The Massachusetts General Hospital Handbook of Neurology

2017-07-07 02:10:07

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

> Table of Contents > Adult Neurology > Venous Sinus Thrombosis, CNS

Venous Sinus Thrombosis, CNS

A. Sx

Great mimic in stroke; HA 80%, papilledema 50%, seizure 40%, variable confusion, cranial nerve deficits, uni- or bilateral cortical signs. Variable time course. Can look like pseudotumor cerebri.

B. Tests

1. MR or CT venogram: The test of choice true angiogram usually not necessary. Sinuses need to be traced out. Note that dural venous sinuses asymmetry is common; follow contrast flow through to bilateral IJ veins to verify flow difference between the dominant and hypoplastic sinuses.

2. CT (not sensitive): Focal hypodensity or petechial blood; can look like metastases. Small ventricles. Without contrast, the triangular delta of the sagittal sinus looks dense. If contrast given, can sometimes see empty delta sign or gyral and falx enhancement.

3. MRI (not sensitive): After day 5, standard MRI may show increased T1 and T2 signal along sinus. Iron susceptibility scan may show hemorrhagic transformation of thrombosis-related strokes.

4. CSF: Usually normal; sometimes see decreased protein or increased RBCs; may have high opening pressures if significant clot burden.

C. Causes of thrombosis

Hypercoagulable state, pregnancy, estrogenic meds; septic thrombosis); inflammatory disorders (SLE, GCA, Beh et's disease); malignancy (visceral carcinoma, primary CNS tumors, Trousseau's syndrome); and idiopathic (15%-20%).

D. Rx of venous thrombosis

Heparin, even if hemorrhagic infarct (rationale: the only way to prevent hemorrhage expansion is to prevent further clot formation and consequent increase in venous congestion/formation of venous infarcts). When therapeutic on heparin, start warfarin 2-3 mo. Consider thrombolysis, mechanical clot retrieval (thrombectomy). Mannitol and steroids. ACD only if seizure.

E. Prognosis

Good; 75% have complete recovery.

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