Trombosi seno venoso

Question 1

General findings

Answer 1

CVT, also known as cerebral venous sinus thrombosis, is a thrombotic obstruction of the cerebral veins and/or related anatomical structures (dural sinuses) which drain blood from the brain.

Thrombogenesis occurs in the cerebral venous system, including the dural sinuses → ↓ cerebral drainage → ↑ intracranial pressure → clinical features (see below)
Additionally, thrombus formation → congestion within the venous system of the brain → blood stasis → ↓ oxygenated blood in brain tissue → cerebral edema and/or infarcts/stroke

Question 2

Eziologia (colpisce maggiormente le donne!)

Answer 2

🙋‍♀️Oral contraceptives, pregnancy, and postpartum period
-Hypercoagulable states
▫Blot clotting disorders (e.g., factor V Leiden, protein C
and S deficiencies, antiphospholipid syndrome)
-Hematologic diseases (e.g., polycythemia, sickle-cell anemia)
-Pregnancy
-Malignancies
-Minor head trauma
-Neurosurgical procedures (e.g., lumbar puncture)

Additional associated systemic conditions
-Inflammatory bowel disease (e.g., Crohn’s disease)
Collagen vascular diseases and blood vessel disorders (e.g., lupus erythematosus, Granulomatosis with polyangiitis, temporal arteritis)
-Hyperhomocysteinemia
-Hematologic conditions (e.g.,🧨 paroxysmal nocturnal hemoglobinuria, thrombotic thrombocytopenic purpura, sickle cell disease)
-Nephrotic syndrome
-Dehydration
Infectious

👓Otogenic (e.g., after acute otitis media) → generally infection of the lateral sinuses (transverse/sigmoid sinuses) or mastoiditis
-Rhinogenic (e.g., after sinusitis)

Through facial infections
-Meningitis

Question 3

clinica

Papilledema bilaterale! (indica ipertensione endocranica, non confondere con neurite anteriore o papillite)

Answer 3

• bradicardia
• ipertensione endocranica
• cefalea (intensa!)

Headache (acute, subacute, or chronic)
Nausea, vomiting, vision impairment ), bilateral papilledema on ophthalmoscopy
🧨Cranial nerve symptoms (e.g., diplopia, tinnitus, unilateral deafness, facial palsy)
Focal epileptic seizures
Impaired consciousness and awareness
🧨Hemispheric symptoms

👓In cases of cavernous sinus thrombosis: patients may develop cavernous sinus syndrome!!

Question 4

Diagnosi

Answer 4

CT/MRI (with or without venography): tests of choice to confirm the diagnosis

1. CT :
   - Hypodense structures indicate ischemic event
   - Thrombus can appear as a hyperdense vein or sinus
   - CT venography shows a filling defect in a vein or sinus (segno del delta)

2.MRI :
Thrombus is isointense on T1 and hypointense on T2 early in the disease
Cerebral edema can be identified
MR venography demonstrates a lack of flow

Un Di-dimero maggiore di 500 se affiancato a imaging è fortemente diagnostico mentre se basso non esclude la diagnosi (al contrario di ciò che accade per PE dove in un soggetto non in stato emodinamico alterato , un di dimero basso esclude la diagnosi)

Question 5

Trattamento

Answer 5

Initial management consists of treating underlying causes (e.g. seizures, hypertension) , general stabilization procedures , and 👓 antithrombotic therapy, which is the mainstay of treatment for CVT. Only if there is no improvement shown with medical therapy, is surgical intervention considered.

1. Medical therapy
   - Acute phase: heparinization🧨
   - In individual cases: local thrombolysis
   - Antibiotic therapy for infectious CVT!!!
   - Possibly anticonvulsants
2. Surgical therapy
   - Indications
   - Progressive neurologic worsening (despite adequate anticoagulation)
   - Acute rise in intracranial pressure
   - Impending herniation
   - Surgical options:
   - Blood clot removal
   - Vessel recanalization
   - Shunt placement