In this post I link to and excerpt from IBCC chapter & cast – Cerebral Venous Thrombosis, [Link to the podcast] [Link to the chapter], September 7, 2020 by Dr. Josh Farkas.
Dr. Farkas introduces us to the subject:
Cerebral vein thrombosis is a neurological emergency with a frequency similar to meningitis. We don’t often think about this, but we probably should. With early diagnosis and appropriate management, outcomes are often very good (making this one of the most treatable forms of stroke).
And here are direct links Dr. Farkas has created to every part of the chapter (outstanding).
And here are excerpts:
- Failure to consider the diagnosis of cerebral venous thrombosis, leading to a failure to perform adequate imaging* and thereby missing the diagnosis.
- [*Adequate imaging means ordering a CT Venogram]
- Incorrect belief that patients with cerebral venous thrombosis and hemorrhagic transformation cannot be anticoagulated. In fact, most patients with controlled hemorrhagic transformation should be anticoagulated.
- Cerebral Venous Thrombosis: Pearls & Pitfalls, in emDocs, by Brit Long and Alex Koyfman
- Cerebral Venous Thrombosis, on CoreEM, by Anand Swaminathan
- Cerebral Venous Thrombosis Imaging, in Radiopaedia, by Tee Yu Jin and Frank Gaillard
- This typically affects young patients (most commonly between 20-50YO)(29752489)
- There is a 2-3 fold female predominance.
- Venous thrombosis accounts for ~1% of all strokes.
- Its overall incidence is comparable to that of bacterial meningitis. Although this disease is uncommon, it will be encountered on a regular basis.(29752489)
- Thrombophilia (suggested by prior venous thromboembolic disease)
- Inherited thrombophilias
- Oral contraceptive use (Increases risk six-fold, or 30-fold when combined with obesity)(29923367)
- Pregnancy (especially in the first months following delivery)
- Antiphospholipid syndrome
- Sickle cell disease
- Autoimmune disorders (e.g., lupus, vasculitis, inflammatory bowel disease)
- Nephrotic syndrome
- Severe dehydration
- Malignancy (especially chemotherapy with L-asparaginase, intrathecal methotrexate)
- Head and neck infections
- Mastoiditis, sinusitis, otitis media
- Meningitis, cerebral abscess
- Mechanical causes
- Head trauma*, neurosurgical procedures
- [* for example basilar skull fractures or other skull fractures]
- Jugular vein catheterization
signs and symptoms
diagnosis is difficult
- The manifestations are variable and nonspecific. This reflects the varying location of thrombosis and its evolution over time (e.g., clots may extend or recanalize).
- There is a median of one week’s delay between initial presentation and diagnosis. Evolution may occur acutely, subacutely (over several days), or chronically (over more than a month).
- Different patients can present with a variety of chief complaints, including:
- Focal neurologic findings
- Headache due to elevated intracranial pressure (90%)(31440838)
- This is often the first symptom. If untreated, the thrombus may extend and patients will accrue additional symptoms.
- Pain may be exacerbated by lying down or by performing the Valsava maneuver.
- Pain may start gradually or abruptly (causing a “thunderclap” headache).
- There may be associated features of intracranial pressure elevation:
- Vision changes, diplopia
- Nausea, vomiting
- Papilledema (30%)
- Cranial nerve 6 palsy (inability to abduct the eye)
- Focal neurological deficits
- Paresis (37% of patients)
- Dysarthria, aphasia
- Thrombosis of the cavernous sinus may cause dysfunction of CN3, CN4, or CN6 (leading to ocular motor palsies).
- Seizures (10-40%)
- May be focal, generalized, or focal with secondary generalization.
- Mental status changes (22%)
- Occipital or neck pain may associate with sigmoid sinus involvement.
anatomic basis of symptomatology
- Thomboses in various vessels may cause specific clinical symptoms (table below).
- However, reality may be a bit more confusing than this, because patients can have multiple sites of thrombosis simultaneously.