Cerebral venous thrombosis: A clinical pictureSurat Tanprawate, MD, MSc(Lond.), FRCP(T) the Northern Neuroscience Center in collaboration with Division of Neurology, Department of Medicine Chiang Mai University

MeSS 2013!Chiang Mai University

Case scenario-1A 52 years old man presented with motor seizure on the right side with subsequently mild hemiparesis and headache on the right side

Cerebral cortical vein, sagittal sinus, right lateral and sigmoid sinus thrombosis with brain edema

Cerebral vein thrombosis (CVST)

• CVST is a stroke of (venous site)

• but… the clinical symptoms are not typical as stroke syndrome

• Arterial stroke:

• sudden onset, reach a peak at the onset, typically no seizure, typically no headache

• Venous stroke: ???

Clinical feature of CVST

The onset of symptoms• subacute onset (2 days to 1 month;50-80%)

• can be chronic (more than 2 months) in patient presenting with isolated intracranial hypertension

Bousser MG. Stroke 1985;16:199–213.

Neurological deficit

• can be unilateral or bilateral

• negative symptoms(weakness) +/- positive symptoms (seizure)

• Bilateral cerebral infarct +/- haemorrhage is common

Hemorrhagic venous infarct

Venous infarct

Hemorrhage infarct

Seizure• Seizure: partial or generalize

• Associated location: supratentorial lesion (OR=4.05), cortical vein thrombosis (OR=2.31), sagittal sinus thrombosis (OR=2.18), puerperal CVST (OR=2.06)

Ferro J M, Stroke. 2008;39:1152-1158

Headache : when to suspect CVST?• Headache is the most common symptoms

• Warning sign

• First or worst

• Abrupt onset

• Subacute headache with increasing frequency or severity

• Headache bought by exertion or Valsalva manoeuvre

• Systemic symptoms/signs such fever, vomiting

• Headache associated with neurological symptoms/signs

Case scenario-1

A middle age man with progressive headache

Headache and CVST• 123 patients with CVST/ 17 patients had only

headache

• Headache character:

• 11 progressive

• 3 acute

• 3 thunderclap

Cumurciuc R et al. J Neurol Neurosurg Psychiatry 2005;76:1084-1087

J Headache Pain (2012) 13:487–490

J Headache Pain (2012) 13:487–490

Headache as the sole presentation

Thunderclap headache and CVST

• “Thunderclap”—sudden onset of an excruciating headache (VAS more than 8/10), reaching maximum intensity in less than one minute, and lasting more than 1 hour

• The differential diagnosis of Thunderclap headache

• : SAH, carotid/vertebral artery dissection, CVST, pituitary apoplexy, 3rd ventricular colloid cyst, Call-Fleming syndrome(reversible vasoconstriction syndrome), post-coital headache, primary

Venous infarct with haemorrhage

Primary intracerebral haemorrhage

Intracerebral haemorrhage in HT and CVST

Transverse sinus thrombosis Subarachnoid hemorrhage

Thunderclap headache patient

Bruijin et al. The Lancet 1996, 348: 1623 - 1625

CT brain in 10 patients with CVST presenting with thunderclap headache - 5 normal - 3 SAH - 2 multiple intracerebral haemorrhage

Topographic diagnosis

the location of thrombosis can determine characteristic clinical patterns

From: http://www.radnet.ucla.edu

Deep cerebral vein thrombosis

From: http://wfffun.info/

Diencephalon hemorrhagic infarct with deep cerebral vein thrombosis in comatose patient

Unusual presentation• Subarachnoid hemorrhage

• Isolated psychiatric symptoms

• Reversible parkinsonism

• Trigeminal neuralgia

• Acute visual loss

• Migraine like phenomena

• Hearing loss

• ocular flutter