Cerebral Venous Thrombosis

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Iris Jackson
7 years ago
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1 Cerebral Venous Thrombosis Proposed algorithm for management of CVT Clinical suspicion of CVT MRI T2 W + MRV CT/CTV if MRI not readily available CVT confirmed by imaging No evidence of CVT. Consider other differential diagnosis Arterial stroke, Meningitis, idiopathic intracranial hypertension, brain abscess, neoplasms Initiate anticoagulation (IV heparin or SC LMWH) if no major contraindication Neurological improvement or stable Neurological deterioration or coma despite medical management Continue oral anticoagulation for 3-12 months or lifelong according to underlying etiology 1. Transient reversible factor 2. Low risk thrombophilia 3. High risk/inherited thrombophilia 1 Severe mass effect or ICH on repeat imaging May consider decompression procedures No or mild mass effect on repeated imaging May consider endovascular therapy (with or without mechanical disruption

2 All patients should receive support for the prevention of complication and symptomatic therapy e.g. management of seizures and intracranial hypertension Intracranial Hemorrhage In patients with lobar ICH of otherwise unclear origin or with cerebral infarction that crosses typical arterial boundaries, imaging of the cerebral venous system should be performed. Isolated Headache/Idiopathic Intracranial Hypertension In patients with the clinical features of idiopathic intracranial hypertension, imaging of the cerebral venous system is recommended to exclude CVT In patients with headache associated with atypical features, imaging of the cerebral venous system is reasonable to exclude CVT Imaging in the Diagnosis of CVT A venographic study (either CTV or MRV) in suspected CVT if the plain CT or MRI is negative or to define the extent of CVT if the plain CT or MRI suggests CVT An early follow-up CTV or MRV in CVT patients with persistent or evolving symptoms despite medical treatment or with symptoms suggestive of propagation of thrombus Catheter cerebral angiography can be useful in patients with inconclusive CTV or MRV in whom a clinical suspicion for CVT remains high Management and Treatment Appropriate antibiotics and surgical drainage of purulent collections of infectious sources associated with CVT when appropriate In increased intracranial pressure, monitoring for progressive visual loss, 2

3 urgent treatment for increased intracranial pressure Seizure with parenchymal lesions, early initiation of antiepileptic drugs Single seizure without parenchymal lesions, early initiation of antiepileptic drugs may be given to prevent further seizures Initial anticoagulation as soon as clinico-radiological diagnosis has been made, adjusted-dose UFH or weight-based LMWH in full anticoagulant doses followed by vitamin K antagonists, regardless of the presence of ICH Increased intracranial pressure- initiate treatment with acetazolamide Endovascular intervention with fibrinolytic agents may be considered if deterioration occurs despite intensive anticoagulation treatment In patients with neurological deterioration due to severe mass effectdecompressive hemicraniectomy CVT during Pregnancy LMWH in full anticoagulant doses should be continued throughout pregnancy, and LMWH or vitamin K antagonist with a target INR of 2.0 to 3.0 should be continued for at least 6 weeks postpartum (for a total minimum duration of therapy of 6 months) Reasonable to treat acute CVT during pregnancy with full-dose LMWH rather than UFH 3

4 Supplement: Comparison of Advantages and Disadvantages of CT and MRI in the Diagnosis of CVT Advantages CT+ CTV Good visualization of major venous sinuses MRI + MRV Visualization of the superficial and deep venous systems Quick (5 10 min) Readily available Fewer motion artifacts Can be used in patients with a pacemaker, defibrillator, or claustrophobia Good definition of brain parenchyma Early detection of ischemic changes No radiation exposure Detection of cortical and deep venous thrombosis Disadvantages Exposure to ionizing radiation Risk of contrast reactions Risk of iodinated contrast nephropathy (eg, in patients with diabetes, renal failure) Low resolution for small parenchymal abnormalities Poor detection of cortical and deep venous thrombosis Detection of macrobleeding and microbleeding Time consuming Motion artifacts Availability Limited use in patients with cardiac pacemaker or claustrophobia Confers a low risk of gadolinium-induced nephrogenic systemic fibrosis Slow flow states, complex flow patterns, and normal anatomic Variations in dural sinus flow can affect the interpretation 4

5 Sensitivity/ specificity Small studies comparing multiplanar CT/CTV vs DSA showed 95% sensitivity and 91% specificity* (*Wetzel et al) Overall accuracy 90% to 100%, depending on vein or sinus The sensitivity and specificity of MRI/MRV are not known owing to the lack of large MRI/MRV head-to-head studies with DSA. Echoplanar T2 susceptibilityweighted imaging combined with MRV are considered the most sensitive sequences Practical application Acute onset of symptoms Emergency setting Multidetector CTV can be used as the initial test when MRI is not readily available Acute or subacute onset of symptoms Emergency or ambulatory setting Patients with suspected CVT and normal CT/CTV suspected deep CVT, because complex basal dural sinuses and their emissary channels more commonly seen 5

Hemorrhagic venous infarction Heather Borders, MD

Hemorrhagic venous infarction Heather Borders, MD 12/13/2010 History 16 year old female with four day history of headache and acute change in mental status. History of two days of oral contraceptive use