Cerebral Venous Thrombosis: an Update

Cerebral and Splanchnic Vein Thrombosis: Advances, Challenges, and Unanswered Questions

Cerebral vein thrombosis (CVT) and splanchnic vein thrombosis (SVT) are two manifestations of venous thromboembolism (VTE) at unusual sites. They have an incidence at least 25-50 times lower than usual site VTE, but represent true clinical challenges. Recent evidence on the epidemiology, risk factors, prognosis, and treatment of CVT and SVT has been published in the last two decades, thus contributing to a better understanding of these diseases. The improvement in imaging techniques and a higher degree of clinical suspicion may have led to the observed increased frequency, whereas a better knowledge of provoking mechanisms could have contributed to reducing the proportion of events classified as unprovoked or idiopathic (13%-21% of CVT, 15%-27% of SVT). Few small randomized clinical trials and a number of observational studies, although hampered by heterogeneous therapeutic approaches, shed light on the safety and effectiveness of anticoagulant therapy in these populations. However, there are still some grey areas that warrant future research. In this narrative review, we discuss recent advances and therapeutic challenges in CVT and SVT.

Dural Venous Sinuses: What We Need to Know

BACKGROUND

The dural venous sinuses (DVS), in general, are frequently asymmetrical and display far more anatomical variations than arterial systems. A comprehensive study of the anatomy and variants of the DVS can help surgeons in the preoperative evaluation and management as well as minimizing possible complications in the following treatment.

METHODS

The current review was designed to provide a general overview of the normal anatomy and notable variants of the cerebral venous system as surveyed from the available literature. The pros and cons of different multimodal imaging methods for investigating DVS are also outlined. Finally, cases of various pathological entities are illustrated from our clinical practice.

CONCLUSION

There are many anatomical variations and lesions involving the DVS. MRI examination can provide essential information both on anatomical variation and morphological or functional change of the offending DVS in most circumstances. Multimodal non-invasive venography protocols may become a feasible alternative to the classical digital subtraction angiography and would improve the diagnostic accuracy in future studies.

Cerebral Venous Thrombosis in Hematological Malignancy: Balancing the Risks

BACKGROUND AND AIM

The coexistence of cerebral venous thrombosis (CVT) and hematological neoplasms is rare. Currently available therapeutic options raise problems concerning the balance of thrombotic and hemorrhagic risks. Our purpose is to characterize a series of cases of CVT and concomitant hematological malignancy, focusing on predisposing factors and treatment strategies.

METHODS

We performed a descriptive retrospective analysis of the cases of CVT and hematological neoplasms diagnosed in a tertiary center from 2006 to 2015.

RESULTS

From the 111 CVT cases diagnosed, only 7 coexisted with hematological malignancy (lymphoma, leukemia, multiple myeloma, and myelodysplastic syndromes). These included 4 women; median age was 44 years old. Median follow-up time was 72 days. The hematological condition was already known in 5 cases. Besides malignancy, we identified other prothrombotic conditions in all cases. Several anticoagulant strategies were used during the acute phase, after which 5 patients remained on warfarin indefinitely. One patient died due to cerebral hemorrhage during the acute phase. In the remaining 6 patients, there was no recurrence of CVT or other complications of anticoagulation.

CONCLUSIONS

Although these results reiterate the role of hematological malignancy as predisposing factor to CVT, in all cases other factors contributed to CVT etiology, potentiating the risk. We report 1 death directly attributable to a fatal hemorrhagic complication of anticoagulation, evidencing the delicate balance of thrombotic and hemorrhagic risk. Nevertheless, most patients benefited of long-term anticoagulation, which proved a reasonable option. A multidisciplinary approach is paramount in making decisions regarding the time and type of anticoagulation.