Download cerebral venous thrombosis (cvt)

CEREBRAL VENOUS THROMBOSIS (CVT)
By- Dr. Pramod Kumar Mohanty
Secretary, IAP Khurda Branch
It is a difficult clinical diagnosis. Because of the strong bias of its rarity and gravity have led to the
persistent under recognition of the condition. Cvt is not parse a disease rather a condition that occurs as
a result of some other predisposing condition or conditions.
INCIDENCE :Exact incidence is not known.
Pre CT / pre angio era – retrospective autopsy diagnosis
During autopsy also it is not routine to examine the venous sinuses.
So the postmortem diagnosis was made only when suspected clinically.
That is why these estimates underestimate the incidence and over estimate the gravity
1973 – Tow bin etal – 9.3%
1971-72- Scotti etal – 3.3%
In India – 50% strokes in women – Pregnancy related.
ANATOMY OF CEREBRAL SINOVENOUS SYSTEM :Cerebral lesions and clinical syndromes due to CVT occur in patterns directly related to venous
anatomy. patterns are different from that of arterial disease as cerebral veins unlike peripheral ones have
no valves, are thin walled with minimal smooth muscles without vasomotor innervation.
VENOUS STRUCTURES WITH TRIBUTARIES:a. Superior sagittal sinus
- Cortical veins
- Frontal dibasic veins
- Frontal emissary veins
b. Inf. Sagittel sinus
- Callosal vein
- Cingulate vein
- Medial frontal
c. Straight sinus
- Inf. sagittal
- Great cerebral vein of Galen
- Sup. Cerebellar veins
d. Transverse sinus
- Superior sagittal
- Straight sinus
e. Sigmoid sinus
- Transverse sinus
- sup. petrosal sinus
- Pontino cerebellar veins
Cavernous sinus
-
Facial veins
Ophthalmic veins
Retinal veins
Middle cerebral veins
Meningeal veins
Circular sinus
CLINICAL FEATURES:Headache
Vomiting
75%
Fever
Seizures – 32%
Focal neurological deficits – 34 - 75%
Papiloedema – 12 - 49%
Cranial nerve palsies - 12%
Altered sensorium - 30%
Others
- Evidences of meningitis
- A kinetic mutism
- Cortical blindness
- EPS
- Neuro Psychiatric
Deep Vein Thrombosis
- Acute Coma
- Decerebration
- EPS
CLINICAL PRESENTATIONS:Highly variable but usually a combination of
a. Nonfocal syndrome of ICT
b. Focal signs – Parenchymal Pathology
Focal signs of superficial CVT are different from deep Parenchymal venous thrombosis. Cavernous
sinus thrombosis is a distinctentity, where eye signs are the rule. Intracrnial hyperteniom usually
presents with headache and vomiting.
Parenchymal involvement can be in form of
-
Cerebral oedema
Bland infarction
Hemorrhagic infection
Intracerebral hemorrhage
SUPERFICIAL SINOVENOUS THROMBOSIS: Oedema / infarction / hemorrhage of central white / gray matter
Present with
-
Aphasia
Hemiparresis
Hemisensory loss
Homonymous hemianopia
Focal / generalized convulsion
Midline location – Bilateral involvement
- Legs & arms
Deep CVT –
Thalamic oedema / infraction / hemorrhage
Thalamic dementia
- Disorientation
- Attention deficit
- Snort term memory loss
- Confabulation
Basal ganglia
Chorea – athetosis
NEONATES – INFANTS: Seizure – most Prominent ( 80% )
Lethargy – Irritability – Bulging AF ( 30% )
Scalp oedema / macrocephaly / hydrocephalus
PREDISPOSING CONDITIONS: A. Hyper coagulable states
Primary
Secondary
B. Low flow states
C. Vessel wall abnormality
-
Infection
Inflammation
Trauma
Tumor
Primary hypercoagulable states
Deficiency of
-
Antithrombin III
Protein C
Protein S
-
plasminogen
Dysfibrinogenemic
Antiphospholipid
Antibodysyndrom
Secondary hypercoagulable states
-
Platlate abnormality
Polycythemia Vera
Hemolytic anemia
PNH
Reactive thrombocytosis – IDR
Coagulation abnormality
-
Nephrotic land
Cancer – Lasparaginase
IBD
SLE
DIC
Case Summary: 4 years baby girl presented with C/O
Irregular Fever – 6weeks
Swelling of (lt) eye lids, lt eye ball – 4Weeks
Severe headache with on and off vomiting - 2Weeks
Illness started with a boil over (lt) supra orbital area followed by swelling of left eye lids subsequently
left half of the face. Treated by general practitioner then ophthalmologist. Eyelid swelling decreased a
bit only to be replaced by painful swelling and protruding left eye ball. Pediatrician consulted treated
with IV antibiotics. Developed headache and vomiting, fever continued.
Upon admission: - Conscious, ambulatory.
- Temp- 1040F, Pulse, Respiration- WNL
- Polar – Proptosis (Lt)
- (Lt) lateral rectus palsy (+)
- Other wise – NAD No sign of meningeal irritation.
Upon Inv:Hb – 10.8
WBC – 10,200
DC – N54, LY16
ESR – 50mm Mx – Negative
Mycobacterial - Igm, 1g – Negative
Widal – Negative, Mp – Negative
CT scan brain including (LT) orbit –
(Lt) orbital cellulites
Bilateral cavernous sinus thrombosis
Blood cls obtained.
Commenced on IV Cefepime
CT scan followed by LP
CSF –
Sugar – 7.9mg%
Protein – 104.19mg%
Cells – 820/mm3 mostly polys
Gram Stain – Gram Negative bacilli
Cls - Enterobacter
Blood cls – No growth
I.v. Gentamycin and Flagyl added to Cefiipime
Treated for 2weeks of Iv antibiotics. Child improved became a febrile, headache vomiting disappeared.
Discharged on po antibiotics with advice for repeat CT scan.