Prof.Ramasamy Unit (M1)Dr. S.Hariharan

• Babu, 27/M, admitted on 18.8.09 • h/o intermittent, involuntary movements of

the Rt. hand-1 day duration• h/o low grade fever-3 days• No h/o altered sensorium• No h/o vomiting, blurring of vision, bladder

or bowel incontinence• No h/o suggestive of motor or sensory

system involvement

Past h/o: no sigficant past history Personal h/o : alcoholic and smoker -no h/o any drug abuse

Pt. is C/C/C oriented Afebrile General exam-Normal CNS-Rt. Focal seizure involving only Rt.hand No meningeal signs Fundus- Normal Other system exam- Normal

Partial seizure for evaluation- Viral encephalitis Treated with Inj.Acyclovir 600mg IV TDS Inj.Ceftriaxone 2g IV TDS T.CBZ 200mg BD Supportive measures

CBC, RFT, LFT & Urine routine-Normal QBC for MP-Negative CXR-PA view & ECG –Normal CT brain –Normal Cardiac Evaluation : Normal ELISA for HIV 1 and 2 : Non reactive

Neurology opinion: ?viral enchephalitis and added T.Phenytoin 100 mg 2HS

CSF analysis-Normal MRI Brain-Normal EEG-Seizure activity noted on Lt frontal

cortex

On review, neurologist suggested - T.Phenytoin 2HS & Rpt. MRI; - discharge & follow up at neurology op. Pt. was discharged with the diagnosis of

viral encephalitis. Pt was told to take MRI with MRV and MRA .

Rpt MRI with MRV and MRA : -T2 flair showing superior sagital

sinus thrombosis. Pt. was started on T.Acitrom 4mg with

target INR of 2-3. Pt. was screened for pro coagulant

conditions and they are negative(lupus anti coagulant, Protein C & S, anti thrombin III defi. and Sr.Homosysteine).

Sagital sinus thrombosis(Dural Sinus Venous thrombosis)

Now pt is on T.Phenytoin 2HS and Acitrom 2mg(target INR=2-3)

Mr.Damodharan, 35/M, painter, admitted on 11.8.09

h/o seizures-4 episodes, GTCS in nature h/o headache- 2 days duration No h/o fever, altered sensorium, vomiting,

blurring of vision or head injury No h/o bladder or bowel incontinence

Past history : not a known case of seizure/DM/ HT/IHD/PT/COPD

Personal h/o : ch.alcoholic and smoker for the past 10yrs.

-no h/o any drug abuse

Pt in unconsciuos (?post ictal status) poorly responding to painful stimuli Afebrile Hydration :Fair Vitals : Stable CVS,RS & P/A : Normal

Pt is unconscious (postictal status) poorly responding to painful stimuli No obvious facial asymmetry Moves all 4 limbs DTR :just present Plantar : b/l extensor PERLA No meningeal signs Fundus : not visualized

Seizure disorder for Evaluation (to r/o ICH) Treated with Inj.Phenytoin. Base line investigations : normal CT brain : multiple hemorrhagic infarct on

both hemispheres

Pt is C/C/C Oriented Afebrile Hydration :fair CVS,RS & P/A : Normal CNS : Rt.hemiparesis & Rt.7th UMN palsy Fundus : Normal

Bilateral fronto-parietal hemorrhagic infarct

Filling defect noted in SSS- suggeting SSS thrombosis

.Final Diagnosis: Dural Venous Sinus thrombosis

Pt retained full power on Rt. UL&LL. On T.Acitrom with target INR 2-3 for 3 to 6

months Advised : to get screened for pro coagulant

conditions

Mr.Anandhan, 37/M, admitted on 11.8.09 Presenting H/O: -h/o seizure-5episode -h/o headache Past H/O : Nil Personal h/o : alcoholic and smoker

Pt is unconscious (postictal status) responding to painful stimuli Moves all 4 limbs No facial asymmetry Plantar b/l extensor PERLA Fundus not visualized Other System Examination-Normal

Seizure disorder for Evaluation(?ICH) RFT,CBC,LFT,ECG,CXR-PA view-Normal CT brain-features suggestive of sub dural

Hge. Neurosurgery opinion: a case of subdural

hge and transferred to neurosurgery ward.( on 13.8.09)

Rpt CT scan(12.8.09):ICH with midline shift(CT report Not available)

Rpt CT scan(22.8) :Lt. parieto-occipital hemorrhagic infarct

MRI and MRV(22.8) : Lt. fronto parietal hemorrhagic infarct

-Rt.tranverse, Rt.sigmoid and SSS thrombosis

On 24.8.09, Pt was taken over and anti-coagulation started.

On receiving, pt is C/C Oriented Afebrile Hydration Vitals-Stable

CVC, RS and P/A-Normal CNS : conscious,oriented - B/L mini. UMN facial palsy - flaccid quadriparesis - plantar : B/L extensor - PERLA - No meningeal stiffness - Fundus –B/L papilloedmea

Anti coagulation Inj.Mannitol Physiotherapy and Other Supportive care On discharge(7.9.08), pt power was 4+/5

on all 4 limbs

Rare and severe disease characterised clinically by headache, papilledema, seizures, focal deficits, coma and death

• Superior sagittal sinus 72%• Lateral sinus 70%• Right 26%• Left 26%• Both 18%• Straight sinus 14.5%• Cavernous sinus 2.7%• Cerebral veins 38%• Superficial 27%• Deep 8%• Cerebellar veins 3%

1.Isolated intracranial hypertension 40%◦ mimic benign intracranial hypertension

2.Focal signs 50% 3.Cavernous sinus thrombosis 4.Unusual presentations

◦ Psychiatric disturbances, migraines, subarachnoid hemorrhages.

• Headache 75%• Papilledema 49%• Motor or sensory deficit 34%• Seizures 37%• Drowsiness, mental changes, confusion, or coma

30%• Dysphasia 12%• Multiple cranial nerve palsies 12%• Cerebellar incoordiantion 3%• Nystagmus 2%• Hearing loss 2%• Bilateral or alternating cortical signs 3%

• Hypercoagulable states : - Antiphospholipid syndrome - protein S and C deficiencies - antithrombin III deficiency - lupus anticoagulant - the Leiden factor V mutation - Pregnancy and puerperium• Collagen-vascular diseases :SLE,

Wegner granulomatosis and Behcet’s • Hematologic conditions :PNH, TTP,

sickle cell disease and Polycythemia..

• Hyperhomocysteinemia is a strong and independent risk factor for CVT.

• Nephrotic syndrome, dehydration, spontaneous intracranial hypotension, high altitude, hepatic cirrhosis, sarcoidosis and malignancy.

• Drugs:, steroids, epsilon-aminocaproic acid, thalidomide, tamoxifen, erythropoieten, phytoestrogens and L-asparaginase.

• Heparin therapy has been reported to produce thrombotic thrombocytopenia with associated venous sinus thrombosis.

Sinus involvement Predisposing Condition

Clinical features

1.SSS Thrombosis Meningitis Headache, fever, vomiting, confusion, seizure,weakness of both LL with bilateral babinski sign

2. Cavernous sinus Thrombosis

Face, ethmoid and sphenoid

Cranial Nerve 3,4,V1 and V2 invovlement

3. Transverse sinus Mastoid Headache, earache and Gradinego’s syndrome

4. Sigmoid sinus and IJV Thrombosis

Neck pain

Three clinical presentation1.superficial thrombosis of Cortical Veins: -partial seizures and superficial hgc. Infarct2.dural sinus thrombosis : -SSS ,Lateral sinus and Cavernous sinus

thrombosis3.Deep cerebral vein thrombosis:occlusion of

vein of Galen and intracerebral veins.rare entity;often presented with neuropsychological features

.CT Infarction in nonarterial distribution

(often hemorrhagic) Empty delta sign Dense triangle sign Cord sign

DIRECT SIGNS

Direct sign : i. Cord sign :on plain CT, represents the

spontaneous visualization of a thrombosed cortical vein; it’s rare .

ii. Dense triangle sign :reflects spontaneous SSS opacification by freshly clotted blood

iii. Empty delta sign : after contrast, it reflects the contrast between the opacified collateral veins in the SSS wall and non opacification of the clot inside the sinus.MC direct sign and seen approximately 35% of the cases.

To rule out other conditions, such as arterial stroke, abscess, tumors and SAH on emergency basis.

In a minority of cases, CT scanning shows the direct pathog. Signs of CVT

Combination of non contrast MRI and MRA and MRV : best method for the diagnosis and follow up of CVT .

MRI/V -Early: absence of flow void & isointense on T1 for occluded vessel; Hypo intense on T2

Late: hyper intense thrombus on T1 & T2

I.V.Heparin-bolus of 80U/kg followed by 18u/kg/hr continous infusion with control APTT 2.5times the control.followed by

Warfarin (INR=2-3) for 3-6 months If underlying hypercoagulable state, life

long anticoagulation. Others : anti edema measures and

antibiotics if suppurative thrombophlebitis

Ferro et al(2001)

Bousser (2001)

No. of pts 142 200

Full recovery 68 % 77 %

Minor sequelae

22 % 11 %

Major sequelae

4 % 9 %

Death 6 % 3 %

Age of the pt.(infants and aged) An infectious cause coma Presence of a hemorrhagic infarct Rate of evolution of thrombosis Empty delta sign on contrast CT

Figure 1.  MIP image from contrast-enhanced MR venography, with a color overlay, demonstrates the superior dural sinuses

Leach J L et al. Radiographics 2005;26:S19-S41

©2005 by Radiological Society of North America

1.SSS-Green2.Inf.SS-light blue3.Straight sinus-dark purple,4.Transverse sinus-dark blue,5.Sigmoid sinus-yellow,6.IJV-light purple

Figure 10a.  (a) Contrast-enhanced CT image in a patient with superior sagittal sinus thrombosis shows a central filling defect in the superior sagittal sinus (arrow), surrounded

by intensely enhanced dura mater

Leach J L et al. Radiographics 2005;26:S19-S41

©2005 by Radiological Society of North America

CVT is far more common than previously assumed

The spectrum of its clinical presentation is extremely wide.

Its mode of onset is highly variable Its outcome usually favorable