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Cerebral Venous Sinus Thrombosis

Dr Rajiv Jha, MSSenior Resident M Ch Neurosurgery

National Neurosurgical Referral CenterNational Academy Of Medical Sciences

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Introduction

A rare condition,3-4 cases / million./year The first description -French physician Ribes in

1825. Until the second half of the 20th century remained a

diagnosis generally made after death. In the 1940s-Dr Charles Symonds et all.

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Introduction

< 2% of all strokes Predominantly affects young adults and children Male: Uniform age distribution 75% of adult patients are women (ISCVT study) Accounts for up to 50% of strokes during pregnancy and

puerperium Most sensitive examination: MRI + MR Venography Treatment usually with anticoagulation

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Objectives

To describe the features of a series of patientwith CVST treated at National NeurosurgicalReferral Center and to find the risk factors,

presentation, and outcome of the disease

process.

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Study design

Retrospective study September 2008 – September 2010 National Neurosurgical Referral Center,

National Academy of Medical Sciences, Bir Hospital

Group assignment – all ages / sex Outcome measured at 3 months

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Age

0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 >600

2

4

6

8

10

12

1 1

11

8

32 2

Age

Nu

mb

er o

f cas

es

7

Sex

61%

39%

Female

Male1711

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Clinical presentation

Dutch-European study

Our study

0 50 100

Headache

Vomiting

LOC

Seizure

FND

Fever

Neck pain

96

46

43

18

18

7

3.5

9

GCS < 7, 8

GCS 8 - 13, 6

GCS > 13, 14

Papilloedema, 5

Slurred speech,

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Hemianopia, 1

Hemiparesis, 4

Neck Rigidity, 4

Objective Findings

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Risk factors

Dehydration → 8 [29%] Estrogen containing

contraception → 9 [32%] Puerperium → 2 [7%] Sinusitis → 1 [3.6%] Mastoiditis→ 1 [3.6%] Pituitary adenoma → 1

[3.6%] Undiagnosed → 7 [25%]

ISCVT study: International Study on Cerebral Vein & Dural Sinus Thrombosis

43.6% of patients had multiple risk factors

Thrombophilia (acquired or inherited) 34.1 %

Oral contraceptives 54.3% IBD 1.2%-6.1%

Dutch study : (Lancet 352 (9124) p 326)OCP’s – 56%IBD - Rate of thromboembolism 1.2 - 6.1%, up to 39%

Our Study

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Diagnosis

CT Scan brain Non-contrast / Contrast MRI/MRV Angiography LP Blood work (protein C and S levels,

antiphospholipid antibodies, CBC, factor II level, serum homocystine level, PNH panel, leukocyte, alk.phosphotase, D-dimer)

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CT/MRI

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MRV

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MRI

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MRI

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MRI

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MRI

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Unusual association of a pituitary adenoma and a neurological emergency: case report and diagnostic step.

Internal and Emergency Medicine Volume 3, Number 3 / September, 2008

The action of PRL as a platelet aggregation co-activator is recognized; previous studies suggested that increased PRL concentrations could concur to the hypercoagulable state observed in pregnancy and the puerperium or other hyperprolactinemic conditions

Dural sinus thrombosis is a rare but dangerous complication of estroprogestin assumption; in this case the hyperprolactinemia associated to the pituitary macroadenoma might have concurred to the thrombophilic state

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Frequency of Thrombosis of the Major Cerebral Veins and Sinuses

Our SeriesNew England Journal of Medicine Volume 352:1791-1798 April 28, 2005 Number 17

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Treatment• General: supportive, symptomatic correct underlying abnormalities(antibiotic for infection) Avoid steroids Anticonvulsants to control seizure Hydrate aggressively

• Anticoagulation with IV Heparin – 15 cases loading dose of 50-100 units/kg of heparin constant infusion of 15-25 units/kg/hr – next 24 hrs Maintenance dose of 50-100 units/kg of heparin,

• LMWH(Fragmin) – 3 cases 5000 IU qd s/c for 5-10 days

• warfarin initiated on day 5 - minimum upto 6 months

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The Controversy of Anticoagulation

• No data comparing the effect of Unfractionated Heparin with Low molecular weight heparin

• Tendency for venous infarcts to become haemorrhagic• 40% of patients with sinus thrombosis – haemorrhagic infarct

prior to anticoagulation commencing• Weak Evidence for anticoagulation• BUT – anticoagulation is safe, even in the setting of ICH• 3 small randomised clinical trials (NEJM

2005;352:1791-8)/ ISCVT: • All showed non-significant benefit of anticoagulation as

compared with placebo• All included patients who had haemorrhagic infarcts prior to

treatment, no increased or new cerebral haemorrhages developed after treatment with heparin

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After 2 weeks After 6 weeks

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Thrombolysis

The 2006 European Federation of Neurological Societies guideline :

Thrombolysis is only used in patients who deteriorate despite adequate treatment, and other causes of deterioration have been eliminated.

It is unclear which drug and which mode of administration is the most effective.

Bleeding into the brain and in other sites of the body is a major concern in the use of thrombolysis.

American guidelines: Makes no recommendation with regards to thrombolysis, stating

that more research is needed.

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Surgery

When all measures fail… Decompressive craniectomy /decompressive

lobectomy Direct attack on clotted sinusDirect surgical treatment (thrombectomy and sinus

reconstruction) – rarely indicated, “rethrombosis “is common

Surgical technique for direct treatment of SSS thrombosis

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Outcome

Important prognostic factors for death or dependence

Coma (GCS < 9) Cerebral Haemorrhage Malignancy Male sex Age > 37 years Mental status disorder Thrombosis of deep cerebral

venous system – straight sinus CNS infection ISCVT- death/dependency 13.4%

Complete recovery 79%96%

4%

Favorable (27) Unfavorable(1)

Conclusion

CVST is not an uncommon disease, but needs extreme degree of suspicion

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Thank You

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