Cerebral Venous Thrombosis
Cerebral vein thrombosis (CVT), an uncommon and often-unrecognized type of stroke, accounts for 0.5%-1% of all strokes.1 CVT disproportionately affects young individuals < 50 years of age, particularly women. It is characterized by thrombosis of the cortical veins and/or cerebral venous sinuses.
Risk factors for CVT include:
- Use of oral contraceptives
Additional risk factors for this condition include:
- Inherited thrombophilias, such as Factor V Leiden positivity
- Protein C
- Protein S and anti- thrombin III deficiency
- antiphospholipid and anticardiolipin antibodies
- Prothrombin G20210A positivity1
Symptoms of CVT
Headache, progressing in severity over days to weeks, is the most common symptom of CVT and often signals intracranial hypertension.1,2 Patients rarely present with thunderclap headache, which typically suggests subarachnoid hemorrhage. Focal or generalized seizures are also common, reportedly seen in approximately 40% of patients.1
Other features, such as encephalopathy; papilledema; focal neurologic findings, such as hemiparesis and aphasia; and coma (Glasgow Coma Scale score < 8) can also be seen.1,2,3 Coma at presentation has been reported in 5.2%-20% of patients with CVT and is often associated with poor outcome.2,3
Diagnosis of CVT
Noninvasive diagnostics are frequently used to diagnose CVT. Non-contrast CT scanning of the brain is often normal, but may demonstrate findings that suggest the presence of CVT, including hyperdensity of a cortical vein or venous sinus, ischemic infarction crossing arterial boundaries and, infrequently, subarachnoid hemorrhage or intracranial hemorrhage.1
MRI is also useful and can show the presence of markers suggestive of CVT
However, a negative MRI or non-contrast CT do not preclude a diagnosis of CVT. If there is a high index of clinical suspicion of CVT, a follow up CT-venography or MR-venography will be performed.
Invasive imaging such as intra-arterial digital subtraction angiography or direct cerebral venography is typically reserved for patients with inconclusive imaging results and/or if an endovascular procedure is being considered.1
Treatment of CVT
The mainstay of CVT treatment is anti-coagulation, even in the presence of pre-existing intracranial hemorrhage. Additional invasive therapeutic procedures, such as direct catheter thrombolysis, intra-arterial tissue plasminogen activator and mechanical thrombectomy, are particularly useful for comatose patients or in those for whom anticoagulation does not work.1
A combination of advanced endovascular therapy and intensive medical management such as the care offered at Winthrop’s Neuroscience Intensive Care Unit can make a big difference in survivability and subsequent recovery.
1 Saposnik G, Barinagarrementeria F, Brown RD Jr, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Stroke 2011 Apr;42(4):1158-92.
2 Ferro JM, Canhão P, Stam J, et al. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004 Mar;35(3):664-70.
3 Wasay M, Bakshi R, Bobustuc G, et al. Cerebral venous thrombosis: analysis of a multicenter cohort from the United States. Stroke Cerebrovasc Dis. 2008 Mar-Apr;17(2):49-54.