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ALL / Neurology

Cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis

Overview
  • can cause cerebral infarction, much lesson common than arterial causes
  • 50% of patients have isolated sagittal sinus thromboses - the remainder have coexistent lateral sinus thromboses and cavernous sinus thromboses

Risk factors
  • prothrombotic states
    • inherited thrombophilias
    • acquired thrombophilias
  • hormonal factors
    • pregnancy and postpartum period
    • oestrogen-containing drugs (e.g. combined oral contraceptive, HRT)
  • systemic and inflammatory diseases
  • local infections
    • otitis media or mastoiditis → lateral sinus thrombosis
    • sinusitis or facial infections → cavernous sinus thrombosis
    • meningitis or brain abscess
  • other medical conditions
    • severe dehydration (especially in infants or postpartum women)
    • head trauma or neurosurgery

General features

Common features
  • headache (may be sudden onset)
  • nausea & vomiting
  • reduced consciousness

Investigation
  • MRI venography is the gold standard
    • CT venography is an alternative
  • non-contrast CT head is normal in around 70% of patients
  • D-dimer levels may be elevated

Management
  • anticoagulation
    • typically with low molecular weight heparin acutely
    • warfarin is still generally used for longer term anticoagulation

Specific syndromes

Sagittal sinus thrombosis
  • may present with seizures and hemiplegia
  • parasagittal biparietal or bifrontal haemorrhagic infarctions are sometimes seen
  • 'empty delta sign' seen on venography

Cavernous sinus thrombosis
  • other causes of cavernous sinus syndrome: local infection (e.g. sinusitis), neoplasia, trauma
  • periorbital erythema and oedema
  • ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th
  • trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain
  • central retinal vein thrombosis

Lateral sinus thrombosis
  • 6th and 7th cranial nerve palsies

CT with contrast demonstrating a superior sagittal sinus thrombosis showing the typical empty delta sign. Look at the 'bottom' of the scan for the triangular shaped dural sinus. This should normally be white due to it being filled with contrast. The empty delta sign occurs when the thrombus fails to enhance within the dural sinus and is outlined by enhanced collateral channels in the falx. This sign is seen in only about 25%-30% of cases but is highly diagnostic for sagittal sinus thrombosis
+PassMedicine Notes
Overview
  • can cause cerebral infarction, much lesson common than arterial causes
  • 50% of patients have isolated sagittal sinus thromboses - the remainder have coexistent lateral sinus thromboses and cavernous sinus thromboses
Risk factors
  • prothrombotic states
    • inherited thrombophilias
    • acquired thrombophilias
  • hormonal factors
    • pregnancy and postpartum period
    • oestrogen-containing drugs (e.g. combined oral contraceptive, HRT)
  • systemic and inflammatory diseases
  • local infections
    • otitis media or mastoiditis → lateral sinus thrombosis
    • sinusitis or facial infections → cavernous sinus thrombosis
    • meningitis or brain abscess
  • other medical conditions
    • severe dehydration (especially in infants or postpartum women)
    • head trauma or neurosurgery

General features

Common features
  • headache (may be sudden onset)
  • nausea & vomiting
  • reduced consciousness
Investigation
  • MRI venography is the gold standard
    • CT venography is an alternative
  • non-contrast CT head is normal in around 70% of patients
  • D-dimer levels may be elevated
Management
  • anticoagulation
    • typically with low molecular weight heparin acutely
    • warfarin is still generally used for longer term anticoagulation

Specific syndromes

Sagittal sinus thrombosis
  • may present with seizures and hemiplegia
  • parasagittal biparietal or bifrontal haemorrhagic infarctions are sometimes seen
  • 'empty delta sign' seen on venography
Cavernous sinus thrombosis
  • other causes of cavernous sinus syndrome: local infection (e.g. sinusitis), neoplasia, trauma
  • periorbital erythema and oedema
  • ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th
  • trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain
  • central retinal vein thrombosis
Lateral sinus thrombosis
  • 6th and 7th cranial nerve palsies
xrb178.jpg CT with contrast demonstrating a superior sagittal sinus thrombosis showing the typical empty delta sign. Look at the 'bottom' of the scan for the triangular shaped dural sinus. This should normally be white due to it being filled with contrast. The empty delta sign occurs when the thrombus fails to enhance within the dural sinus and is outlined by enhanced collateral channels in the falx. This sign is seen in only about 25%-30% of cases but is highly diagnostic for sagittal sinus thrombosis

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