Ver el código de «Cerebral venous thrombosis»

''The cavernous sinus is one of the several cerebral veins and [[cavernous sinus thrombosis]] is a specific type of cerebral venous (sinus) thrombosis.  See that article for a discussion of that specific clinical entity.''
==Background==
[[File:Cerebral veins.jpg|thumbnail|Cerebral Veins]]
*Occlusion of venous sinus (most commonly superior sagittal and lateral sinuses) by thrombus<ref>Piazza G. Cerebral venous thrombosis. Circulation 2012;125:1704-1709.</ref>
*No precise prevalence or incidence established due to rarity of condition. However the disease is more prevalent in patients with thrombophilia, oral contraceptive use, and during pregnancy.<ref name="lancet">Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007; 6:162-70.</ref>
*Median Age ~ 37 years<ref name="lancet"></ref>
*Female:Male ratio 3:1<ref name="lancet"></ref>

===Predisposing factors===
*Mainly a diverse group of hypercoagulable states
**Cancer
***Leukemia 
***Adenocarcinoma
**[[Pregnancy]] (up to 6 weeks post-partum)
**Polycythemia Vera
**Sickle cell
**Factor V Lediden 
**Protein S & C deficiency
**Hyperhomocysteinemia
**Behcets syndrome
*Severe dehydration in infants and children, mainly in developing countries. 
*COVID-19 vaccines (rare)<ref>Ropper, A. H., & Klein, J. P. (2021). Cerebral Venous Thrombosis. New England Journal of Medicine, 385(1), 59–64. https://doi.org/10.1056/nejmra2106545</ref>
**1 per 1,000,000 for the Ad26.COV2.S (Johnson & Johnson And Janssen brands)
**1 per 100,000 for the ChAdOx1 nCoV-19 (AstraZeneca brand)
*Local infections ([[otitis media]], [[sinusitis]], [[cellulitis]], [[dental problems|dental infections]])
**Mastoiditis common cause in developing countries.
*Direct cranial [[Trauma]] & neurosurgical procedures
*Compression of venous sinus ([[brain tumor|tumor]], [[brain abscess|abscess]])

==Clinical Features==
Clinical presentation varies depending on location, acuity, and severity of thrombosis. More gradual onset of symptoms or thrombosis allows for compensatory collateral venous system to develop 
===Common Symptoms===
''Symptoms are variable and may not all be present<ref name="NEJM>Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791–8.</ref>
*[[Headache]] 74-92%
**Usually progresses during a period of hours or days to severe aching or throbbing over the entire cranium, bifrontally, or at the vertex. 
***Pain at the vertex of the cranium is infrequent but more specific.<ref>Ropper, A. H., & Klein, J. P. (2021). Cerebral Venous Thrombosis. New England Journal of Medicine, 385(1), 59–64. https://doi.org/10.1056/nejmra2106545</ref>
**Coughing, bending over, or head movements tend to worsen headaches.
*[[Seizures]] 35-50%
**Usually focal convulsions
*[[Papilledema]] 28-45%
*Focal neurologic sequelae 
**Occurs hours to days after headache in about half of patients
**[[dizziness]]) 25-71%
*[[Encephalopathy]]
[[File:sinus thrombosis.jpg|thumbnail]]

===[[focal neuro deficits|Neurodeficits]]===
Although presentation can be highly variable, neuro deficits can be correlated with the location of the occlusion<ref name=NEJM></ref>
*'''Superior Sagital sinus''' 
**[[weakness|motor deficits]]
***Paresis of one or both legs or hemiparesis from infarction in the frontoparietal regions surrounding the vein of Trolard<ref>Ropper, A. H., & Klein, J. P. (2021). Cerebral Venous Thrombosis. New England Journal of Medicine, 385(1), 59–64. https://doi.org/10.1056/nejmra2106545</ref>
**Seizures
*'''Left transverse sinus''' 
**Aphasia and confusion from infarction in the temporal lobe surrounding the vein of Labbe<ref>Ropper, A. H., & Klein, J. P. (2021). Cerebral Venous Thrombosis. New England Journal of Medicine, 385(1), 59–64. https://doi.org/10.1056/nejmra2106545</ref>
*'''[[cavernous sinus thrombosis|Cavernous sinus]]''' 
**[[eye pain|ocular pain]], [[proptosis]], oculomotor palsies'''
***CN palsy of 3,4, and 6 as well as the ophthalmic and maxillary divisions of the 5th cranial nerve. 
*'''Deep venous sinus''' 
**Drowsiness or stupor from bilateral thalamic dysfunction and obstructive hydrocephalus.

==Differential Diagnosis==
{{Headache DDX}}

==Evaluation==
[[File:Sagital sinus thrombus.JPG|thumbnail|Sagital sinus thrombosis on CT]]
''Suspect in patients with headache, signs of increased ICP, or focal neurologic deficits, especially if any of above predisposing factors are present''
===Imaging===
*[[Brain MRI|MRI]] and MRV are considered diagnostic study of choice<ref name="rads">Khandelwal N et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol 2006;187:1637–1643.</ref>
*CT venography is a reasonable alternative if there is a contraindication to MRV and may have a similar sensitivity to MRV in recent studies<ref name="rads"></ref><ref>Rodallec MH, Krainik A, Feydy A et-al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics. 2006;26 Suppl 1 (suppl_1): S5-18.</ref>
**May see "Empty delta sign" dense triangle in superior sagittal sinus<ref>Lee Emil J. Y. “The Empty Delta Sign.” Radiology. 224(3). 2002. 788-789.</ref>
**Cord sign: thrombus in the cerebral sinus may appear as a hyperattenuated foci. It is homogenous in nature and appears linear or round based on the affected sinus. This is most commonly seen in the first week. <ref>Ram K. P. Vijay. "The Cord Sign."Radiology. 2006; 240:299-300.</ref>
**Vein Sign: After two weeks, the thrombus becomes hypoattenuated. When the thrombus is located in the deep vein it is referred to as the vein sign. <ref>Linn J, Pfefferkorn T. "Noncontrast CT in Deep Cerebral Venous Thrombosis and Sinus Thrombosis: Comparison of Its Diagnostic Value for Both Entities."AJNR Am J Neuroradiology. 2010; 30: 728-735. </ref>
*Non contrast [[head CT|CT]] possesses insufficient sensitivity or specificity to be of diagnostic value in the setting of high clinical suspicion
**May see "dense delta sign" (hyperattenuation consistent with thrombus in the posterior sagittal sinus)

===Labs===
*[[D-Dimer]] is not a reliable test to rule out a cerebral venous thrombosis<ref>Crassard I, Soria C, Tzourio C, Woimant F, Drouet L, Ducros A, Bousser MG. A negative D-dimer assay does not rule out cerebral venous thrombosis: a series of seventy-three patients. Stroke 2005;36:1716 –1719.</ref><ref>Kristoffersen ES, Harper CE, Vetvik KG, Faiz KW. Cerebral venous thrombosis – epidemiology, diagnosis and treatment. Cerebral venetrombose – forekomst, diagnostikk og behandling. Tidsskr Nor Laegeforen. 2018;138(12):10.4045/tidsskr.17.1047. Published 2018 Aug 20. doi:10.4045/tidsskr.17.1047</ref>
*In patients with a concern for [[meningitis]] then pursue diagnosis via standard workup which includes a [[CT before lumbar puncture]]

==Management==
===Anticoagulation===
*[[Heparin]] or [[low molecular weight heparin]] (Grade 1C)
**Of note, heparin initial bolus is 3000-5000U, lower than the dosing for PE/DVT
*Following the acute phase, patients should transition to oral anticoagulation for a 3-6 month duration
**[[Warfarin]] is recommended as oral anticoagulation of choice
**There is a controversy regarding the use of direct oral anticoagulants. However, findings from the RE-SPECT CVT trial which was published recently and compared warfarin to dabigatran, suggest that both agents have similar effectiveness and safety for preventing recurrent CVT. 
 
===[[Seizure]] prophylaxis===
*Recommended for patients with seizure at presentation PLUS focal cerebral lesion (edema, infarction or hemorrhage on CT/MRI) (Grade 1B)
*Only required if the patient has a [[seizure]]<ref>Ferro JM et al. Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics. Stroke 2008;39:1152–1158.</ref>
*Prophylaxis with antiepileptic is NOT required if the patient has a single seizure with no signs of supratentorial cerebral lesion.

===Supportive care===
*Frequent neurologic checks and clinical monitoring for [[increased ICP]]
*Neurology or neurosurgical consultation depending on institutional resources

===Acute Decompensation===
*If persistent or severe [[elevated intracranial pressure]] a hemicraniectomy may be necessary
*Intravascular [[thrombolytics]] (either catheter guided or systemic) in coordination with neurology may be required if the patient experiences rapidly progressing decompensation<ref>38.Dentali F et al. Safety of thrombolysis in cerebral venous thrombosis: a systematic review of the literature. Thromb Haemost 2010;104:1055–1062.</ref>

==Disposition==
*Admission
**To a level of care capable of frequent neurologic monitoring.  Inpatient, the patient should also have a evaluation for a coagulopathy.

==See Also==
*[[Headache]]
*[[Head CT]]
*[[Cavernous sinus thrombosis]]

==References==
<references/>
[[Category:Neurology]]