What is cerebral venous sinus thrombosis?
Cerebral venous sinus thrombosis is a specific type of cerebrovascular disease that occurs in less than 1% of all strokes. It is usually more common in children and young adults, and in pediatric patients, it is more common in the lateral and cavernous sinuses due to infection. Patients with suppurative otitis media and mastoiditis are prone to complications of thrombosis of the transverse and sigmoid sinuses, collectively referred to as lateral sinus thrombosis. Depending on the nature of the lesion, CVST can be divided into two categories: inflammatory and non-inflammatory. In the inflammatory type, the cavernous and transverse sinuses are the most frequently involved sites, whereas in the non-inflammatory type, the superior sagittal sinus is most likely to be involved. Transverse sagittal sinus thrombosis is most often secondary to septic mastoiditis or otitis media.
What are the causes of cerebral venous sinus thrombosis?
1. Inflammatory intracranial venous thrombosis is secondary to infectious lesions most commonly occurring in the cavernous and sigmoid sinuses
(1) Facial lesions, especially septic lesions such as boils and carbuncles in the danger triangle, are likely to enter the cavernous sinus through the ophthalmic vein.
(2) Ear lesions such as otitis media or mastoiditis can cause thrombosis of the sigmoid sinus.
(3) Inflammation of the pterygoid or septal sinus can enter the cavernous sinus through the septal vein or by destroying the wall of the pterygoid sinus.
(4) Deep cervical or peri-tonsillar abscesses, maxillary osteomyelitis, etc. can involve the transverse sinus rocky sinus cavernous sinus garden along the pterygoid plexus or by invading the jugular vein.
(5) Meningitis brain abscess may involve the superior sagittal sinus via the cortical vein.
(6) Systemic infections such as sepsis caused by various bacterial infections.
2. Among the non-inflammatory intracranial venous thrombosis etiology and risk factors are various diseases or syndromes that cause the blood to be in a hypercoagulable state
(1) Systemic failure, dehydration, chronic wasting disorders.
(2) Pregnancy and puerperium.
(3) Traumatic brain injury.
(4) Hematologic disorders such as true erythrocytosis, acute lymphoblastic leukemia, thrombocytosis paroxysmal hemoglobinuria, congenital or acquired disorders of coagulation mechanisms (antithrombin III deficiency protein C, protein S deficiency, coagulation factor Vleiden mutation and active protein C resistance) like park.
(5) Autoimmune diseases, such as Bechet’s disease, systemic lupus erythematosus (SLE) ulcerative colitis antiphospholipid antibodies (including lupus anticoagulant antibodies and anticardiolipid antibodies, etc.) syndrome.
(6) Surgery.
(7) Heart disease congenital or acquired.
(8) Long-term oral contraceptive use.
(9) Still 20% to 25% of patients have no etiology or risk factors.
(10) Sedentary in the same position, caused by blood flow to the neck. Such as prolonged in front of the computer.
Common symptoms of cerebral venous sinus thrombosis
1. general performance of inflammatory intracranial venous thrombosis is divided into systemic symptoms, symptoms of local foci of infection and sinus symptoms systemic symptoms are manifested as irregular high fever chills weakness, general muscle pain, mental depression, subcutaneous bruising and other symptoms of infection and sepsis non-inflammatory intracranial venous thrombosis is mainly manifested as symptoms of etiology and risk factors and sinus symptoms
The clinical manifestations of intracranial venous sinus thrombosis lack specificity and its signs and symptoms vary from acute onset to slow onset over several weeks. The most common symptoms include headache, focal neurological deficits, seizures, impaired consciousness, optic disc edema, etc.
Tests required for venous sinus thrombosis
Laboratory tests
1. Blood routine, blood electrolytes.
2. blood glucose, immunological items, cerebrospinal fluid examination, if abnormal, there is a differential diagnosis.
Imaging examination
1. Head CT and CTA
The characteristic changes of CT are abnormal high-density foci in venous sinus or high-density foci in cerebral vein, i.e., the stripe sign, and an empty triangular shadow is seen after the superior sagittal sinus after enhancement scan, i.e., the δ sign. CT changes also include images of cerebral edema, hemorrhage and infarction and ventricular system changes, but 20%-30% of patients show normal on CT scan. Indirect signs of deep venous thrombosis are images of bilateral thalamic and basal nucleus infarcts or hemorrhagic infarcts.
CTA shows poor venous sinus and vein visualization of thrombus, but good lateral branch vein visualization.
2. MRI and MRA of the head
In the acute phase (<1 week after onset), the normal vascular flow-through phenomenon in the venous sinus or vein disappears in the T1- and T2-weighted phase, with equal signal in T1 and low signal in T2; in the subacute phase (1-2 weeks after onset), T1 and T2 show high signal; in the chronic phase (2 weeks to 3 months after onset), the vascular flow-through phenomenon reappears, and the signal in T1 and T2 decreases. In some patients, 4 months after onset, MRI shows isointense signal in the lumen without normal flow-through, indicating persistent occlusion. indirect signs of MRI appear as well as CT with images of cerebral edema, hemorrhage, infarction, and changes in the ventricular system. mRA can confirm occlusion of major veins and venous sinuses, such as superior and inferior sagittal sinuses, straight sinus, transverse sinus, and Galen's vein, in which the blood flow signal disappears.
3. Angiography can show partial or complete obstruction of venous sinuses and veins, spiral dilatation of cortical veins in the drainage area, and also shows venous reflux phenomenon, but the disadvantage is that it is invasive and expensive, and it is suitable for those who cannot be diagnosed by MRI and MRA.
Treatment of cerebral venous sinus thrombosis?
The treatment of cerebral artery stenosis should be diagnosed as early as possible and treated promptly. The treatment principles include lowering cranial pressure, improving circulation, symptomatic treatment and etiological treatment.
1.Inflammatory thrombosis
Actively deal with the foci of infection, and perform bacterial culture on the patient’s blood and cerebrospinal fluid to select antibiotics that are sensitive and easy to pass the blood-cerebrospinal fluid barrier. After the fever subsides, antibiotics should be continued for a sufficient period of time, and the general antibiotic application time should not be less than 1 month.
2.Non-inflammatory thrombosis
(1) Surgical treatment: direct venous sinus thrombosis removal balloon angioplasty and stenting, etc.
(2) Internal treatment: the main principle is anticoagulation and thrombolytic therapy. However, there is no unified understanding of the route dose, time, combination of drugs and their effect on blood flow recanalization and side effects.