[Current controversies in the diagnosis and management of cerebral venous and dural sinus thrombosis]

Cerebral venous thrombosis in adults

Summary. Thromboses of cerebral veins and/or sinuses (CVT) encompass a clinically rather heterogenous, relatively rare entity, which is nonetheless an important cause of stroke in the young. While until the mid of the last century the prognosis of CVT was thought to be poor or even fatal in the majority of cases, the advance and wider use of modern imaging technology since the early 1980s, together with the results of registries and population-based studies, revealed that CVT is more frequent and less life-threatening than previously assumed. However, because headache is frequently the only symptom, many oligosymptomatic cases might be overlooked. Both, CT- and MR-venography are suitable methods to confirm or rule out CVT, while the sensitivity of laboratory tests (D-dimer) alone is too low to rely on. Despite low evidence anticoagulation remains the treatment of choice during the acute phase and for secondary prevention.

Septic cavernous sinus thrombosis complicated by occlusion of the internal carotid artery and multiple embolic strokes after surgery of an anorectal abscess: a clinical chameleon

BACKGROUND

Septic thrombosis of the cavernous sinus (CST) is a rare and potentially life-threatening condition mostly caused by facial or ear, nose, and throat infections. Anatomic structures in vicinity of the cavernous sinus are thereby susceptible to inflammatory damage. In particular nervous system structures are almost regularly affected; however, only few authors reported severe involvement of the internal carotid artery (ICA).

CASE PRESENTATION

We present an atypical clinical course of CST in a 61-year-old male diabetic patient caused by a distant focus of inflammation. Septic CST after surgical treatment of an anorectal abscess was complicated by occlusion of the ICA and multiple embolic strokes. The diagnosis was established by magnetic resonance imaging scan, symptoms resolved after antibiotic therapy and heparin anticoagulation.

CONCLUSIONS

The presented case and review of literature emphasizes the variability of signs and clinical course of CST, a frequent cause of delayed diagnosis. Especially in immunocompromised patients, the primary source of CST may be a distant inflammatory focus with nonspecific and subacute symptoms. Septic CST can be a rare cause of ischemic stroke when complicated by ICA occlusion because of septic arteritis. Expedited diagnostic workup is necessary and rests upon radiologic investigations.

[Isolated cortical vein thrombosis. Clinical and neuroradiological aspects]

Isolated cortical vein thrombosis is only rarely diagnosed, although it presents with typical signs on imaging, presented in the paper. We report on five patients with this diagnosis, who all presented with focal sensomotoric seizures. Imaging with CT and MRI was the leading method. All patients were treated with oral anticoagulation and showed full recovery.

Heparin or local thrombolysis in the management of cerebral venous sinus thrombosis?

SUMMARY

Patients with acute cerebral venous sinus thrombosis treated with Heparin or in situ thrombolysis in our department were evaluated in an attempt to rationalize treatment with heparin or thrombolysis. 279 patients with angiographically proven acute cerebral venous sinus thrombosis were included in the study. Patients were classified into mild and severe clinical grade. The study was divided into three phases. Phase I included 27 patients treated with systemic heparin. Phase II included 72 patients, 30 in severe grade and 42 in mild. 26 were thrombolysed with 14 in severe and 12 in mild grade. Phase III included 180 patients treated according to a defined protocol. 133 were in mild grade and 47 in severe. 67 patients were thrombolysed. In the thrombolysed group 27 patients were in mild grade and 40 in severe. 113 patients were treated with systemic heparin. Following acute management all were anticoagulated for six months. The baseline characteristics were found to be same in all three phases. On comparison of outcome in Phase III with Phase 1 the likelihood ratio was found to be statistically significant in favor of Phase III (p<0.0001). The likelihood ratio was found to be statistically significant in mild and severe clinical grade in favor of thrombolysis in Phase III (p 0.039 in mild and p 0.00001 in Severe clinical grade). This ratio was insignificant (p=0.716) for intracranial bleed; however, local puncture site bleeding was found to be significant in the thrombolysed group (0.00005).

Clinical and neuroradiological spectrum of isolated cortical vein thrombosis

BACKGROUND

Isolated cortical vein thrombosis is only rarely diagnosed, although it may commonly be overlooked.

RESULTS

We report on four patients with this diagnosis who all presented with focal sensorimotor seizures. The diagnosis was made by a typical CT and MRI-pattern, which is described in detail.

CONCLUSIONS

The prognosis was excellent in all patients and the treatment options are discussed.

Is heparin treatment the optimal management for cerebral venous thrombosis? Effect of abciximab, recombinant tissue plasminogen activator, and enoxaparin in experimentally induced superior sagittal sinus thrombosis

BACKGROUND

Based on a newly developed model of reversible superior sagittal sinus (SSS) thrombosis in the rat, we investigated the effect of thrombolytic and anticoagulant treatment on recanalization, brain parenchymal changes, and motor deficits.

METHODS

Thrombosis of the SSS was induced by topical application of ferric chloride. Occlusion was confirmed by magnetic resonance angiography (MRA). Six hours after operation, single treatment with 10 mg recombinant tissue plasminogen activator (rtPA)/kg and 6 mg abciximab/kg or subcutaneous injection of 450 IU/kg enoxaparin twice daily was started, each group containing 10 rats. Follow-up MRI with T2- and diffusion-weighted images was performed on the first, second, and seventh postoperative day.

RESULTS

Control and enoxaparin-treated animals developed diffuse brain edema without infarction or intracerebral bleeding. This was indicated by an increase of T2 relaxation time and a decrease of the apparent diffusion coefficient in the parasagittal and lateral cortex. In these groups, the degree of recanalization after 7 days was comparable (48% versus 52%). Enoxaparin-treated animals showed significant amelioration of functional deficits. Clinical outcome was best in the abciximab-treated group, with a residual sinus occlusion of 36% after 1 week. Highest recanalization was achieved by lysis with rtPA (85%).

CONCLUSIONS

Enoxaparin treatment in rats with cerebral venous thrombosis significantly influences clinical outcome. However, it has no effect on recanalization. GPIIb/IIIa antagonists and rtPA accelerate thrombolysis. They may represent an alternative in treatment of cerebral venous thrombosis.