Intracranial venous thrombosis

Question 1

What is the most common venous sinus thrombosis

Answer 1

Sagittal sinus thrombosis or transverse sinus thrombosis

Question 2

Describe the symptom onset of dural venous sinus thrombosis

Answer 2

Several days or weeks

Question 3

Describe the features of sagittal sinus thrombosis

Answer 3

Headache
Vomiting 
Seizures
Decreased vision
Papilloedema

Question 4

Describe the features of transverse sinus thrombosis

Answer 4

Headache 
Mastoid pain 
Focal CNS signs
Seizures
Papilloedema

Question 5

Describe the features of sigmoid sinus thrombosis

Answer 5

Cerebellar signs

Lower cranial nerve palsies

Question 6

Describe the features of inferior petrosal sinus thrombosis

Answer 6

5th and 6th cranial nerve palsies with temporal and retro-orbital pain

Question 7

Describe cavernous sinus thrombosis

Answer 7

Often due to spread from facial pustules or folliculitis causing headache, Chemosis, oedematous eyelids, proptosis, painful ophthalmoplegia, fever

Question 8

Describe cortical vein thrombosis

Answer 8

Usually occurs with sinus thrombosis as it extends into the cortical veins, causing infarction in a venous territory. These infarcts give rise to stroke like focal symptoms that develop over days. Often seizures and are associated with headache which may come on suddenly

Question 9

List the causes of intracranial venous thrombosis

Answer 9

Numerous - any hypercoagulable state causes 
Pregnancy/puerperium
COCP
Head injury
Dehydration 
Blood dyscrasis
Tumours
Extracranial malignancy 
Recent LP
Drugs - antifibrinolytics, androgens
Infection
SLE
Vasculitis 
Crohns

Question 10

What is the differential diagnosis for an intracranial venous thrombosis

Answer 10

Subarachnoid haemorrhage
Meningitis 
Encephalitis
Intracranial abscess
Arterial infarction

Question 11

What investigations should be done for intracranial venous thrombosis

Answer 11

Exclude subarachnoid haemorrhage
Bloods - thrombophilia screen
Imaging - CT/MRI venography may show absence of a sinus though an absent transverse sinus can be a normal variant
MRI T2 weighted gradient echo sequences can visualise thrombus directly and also haemorrhagic infarction
CT may be normal early but show a filling defect in a week
LP - raised opening pressure, CSF normal or show RBCs and xanthochromia

Question 12

Describe the management of intracranial venous thrombosis

Answer 12

Seek expert help early
Anticoagulation with heparin or LMWH and then warfarin (INR 2-3 weeks) may benefit even if there is secondary cerebral haemorrhage
If there is deterioration despite adequate anticoagulation, endovascular thrombolysis or mechanical thrombectomy may provide limited benefit
Increased ICP requires prompt attention, decompressive hemicraniectomy may prevent impending herniation