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Cerebral Venous Sinus Thrombosis Yadollahikhales G GMJ.2016;5(Supp.1):48-61 Cerebral Venous Sinus Thrombosis Yadollahikhales G GMJ.2016;5(Supp.1):48-61 www.gmj.ir Cerebral Venous Sinus Thrombosis Golnaz Yadollahikhales1, Afshin Borhani-Haghighi1, 2, Anahid Safari1 , Mohammad Wasay3,Randall Edgell4 1Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. 2Department of Neurology, Shiraz University of Medical sciences, Shiraz, Iran. 3Division of Neurology, Department of Medicine, The Aga Khan University, Karachi, Pakistan. 4Departments of Neurology and Psychiatry, Saint Louis University, Saint Louis, USA. Abstract Cerebral venous thrombosis (CVT) is occlusion of dural sinuses and/or cortical veins due to clot formation. It is a potentially life-threatening condition that requires rapid diagnosis and urgent treatment. Cerebral venous thrombosis is more common in females and young peo- ple. Pregnancy, postpartum state, contraceptive pills, infection, malignancy, hyper-coagulable state, rheumatological disorders, trauma are among the major etiologies of cerebral venous thrombosis. Headache, focal neurologic deficits and seizure were the most common clinical presentations. Different techniques of unenhanced and contrast enhanced brain computerized tomography (CT scan) and, magnetic resonance imaging (MRI) are the most helpful ancillary investigations for diagnosis of Cerebral venous thrombosis. Specific treatment of the underly- ing cause of cerebral venous thrombosis should be considered as the mainstay of the treatment. Anticoagulation with heparin or low molecular weight heparinoids is the most accepted treat- ment. In acute phase, medical or surgical management to decrease intracranial pressure (ICP) is also recommended. If the patient’s clinical condition aggravates despite adequate anticoag- ulation, thrombolysis or mechanical thrombectomy can be an additive option. [GMJ.2016;5(- Supp.1):48-61] Keywords: Cerebral venous thrombosis; Stroke; Hypercoagulable disorders; Virchow’s triad Introduction hospitalized patients was reported by Daif in Saudi Arabia [3]. Number of Indian studies erebral venous thrombosis (CVT) is a have reported a very high frequency of CVT Cform of cerebrovascular disease primari- among young stroke patients ranging from ly affecting cerebral venous sinuses. Although 10-20% [4]. Pungayara et al [5] reported that considered to be more common in Asia and CVT accounts for half of all young strokes central/ south America most of the published and 40% of strokes in women. data is reported from Europe or North Amer- A study of young women from Asian coun- ica. It affects about 5 people per million tries reported a frequency of 20% CVT cases and accounts of 0.5% of all strokes [1]. The among all stroke [6]. The age of the patients largest reported series of CVT patients were of a cumulative data of published Iranian published by ISCVT (International study on studies were between 29.5-43.8 [7]. CVT) investigators; reporting 630 patients CVT in children and neonates is increasingly predominantly from European countries [2]. recognized. A Canadian study reported annu- A frequency of 7 CVT patients per 100,000 al incidence of 6.7 cases per million popula- Correspondence to: GMJ Afshin Borhani-Haghighi, Neurology department, ©2015 Galen Medical Journal Namazi hospital, Zand St. 71937-11351, Shiraz, Fars, Fax: +98 731 2227091 Iran PO Box 7461686688 Telephone Number: +98-718-8768543 Email:[email protected] E-mail: [email protected] Cerebral Venous Sinus Thrombosis Yadollahikhales G tion [8]. It is more common in women which cipital, transverse and sigmoid sinuses. is probably related to women specific risk Cavernous sinus drains blood from sphe- factors for CVT especially pregnancy, puer- noparietal sinus, and superior and inferior perium and use of oral contraceptives. In the ophthalmic veins. Two cavernous sinuses con- last three decades advances in neuroimaging nect via a circular (intercavernous) sinus in a and neurointerventions have completely rev- butterfly appearance. Cavernous sinus com- olutionized the diagnosis and management of municates with the transverse sinus and in- CVT. More cases are being diagnosed with up ternal jugular vein via superior petrosal sinus to 85% patients in whom risk factors could be and inferior petrosal sinus, respectively. Oc- identified. Outcome is favorable with mortal- culomotor(III), trochlear(IV), abducent(VI) , ity less than 8-10%. ophthalmic(V1) and maxillary branches(V2) of trigeminal nerves and the syphon of the This chapter intends to cover anatomy of cere- internal carotid artery are located within the bral venous system, etiologies, pathophysiol- cavernous sinus. ogy, clinical and radiological manifestations, Superior sagittal sinus travels from anterior to medical and interventional management and posterior in a groove between falx cerebri and prognosis of CVT. dura of inner table and terminates to torchular herophili (confluence of sinuses).Occipital si- Anatomy nus, located in the margin of falx cerebelli, run Venous drainage of skull and brain is done into confluence as well. It is absent in about of by a network of extracranial veins, diploic one third of persons. Inferior sagittal sinus and veins, dural venous sinuses, and superficial vein of Galen unite to form the straight sinus, and deep cerebral veins. External jugular vein which runs posteriorly to the confluence of si- drains retromandibular venous plexus, poste- nuses. The venous blood drained from superi- rior auricular, transverse cervical, suprascap- or sagittal, occipital and straight sinuses goes ular and anterior jugular veins and ends in the into internal jugular vein through transverse subclavian vein. Internal jugular vein orig- and sigmoid sinuses. Each Transverse sinus inates from jugular bulb and takes branches begins from internal occipital protuberance from common facial, lingual, pharyngeal, su- and run to petrous bone. It receives superior perior thyroidal and middle thyroidal veins. petrosal sinus and then forms sigmoid sinus. Occipital emissary vein, suboccipital venous Transverse sinuses are asymmetric in most of plexus, and deep cervical veins go to the ver- the individuals and one of them can be aplas- tebral vein, which ends in the suclavian vein. tic or hypolplatic. The right one is the larger in Internal jugular vein unites with the subcla- the majority of the individuals. Sigmoid sinus vian vein to form the brachiocephalic vein. is a S-shaped structure turn into jugular bulb. Inferior thyroidal vein directly pours to bra- Cerebral veins can be categorized to superfi- chiocephalic vein. Diploic veins are valveless cial, deep and posterior fossa veins. Super- veins course through the calvarium and con- ficial cerebral vein courses along sulci and nect with meningeal veins and dural sinuses to drain cortical gray matter and subcortical pericranial veins. Diploic veins are not usual- white matter. Of the numerous superficial ly seen in conventional angiography. cerebral veins, vein of Labbe and vein of Tro- Cerebral venous sinuses are pockets of blood lard worth mentioning. Superior anastomotic between two layers of dura. They drain the ve- vein of Trolard travels posterosuperiorly and nous blood from superficial and deep cerebral connects superior middle cerebral vein into veins and communicate with extracranial ve- the superior sagittal sinus. Inferior anastomot- nous system through diploic veins. For better ic vein of Labbe courses along the occipito- understanding, it is better to divide the cere- temporal sulcus and connects superior middle bral dural sinuses to anterior and posterior cerebral vein and the transverse sinus. systems. The main sinus of the anterior system Deep cerebral veins drain venous blood from is cavernous sinus. Posterior system includes deep white matter and basal ganglia through superior sagittal, inferior sagittal, straight, oc- subependymal veins and from superficial GMJ.2016;5(Supp.1):48-61 49 www.gmj.ir Yadollahikhales G Cerebral Venous Sinus Thrombosis Cerebral Venous Sinus Thrombosis Yadollahikhales G white matter through medullary veins. An- Etiologies terior caudate vein and terminal vein form the thalamostriate vein. Thalamostriate vein More than one hundred risk factors have been unites to septal vein to form the internal cere- reported in published literature. About 50% bral vein. Internal cerebral vein and basal vein patients have multiple risk factors. A rational of Rosental form the short U-shaped greater approach to identify risk factors is warranted vein of Galen. after confirmation of diagnosis. A comprehen- Posterior fossa veins include superior (Galen- sive list of established risk factors is provided ic), anterior (petrosal) and posterior (tentorial) in table 1. groups of veins with numerous small veins [9- 11]. Table 1. Risk Factors for CVT Pregnancy Medications Related Puerperium Oral contraceptive pills Androgens Infection Related Anti estrogen therapy Direct septic trauma Anti-neoplastic agents: Cisplatin, L asparaginase Cerebral abscesss Sildenafil Subdural empyema Carbamazepine Meningitis Tuberculous meningitis Malignancy Otitis media Squamous cell metablastic cervical cancer Orbital cellulitis Non hodgkins lymphoma Tonsillitis Bilateral glomus tumors Dental infections Colorectal cancer Stomatitis Epidermoid carcinoma of tongue Cellulitis Dysgerminoma Septicemia Ewing’s sarcoma TB Allogenic transplant for acute lymphoblastic leuke- Endocarditis mia Measles Paraneoplastic syndrome Hepatitis Meningioma Herpes simplex Varicella Zoster Rheumatologic Diseases Cytomegalovirus
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