Cerebral venous sinus thrombosis (patient information)

Associate Editor(s)-in-Chief: Sharmi Biswas, M.B.B.S

Cerebral venous thrombosis (CVT) is most common in young adults.0.5 -1.0% of stroke admissions are CVT with an incidence of 1.3 per 100,000 per year. The median age of CVT is 37 years and 2 times more common in females than males. Complete or partial occlusion of major cerebral veins or smaller cortical veins causes cerebral venous thrombosis. Due to the similarity of the presenting symptoms CVT can be misdiagnosed as other neurological conditions. The most common risk factors are oestrogen containing oral contraceptives, genetic or acquired hypercoagulable states, pregnancy, puerperium, malignancy, infections, head injury and inflammatory conditions. MRI venography is the diagnostic choice in most of the cases. Treatment is mostly with anticoagulants and symptomatic managements. Prognosis of CVT is better comparing to other strokes. But many patients who survive have consistent neurological deficits, residual epilepsy and other motor and sensory deficits.

The most common symptoms of cerebral venous thrombosis are

– headache, subacute in nature ,developing over several days. Acute headaches also can happen.

– focal or generalized seizure

– papilledema

– focal neurological deficits presenting as monoparesis or hemiparesis

– coma in 10% of patients as the presenting symptom

– multiple pregnancies,

– untreated inflammatory conditions

– infections and injuries of the central nervous system

– venous thromboembolism,

– pregnancy

– oestrogen therapy/oral contraceptives,

– thrombophilia (especially antithrombin deficiency, protein C and S deficiency and factor V Leiden mutation),

– hypercoagulability

– head trauma,

– local infections

– underlying cancer

– surgery

– trauma

– pregnancy

– puerperium

– antiphospholipid syndrome

– cancer

– exogenous hormones

– genetic risks (inherited thrombophilia)

– No specific confirmatory laboratory test

– Elevated D-dimer level is supportive to diagnose cerebral venous sinus thrombosis(CVT)but normal D-dimer level doesn’t exclude CVT.

– CT scan doesn’t show any specific findings

– CT and MRI venography is the confirmatory diagnostic tests in CVT. In the acute phase of CVT, MRI venography is more sensitive. MRI venography is more preferable as it shows superior views of brain parenchyma, venous infarcts, and hemorrhages.

– Anticoagulant therapy and symptomatic management to prevent complications and death is the most important step

– In all patients including pregnant women, low molecular weight heparin (dalteparin 100 IU/kg x 2 or enoxaparin 1 mg/kg x 2)is recommended

– Vitamin k antagonist (warfarin) should be started after initial treatment with heparin (dalteparin 100 IU/kg x 2 or enoxaparin 1 mg/kg x 2)

– Decompression craniectomy can be helpful in large venous infarction leading to high intracranial pressure

– Antiepileptic drugs are recommended for patients with seizure

– Lifelong prophylaxis with anticoagulant is required in patients with recurrent CVT or pro thrombotic conditions.

Comparing to other types of stroke, the prognosis of cerebral venous thrombosis (CVT) is more favorable. In 80% of patients with CVT, there are no functional disabilities. In the acute phase of CVT 5-10% of patients die. A significant number of patients suffer from chronic complications as headache, fatigue, memory and concentration deficits, or residual epilepsy.

– Permanent neurological deficit as speech, sensory and motor symptoms

– Persistent headache, tiredness

– Blindness

– Ophthalmoplegia

– Hypopitutarism

– Syndrome of inappropriate antidiuretic hormone(SIADH)

– Neuropsychological problems

– Recurrent cerebral venous thrombosis

– Obstructive hydrocephalus

– Subarachnoid hemorrhage

– Pulmonary embolism

– Hemiparesis/ monoparesis

– Coma

– Death