Q 2.21. Cerebral Vein and Dural Sinus Thrombosis

Introduction CVT is a rare form of stroke that presents diagnostic challenges due to its diverse clinical spectrum. It’s less common than arterial strokes but is increasingly recognized thanks to improved MRI techniques and greater clinical awareness.

Epidemiology CVT is predominantly affecting females with a 3:1 ratio compared to males. This gender disparity is partly due to risk factors like pregnancy, puerperium, and oral contraceptive use. 

Pathogenesis CVT can result from various conditions that affect cerebral venous outflow, including thrombophilia, infections, malignancies, and certain medications. It’s crucial to consider these underlying factors when evaluating a patient with suspected CVT.

Clinical Features Symptoms of CVT can be nonspecific and include headache, seizures, visual disturbances, and focal neurological deficits. The presentation can vary widely, making a high index of suspicion necessary for diagnosis.

Diagnosis CT Venography or MRI, along with Magnetic Resonance Venography (MRV), are the preferred imaging modality for diagnosing CVT. It helps in visualizing the thrombosed veins and sinuses.

Management Initial treatment typically involves anticoagulation with low molecular weight heparin (LMWH). Long-term management may include oral anticoagulants. In severe cases, endovascular interventions or surgical decompression might be necessary.

Prognosis While CVT can be life-threatening, the prognosis has improved with early diagnosis and appropriate treatment. Long-term outcomes are generally favorable, with most patients recovering fully or with minor residual symptoms.

New Recommendations Recent guidelines suggest caution with D-dimer testing and thrombophilia screening, preferring LMWH over unfractionated heparin in the acute phase. Post-acute phase management includes oral anticoagulation for 3 to 12 months to prevent recurrence.

Special Considerations Women with a history of CVT related to hormonal contraceptives or pregnancy should avoid estrogen-progestagen combinations and may require LMWH prophylaxis during subsequent pregnancies and the postpartum period.

This summary provides a concise overview of CVT, highlighting key points that are essential for medical students to understand the complexity and management of this condition.

Verified by Dr. Petya Stefanova