What are the different types of intracranial venous thrombosis?
- Dural sinus thrombosis
- Cortical vein thrombosis
What are the different dural venous sinuses that are most commonly affected by thrombosis?
- Sagittal sinus thormbosis
- Transverse sinus thrombosis
- Sigmoid sinus thrombosis
- Inferior petrosal sins thrombosis
- Cavernous sinus thrombosis
What are causes of intracranial venous thrombosis?
- Combined OCP
- Head injury
- Blood dyscarias
- Extracranial malignancy
- Recent LP
What infections can lead to intracranial sinus thrombosis?
- Orbital cellulitis
- Otitis media
- Cerebral malaria
What is the most commonly affected (and most clinically significant) type of venous sinuse thrombosis?
Cavernous sinus thrombosis
What are features of sagittal sinus thrombosis?
- Decreased visual acuity
What are features of transverse sinus thrombosis?
- Headache +/- mastoid pain
- Focal CNS signs
What are featurs of sigmoid sinus thrombosis?
- Cerebellar signs
- Lower cranial nerve palsies
What are features of inferior petrosal sinus thrombosis?
- CNV palsy
- CNVI palsy
- Temporal + Retro-orbital pain
What are features of cavernous sinus thrombosis?
- Facial pain - may affect trigeminal branches
- Oedematous eyelids
- Proptosis - may be pulsatile if internal carotid aneurysm
- Painful opthalmoplegia
- Horner's syndrome - post-ganglionic sympathetic nerve fibre compression
What are features of cortical vein thrombosis?
Usually occurs with sinus thrombosis which extends into cortical veins, producing infarcts:
- Focal neurological signs - develop over days
- Thunderclap headache
If someone presented with symptoms of an intracranial venous thrombosis, what would you differential diagnosis be?
- Intracranial abscess
- Ischaemic Stroke
What would you initially want to exclude in someone presenting with symptoms of intracranial venous thrombosis?
What investigations would you consider doing in someone presenting with symptoms of an intracranial venous thrombosis?
- Bloods - Thrombophilia screen
- Imaging - CT/MRI venography
- LP - if no contraindications
What will CT/MRI vnographyt show in investigation of intracranial venous thrombosis?
Absence of a sinus
What weighting of MRI can diretly visualise a thrombus in intracranial venous thrombosis?
T2-weighted MRI gradient echo sequence
What area of the brain does the superior sagittal sinus drain from?
Diagram shows rough area - a lot of variation between indiviuals
What area of the brain does the transverse sinus drain from?
Diagram below is rough guide - lot of variation between individuals
Why might you do an LP in someone with venous sinus thrombosis?
- Raised opening pressure
- RBC's/xanthochromia - SAH
How would you manage someone with an intracranial venous thrombosis?
Seek expert help
- Anticoagulation - LMWH, then followed by warfarin after 2-3 weeks
- Endovascular Thrombolysis/Mechanical thrombectomy - limited benefit
- Manage raised ICP - immediate management/hemicraniectomy
When would you not consider vascular thrombolysis/mechanical thrombectomy in someone with intracranial thrombosis?
Those with large infarcts and impending herniation
What are predictors of a poor prognosis in someone with intracranial venous thrombosis?
- GCS <9 on admission
- Deep CVT location
- CNS infection
- Intracranial haemorrhage
- Mental status abnormality
- Age > 37 years
What INr would you aim for when treating intracrnail venous thrombosis
How long would you give someone warfarin therapy for an intracranial venous thrombosis?