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Ophthalmology April 2015 the TAMIL NADU DR. MGR MEDICAL NEURO-OPHTHALMIC MANIFESTATIONS OF CEREBRAL VENOUS THROMBOSIS A CLINICAL PROFILE Dissertation submitted for M.S Degree (Branch III) Ophthalmology April 2015 THE TAMIL NADU DR. M.G.R MEDICAL UNIVERSITY CHENNAI CERTIFICATE This is to certify that this dissertation entitled “NEURO-OPHTHALMIC MANIFESTATIONS OF CEREBRAL VENOUS THROMBOSIS-A CLINICAL PROFILE” is a bonafide work done by Dr. M.LAVANYA under our guidance and supervision in the Neuro-ophthalmology Department of Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai during the period of her post graduate training in Ophthalmology for May 2012-April 2015. DR.S.MAHESH KUMAR DR. S. ARAVIND Guide Head of the Department, Consultant, Aravind Eye Hospital, Neuro-ophthalmology Madurai. Aravind Eye Hospital, Madurai. Dr. M.SRINIVASAN Director, Aravind Eye Hospital, Madurai. DECLARATION I, Dr.M.Lavanya, hereby declare that this dissertation entitled, NEURO-OPHTHALMOLOGICAL MANIFESTATIONS OF CEREBRAL VENOUS THROMBOSIS. Is being submitted in partial fulfilment for the award of M.S.in Ophthalmology Degree by the Tamil Nadu DR.MGR Medical University in the examination to be held in April 2015. I declare that this dissertation is my original work and has not formed the basis for the award of any other degree or diploma awarded to me previously. Dr.M.Lavanya Aravind Eye Hospital, Madurai. ACKNOWLEDGEMENT First and foremost I am thankful to Almighty for always being with me and guiding me throughout my life. I would like to express my heartfelt gratitude to my beloved parents for the dreams they have dreamt me and the hardships they have been through to make me stand where I am today. I also thank my friends who had been supporting me throughout my tougher times. I take this opportunity to pay respect and homage to Dr.G.Venkatasamy, our founder. I am privileged to have on my side Dr.P.Namperumalsamy, Chairman emeritus and Director of Research, Dr.G.Natchiar, Director emeritus and chief of Department of Neuro ophthalmology, Dr.M.Srinivasan, Director emeritus and other scholars at Aravind Eye Care System who had been a great source of inspiration to us. I am very grateful to Dr. R.D .Ravindran, Chairman of Aravind Eye Care System for having created an environment enriched with all the facilities for learning and gaining knowledge. Word cannot express my deep sense of gratitude and heartfelt thanks to my mentor and guide Dr.S.Mahesh Kumar, Professor Department of Neuro ophthalmology who with his able guidance , optimistic attitude and constant encouragement gave me all the confidence and determination to complete my dissertation. My sincers thanks to Dr.N.Venkatesh Prajna, Director of Academics, who offered his guidance and support throughout my residency period. I take the privilege to express my gratitude and humble regards to Dr.Kowsalya, consulatant in Neuro ophthalmology for her valuable guidance, timely suggestions during my study. My sincere thanks to Mrs.Kumaragurupari, Senior Librarian for her immediate responses in providing all the articles and the academic support required in the completion of this thesis. I would like to thank the paramedical staffs of Neuro ophthalmology department for their support. I would thank the countless patients who have been the learning ground for my study and my residency. CONTENTS PART-I S.NO TITLE PAGE NO 1 Introduction 1 2 Cerebral Venous System Anatomy 3 Etiology of Thrombosis 3 29 4 Pathogenesis of Venous Thrombosis 33 5 Investigations 40 6 Management 50 7 Review of Literature 70 PART-II S.NO TITLE PAGE NO 8 Aims & Objective 74 9 Materials & Methods 75 10 Analysis & Results 80 11 Discussion 96 12 Conclusions 101 13 Limitations 103 Bibliography Proforma Master Chart INTRODUCTION Cerebral venous sinus thrombosis mostly affects children and young adults. Cerebral venous thrombosis is a chronic pathologic state that involves cortical veins, deep cerebral veins and dural sinuses. Since cerebral venous thrombosis is rare determining its prevalence and incidence is difficult.Incidence of cerebral venous thrombosis in children is 0.67 percent. cerebral venous thrombosis is a common sequalae of infection, coagulopathies ,trauma and dehydration in pediatric age group. Nonfocal neurologic signs and symptoms are presenting features in neonates. Deep venous system thrombosis is rare in adults and is associated with poor prognosis. In deep vein thrombosis thalami are bilaterally involved showing edema, infarction and hemorrhage right more than the left. The other differential diagnosis of bilateral thalamic infarction are glioma, metastasis, top of the basilar syndrome and encephalitis. Cerebral venous thrombosis are serious and life threatening because of its raised intracranial tension and thrombosis of venous system. Cerebral venous thrombosis is one of the major reasons for seeking neurological consultations worldwide. The clinical features and management option depends upon the site, extent of obstruction, rate of occlusion, etiology and health of patient. Neuro – ophthalmic signs and symptoms of cerebral venous thrombosis are headache, vomiting, giddiness, double vision, papilloedema , optic atrophy etc. Visual signs and symptoms form major presentation in cerebral venous thrombosis and may be of great help in early diagnosis when initial signs are unspecific. [1] CEREBRAL VENOUS SYSTEM ANATOMY Cerebral Venous sinuses. Large low pressure veins within the folds of dura between fibrous dura and endosteum except for the inferior sagittal and the straight sinus which lies between two layers of fibrous dura”Cerebral venous system consists of superficial and deep veins all of which drains into the major dural venous sinuses and inturn into the internal jugular veins.The superficial veins drain the outer 2cm of cerebral cortex,the deep veins drain blood from deep white matter, basal ganglia and diencephalon. The superficial veins are thin walled, lacking a muscular wall and valves, lack well defined vascular territories and are not readily visualised with neuroimaging. By contrast the deep cerebral veins are larger, constant and identifiable on imaging.[1] Classification Superficial Deep sup.sagital sinus lateral sinus sup.cortical veins straight sinus sigmoid sinus deep cortical veins DURAL VENOUS SINUSES S.No Unpaired Paired 1. Superior Sagittal Transverse 2. Inferior Sagittal Sigmoid 3. Straight Cavernous 4. Occipital Superior Petrosal 5. Anterior Intercavernous Inferior Petrosal 6. Posterior Intercavernous Sphenoparietal 7. Basilar venous plexus Petrosquamous 8. Middle meningeal CIRCULATION OF CEREBROSPINAL FLUID BLOOD FLOW IN DURAL VENOUS SINUS Superior sagittal sinus Formed by the reflection of the inner layer of duramater to form the falx cerebri. Runs backwards infront of crista galli and forms a grove in frontal bone, parietal bone and occipital bone. Superior sagittal sinus ends at the internal occipital protuberance and continues with right transverse sinus. Inferior sagittal sinus Located within the falx cerebri at lower margin.It begins anteriorly and ends posteriorly by joining the straight sinus. Straight sinus Lies in the triangular interval of falx cerebri joins the tentorium cerebella. Anteriorly it receives the inferior sagittal sinus and great cerebral vein. Posteriorly the straight sinus ends by continuous with the transverse sinus of the opposite side. Sinuses that meet at the internal occipital protuberance are superior sagittal sinus, straight sinus, right and left transverse sinuses-‘Confluence of sinuses’. Transverse sinus It lies at the internal occipital protuberance, right transverse sinus is usually the continuation of superior sagittal sinus and the left transvers sinus is the continuation of the straight sinus. Sigmoid sinus The right and left sigmoid sinuses are continuations of the corresponding transverse sinuses, sigmoid sinus is S shaped.It runs downwards and medially finally forwards to reach the jugular foramen where it ends with internal jugular vein. The upper part of the sinus is related to mastoid antrum which is separated by a thin plate of bone so infaction can easily spread from mastoid antrum into the sigmoid sinus.[2] Superficial Venous System Dural venous sinuses have duramater in wall and are located on the surface of the cerebrum. Superior sagittal sinus flows inferiorly to the trocula and posteriorly in sagittal plane forming the confluence of sinuses the site were superficial drainage joins the deep venous system. Transervse sinuses bifurcate and travel laterally and inferiorly to form sigmoid sinuses which join to form jugular veins. [3] Arachnoid granulations of Pacchioni are most commonly found in superior sagittal sinus and play a major role in resorption of cerebrospinal fluid. These granulations are isoattenuating or hypoattenuating relative to brain parenchyma. Deep Venous System Drains the veins in the deep structures of the brain joining behind the midbrain to form the vein of Galen. It fuses with the inferior sagittal sinus and forms the straight sinus. At the confluence of sinuses it then joins superficial venous system. Draining Sites: 1. Superior Sagittal sinus becomes right transverse sinus or confluenc of sinus 2. Inferior Sagittal sinus drains into Straight sinus 3. Straight sinus typically becomes left transverse sinus or confluence of sinus 4. Occipital sinus drains to confluence of sinus 5. Confluence of sinus drains right and left transverse sinus 6. Sphenoparietal sinus drains into cavernous sinus 7. Cavernous sinus draina into superior and inferior petrosal
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