This document discusses cerebral venous thrombosis (CVT), including: 1) CVT is a type of stroke caused by thrombosis of cerebral veins and sinuses. It is more common in young females and can cause headaches, seizures, and decreased consciousness. 2) Risk factors include inherited thrombophilias, acquired disorders like cancer and pregnancy, and oral contraceptive use. 3) Diagnosis involves imaging like CT, MRI, and MR or CT venography to detect clots in veins and sinuses. 4) Initial treatment is anticoagulation with blood thinners to prevent clot growth and facilitate reopening of veins. Some severe cases may require local fibrinolytic therapy.

1. Cerebral Venous Thrombosis
Dr. Mudasir Mushtaq Shah

2.  Thrombosis of the dural sinus and/or cerebral veins (CVT)
 Incidence varies from 3 to 13 per million population in different studies.
 CVT represents approximately 0.5-1% of all strokes
 Mostly seen in young
(According to the largest cohort study [International Study on Cerebral Venous and
dural sinuses Thrombosis (ISCVT)], 487/624 (78%) occurred in patients younger
than 50).
 3 times more common in females

4. ETIOPATHOGENESIS
 Predisposing causes of CVT are multiple
 Risk factors or causes for thrombosis in general are linked
classically to VIRCHOWS TRIAD
 Causes are usually divided into
1. Acquired
2. Genetic

5.  INHERITED THROMBOPHILIA
Factor V Leiden mutation
Prothrombin gene mutation
Protein S deficiency
Protein C deficiency
Anti thrombin deficiency
Homocysteinemia
Dysfibrogenemia
ACQUIRED DISORDERS
Malignancy
APLA
Surgery/ Trauma
PNH
Polycythemia vera/ Multiple myeloma
Pregnancy
OCP’ s
Nephrotic syndrome
HRT

6. CLINICAL FEATURES
Clinical findings in CVT usually fall into two major categories,
depending on the mechanism of neurologic dysfunction:
Those related to increased intracranial pressure (ICP) due
to impaired venous drainage
Those related to focal brain injury from venous
ischemia/infarction or hemorrhage

7. Pathogenesis

8.  CVT has a highly variable clinical presentation
 It can present as… Acute, Subacute, Chronic
 CVT often presents with slowly progressive symptoms
 In the ISCVT, onset to diagnosis was 2 to 30 days in 56% of patients

9.  Signs and Symptoms can be grouped into 3 main syndromes
1) ISOLATED INTRACRANIAL HYPERTENSION SYNDROME( Headache +/-
vomitings, papilledema, visualdisturbances)
2) FOCAL SYNDROME( focal deficits, seizures, both)
3) ENCEPHALOPATHY( multifocal signs, mental status changes, stupor or
coma)

10.  Headache, generally indicative of an increase in ICP
 most common symptom in CVT
 90% of patients in the ISCVT
 The headache of CVT is typically diffuse and often progresses in severity over
days to weeks
 Some present with thunderclap or migrainous type headache
 Isolated headache without focal neurologic findings or papilledema occurs in up to
25% of patients with CVT

11.  Focal or generalized seizures are quite frequent, occurring in about 40% of
patients
 Bilateral motor signs may also be present like paraparesis, quadriparesis
 Decreased level of consciousness is seen in 20-30% of patients, usually due to
raise intracranial pressure, bilateral cerebral or thalamic strokes or hydrocephalus.

12. Blood Investigations
 complete blood count, chemistry panel, prothrombin time and activated partial
thromboplastin time and D-dimer should be performed
 Screening for potential prothrombotic conditions that may predispose CVT is
recommended in the initial clinical assessment

18. Imaging in the Diagnosis of CVT
 Diagnostic imaging of cerebral venous thrombosis may be divided into two
categories: non-invasive modalities and invasive modalities
 Non-Invasive Diagnostic Modalities: Computed Tomography (CT), Magnetic
Resonance Imaging (MRI) and Ultrasound
 Invasive Diagnostic Angiographic Procedures: Cerebral Angiography and Direct
Cerebral Venography

19.  CT is often initial modality in new onset neurological symptoms.
 Only around 30% cases show abnormal signs in CT associated with CVT like
Dense delta sign/Empty delta sign/ Cord sign
 Other findings usually seen .. Hemorrhagic or non-hemorrhagic venous infarction
 An ischemic lesion that crosses usual arterial boundaries (particularly with a
hemorrhagic component) or in close proximity to a venous sinus and excessive
edema, is suggestive of CVT

20. Non-contrast CT head scan showed hyperdensity of right transverse sinus as acute
thrombosis

22.  MRI is more sensitive for the detection of CVT than CT
 The principal early signs of CVT on non-contrast enhanced MRI are the absent
flow void with alteration of signal intensity in the dural sinus
 Plus secondary signs like cerebral swelling, edema, infarction and/or hemorrhage

23. Flair MRI showed hyperintensity signal at left sigmoid sinus (arrow)

26.  CT venography or MR venography _ reliable modality for detecting CVT
 CT venography is at least equivalent to MR venography in the diagnosis of CVT
 Drawbacks to CT venography include radiation exposure, potential for iodine
contrast allergy and use of contrast in the setting of poor renal function

27.  The most commonly used MR venographic techniques are time of flight (TOF) MR
venography and contrast-enhanced MR venography
 Contrast enhanced MR venography offers better visualization of cerebral venous
structures

28. MR venogram confirmed thrombosis (black arrows) of right transverse and sigmoid
sinuses and jugular vein

29. Frequency of CVT in Dubai,UAE- multi centric study by Pournamy Sarathchandran
et al., – Annals of Neurosciences

30. TREATMENT
Initial Anticoagulation
 There are several rationales for anticoagulation therapy in CVT:
To prevent thrombus growth
To facilitate recanalization
 Controversy is because off frequent association of hemorrhagic transformation or
intracerebral hemorrhage at the time of diagnosis of CVT.

32.  Initial anticoagulation by.. LMWH/ UFH ( dose adjusted with a goal of 2-3 times control
APTT)
 Later patient is started on oral Vitamin K Antagonists with Target INR-2.0-3.0
DURATION..
 Provoked CVT- 3-6mon
 Unprovoked CVT- 6-12mon
 recurrent CVT with severe THROMBOPHILIA / VTE after CVT- Indefinite
anticoagulation

33. Local Fibrinolytic Therapy
 Although most patients with CVT recover with systemic anticoagulation therapy,
9-13% have poor outcomes despite anticoagulation
 A systematic review including 169 patients with treatment refractory CVT treated
with local thrombolysis showed significant benefit in terms of functional
independence and mortality.

36. OUTCOME
 Approximately 3-15% of patients die in the acute phase of the disorder
 In the ISCVT, 21/624 patients (3.4 percent) died within 30 days from symptom
onset
 Complete recovery is seen in around 80% of the patients.