Approach Considerations
With regard to stabilization, medical management of patients with cerebral venous thrombosis (CVT) is similar to that of patients with arterial stroke.
Specific therapy for CVT involves anticoagulation or thrombolytic therapy. [25, 26, 31] However, the use of anticoagulation in CVT has been a subject of consternation among neurologists as concern has been expressed over the possibility of increasing hemorrhage in patients treated in this manner. Existing data support the use of systemic anticoagulation as an initial therapy in all patients, even in the presence of intracranial hemorrhage. [25]
Studies by Einhaupl in 1991 [27] and by de Bruijn and Stam in 1999 [28] indicated that anticoagulation can be used safely in CVT.
Frontal sinusitis
Frontal sinusitis should be aggressively treated before it leads to subdural empyema or CVT
Altered mental status or hemiplegia
Patients with altered mental status or hemiplegia should be given nothing by mouth to prevent aspiration. Intravenous (IV) fluids should not be hypotonic solutions. Normal saline is recommended at a rate of approximately 1000 mL in 24 hours. To decrease intracranial pressure, the patient’s head should be elevated 30-40° at all times. In the treatment of stroke patients, supplemental oxygen has not been shown to be beneficial unless the patient’s level of consciousness is decreased.
Surgical care
In cases of severe neurologic deterioration, open thrombectomy and local thrombolytic therapy have been described as beneficial. [25, 26, 29, 30]
Herniation attributable to unilateral mass effect is the major cause of death in cerebral venous thrombosis (CVT). In CVT patients with large parenchymal lesions causing herniation, decompressive surgery has been lifesaving and often results in good functional outcome, even in patients with severe clinical conditions. [11]
Thrombolytic Therapy
Thrombolytic therapy has been described in several case reports as beneficial in patients with cerebral venous thrombosis (CVT). These patients were treated with infusion of a thrombolytic agent into the dural venous sinus, utilizing microcatheter technique. This treatment at present is limited to specialized centers but should be considered for patients with significant deficit.
A report describes the use of a rheolytic catheter device in a patient who had not responded to microcatheter instillation of urokinase. The rheolytic catheter was designed for use in the coronary circulation and delivers 6 high-velocity saline jets through a halo device at the tip of the catheter. This leads to a Bernoulli effect that breaks up the thrombus. In addition, the particulate debris is directed into an effluent lumen for collection in a disposable bag. The catheter was advanced into the sagittal sinus, resulting in restoration of venous flow and reduction of intracranial pressure.
Anticonvulsant Therapy
Seizures should be treated with appropriate anticonvulsants. Fosphenytoin is recommended for the treatment of seizures in patients who require a parenteral formulation. Alternatively, phenobarbital or sodium valproate injection may be utilized if the patient is allergic to phenytoin. Diazepam or lorazepam may be used to treat status epilepticus, but the patient also should be given an anticonvulsant with a longer duration of action to prevent recurrent seizures.
Consultations
Consultation with a neurosurgeon is indicated in patients with subdural empyema or brain abscess. Consultation should also be considered for patients who have severe deterioration despite aggressive medical management.
Consultation with an infectious disease specialist is to be considered for patients with cerebral venous thrombosis (CVT) who have an associated infection, such as meningitis or sinusitis. Consultation with an otolaryngologist may also be helpful in patients with associated sinusitis.
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Left lateral sinus thrombosis demonstrated on magnetic resonance venography (MRV). This 42-year-old woman presented with sudden onset of headache. Physical examination revealed no neurologic abnormalities.
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Same patient as in the previous image. One week after treatment with heparin, the magnetic resonance (MR) venogram displayed increased flow in the left lateral sinus consistent with early recanalization of the sinus; headache had resolved at this point.
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Magnetic resonance venogram (MRV) - axial view; A = lateral (transverse) sinus; B = sigmoid sinus; C = confluence of sinuses; and D = superior sagittal sinus.
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Magnetic resonance venogram (MRV) - sagittal view; A = lateral (transverse) sinus; C = confluence of sinuses; D = superior sagittal sinus; and E = straight sinus.
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Computed tomography (CT) scan demonstrates a left posterior temporal hematoma in a 38-year-old woman on oral contraceptives (the only identified risk factor).
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Contrast-enhanced magnetic resonance imaging (MRI) scan showing lack of filling of left transverse sinus.
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Axial view of magnetic resonance (MR) venogram demonstrating lack of flow in transverse sinus.
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Coronal view of magnetic resonance (MR) venogram demonstrating lack of flow in the left transverse and sigmoid sinuses.
Tables
|
Treated Group, % (n = 12) |
Nontreated Group, % (n = 21) |
Full recovery |
62.5 |
29 |
Mild disability |
12.5 |
13 |
Severe disability |
12.5 |
9.6 |
Fatal outcome |
12.5 |
48 |
