel bleed
•Acute obstructive hydrocephal
us
•Space occupying lesions
•CVA
•Carbon monoxide poisoning
•Basilar artery dissection
•Preeclampsia
•Cerebral venous thrombosis
•Hypertensive emergency
Maimers
•Giant cell arteritis of temporal artery (tem
poral arteritis)
•Idiopathic intracranial hypertension (Pse
udotumor Cerebri)
•Acute Glaucoma
•Acute sinusitis
•Cavernous sinus thrombosis or cerebral
sinus thrombosis
•Carotid artery dissection
Differential Diagnosis by symptoms

17. Others
•Trigeminal neuralgia
•TMJ pain
•Post-lumbar puncture headache
•Dehydration
•Analgesia abuse
•Various ocular and dental problems
•Herpes zoster ophthalmicus
•Herpes zoster oticus
•Cryptococcosis
•Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
•Ophthalmoplegic migraine
•Superior Vena Cava Syndrome
DDX

18. DDX
Aseptic Meningitis
•Viral
• Varicella
• Herpes
• Enterovirus
• West Nile
•Tuberculosis
•Lyme disease
•Syphilis
•Leptospirosis
•Fungal (AIDS, transplant, chemotherapy, chronic steroid u
se)
•Noninfectious
• Sarcoidosis
• Vasculitis
• Connective tissue disease
• Drug induced aseptic meningitis