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CEREBRAL VENOUS

THROMBOSIS

ETIOLOGIES AND DEMOGRAPHY


Infections

Systemic Condition

Hormonal Factors
and Pregnancy Abnormalities of
Blood and
Coagulation System
Puerperium in
Women
Other
Causes
Neoplasm

DEMOGRAPHY
Intracranial venous occlusive
disease predominantly affects
women and relatively young
individuals

DEMOGRAPHY
Sex & Age Cerebral Venous
Thrombosis ><
Thromboembolic Arterial
Disease (male, 30 year older)

PATHOPHYSIOLOGY
The development of brain pathology in
patients with venous occlusions is quite
different from arterial occlusive disease
In arterial disease, the delivery of nutrients is
directly compromised and brain ischemia and
infarction develop
When elements of the venous system are
occluded, drainage of blood is compromised

PATHOPHYSIOLOGY
Pressure increases in the brain tissue drained by
the obstructed veins and dural sinuses
In order to perfuse brain tissue adequately, the
blood pressure in the feeding artery must exceed
the pressure in the tissue and draining veins
When the venous pressure and intracranial
pressure become high enough, arterial perfusion
may become inadequate and brain infarction can
ensue

PATHOPHYSIOLOGY
Brain edema is potentially
reversible, while brain
infarction is not

CLINICAL FINDINGS
Onset and Course
Focal Neurologic Seizures
Signs and Symptoms
Decreased Level of
Headache Consciousness

DISTRIBUTION OF VENOUS STRUCTURE INVOLVEMENT


AND FINDINGS RELATED TO SPECIFIC LOCATIONS

Cavernous Sinus
Thrombosis
Sagittal Sinus
Thrombosis

Deep Venous System


Occlusions

Cortical Cerebral
Cerebellar Vein
Lateral Sinus Thrombosis
Thrombosis

DIAGNOSIS
Headache is usually the earliest clinical symptom and
often antedates any neurological symptoms or signs
Seizures and decreased alertness are much more
common in sinovenous occlusive disease than in
patients with arterial occlusion-related infarcts
Increased intracranial pressure, especially in the
absence of severe neurological deficits, is also helpful
in suggesting the possibility of venous occlusive
disease

DIAGNOSIS
The clinical findings in patients with dural
and cerebral venous occlusions are often
indistinguishable from patients with
intracranial infections, such as encephalitis,
brain abscess, subdural empyema, and brain
tumors, all of which are important differential
diagnostic considerations
D-dimer measurements have proven helpful
in diagnosis of peripheral venous occlusions

DIAGNOSIS
CT can show abnormalities within the bony
structures of the skull, such as evidence of
paranasal sinus infection, erosion of the
middle ear structures, and changes in the
mastoid regions
CT also effectively shows parenchymatous
brain lesions, especially hemorrhages, and
may even show abnormalities within the
veins and dural sinuses

DIAGNOSIS
Evidence for venous and dural sinus
occlusion on CT can derive from direct
evidence of a sinus or vein abnormality or by
parenchymatous abnormalities
The dural sinuses or deep veins can appear
as hyperdense, round, or triangular (dense
triangle sign) structures on noncontrast axial
CT scan sections, indicating the presence of a
thrombus within a venous channel

DIAGNOSIS
The so-called cord sign, in which a
cerebral cortical vein is imaged as a
high-density, linear, thin, cylindric
structure that contains thrombus, is
rare. When present, however, the cord
sign is specific for venous occlusive
disease

DIAGNOSIS
CT scans are helpful in the diagnosis of occlusion
of the deep venous system
The characteristic finding is bilateral hypodensity,
involving the thalami and basal ganglia
Hyperdensities in these same regions
representing hemorrhages or hemorrhagic
infarction also suggest the diagnosis of deep vein
occlusions

DIAGNOSIS
Magnetic resonance scans are more likely than CT
to provide definitive evidence of intracranial sinus
or venous thrombosis
Direct evidence of abnormal flow in the dural
venous sinuses is more often found on MRI scans
than on CT
Transcranial Doppler (TCD) ultrasonography has
been used to diagnose and follow patients with
dural sinus thrombosis

TREATMENT
Antibiotics and surgical drainage of paranasal
sinus infections and middle ear and mastoid
infections remain the most important
treatments in patients with septic dural sinus
thrombosis
Anticonvulsants for seizure control are
important in patients who have seizures
Raised intracranial pressure can be managed
with osmotic diuretics mannitol, glycerol,
acetazolamide, and lumbar punctures

TREATMENT
The use of anticoagulants was once
controversial in patients with dural sinus
thrombosis, especially in patients with
hemorrhagic infarcts and frank hematomas
However now the great majority of clinicians
use anticoagulants acutely in patients with
dural sinus and venous occlusions unless
there are strong contraindications

OUTCOME
Extent of thrombosis within
the dural venous sinuses
Occlusion of the jugular
veins
Spread to cortical and deep
veins
State of consciousness at
presentation and during
the early course

Use of anticoagulants
and thrombolytic agents
Treatment of raised ICP
Nature of the underlying
causative disease
Presence and extent of
parenchymal infarcts
and hemorrhages