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Cerebral Venous Thrombosis - A Comprehensive Review
Cerebral Venous Thrombosis - A Comprehensive Review
deep brain white matter. Both the superficial and deep S deficiency, and antithrombin III deficiency are less
venous systems eventually drain into the internal jugular commonly encountered risk factors [10].
veins (Fig. 1). A prospective study involving 465 women found that
65% of cases had some form of risk factors like pregnancy,
puerperium, oral contraceptive pill (OCP) use, and hor-
Risk Factors monal replacement therapy associated with CSVT [11].
Studies also show that these gender-specific risk factors
CSVT is a multifactorial disease with at least one risk are not applicable to the pediatric or elderly population
factor implicated in 85% of affected adults [6] (Table 1). [12, 13]. A meta-analysis has shown that OCP users have
These risk factors are usually always associated with 6 times higher risk of developing CSVT than non-users.
thrombogenic triad of Virchow, which includes vessel The same study also concluded an increased risk of CSVT
wall injury, blood stasis, and hypercoagulability [5]. Pro- in patients with G20210A prothrombin polymorphism,
thrombotic conditions are the most common implicated factor V Leiden deficiency, and hyperhomocysteinemia
risk factor for CVT. Patients with hereditary thrombo- [14]. Studies also show an increased risk of CSVT in OCP
philia have an increased predisposition for developing users who are overweight or obese and are carriers of he-
any form of thrombosis, including CSVT. G20210A pro- reditary thrombophilia [15, 16].
thrombin polymorphism, factor V Leiden, and antiphos- Local head and neck infections are the most common
pholipid syndrome are most frequent causes. Protein C, infectious cause of CSVT, and studies have shown that it
Hemorrhagic infarction
Clinical Features
large hemorrhagic infarcts. Contrast-enhanced CT shows MRI and Magnetic Resonance Venogram
direct signs like empty delta sign (a low-attenuated center MRI with contrast and magnetic resonance venogram
surrounded by a triangular area of contrast enhance- (MRV) is the most preferred diagnostic modality for
ment) and indirect signs, similar to non-contrast CT [38, CSVT, and the appearance of thrombus on different MRI
39] (Fig. 3). sequences are time dependent. Within 5 days, it appears
isointense on T1 and hypointense on T2-weighted im-
CT Venography ages. In 6–15 days, thrombus appears hyperintense on
Venous enhancement following a CT scan help evalu- both T1 and T2 sequences. After 15 days, they appear
ate filling defects in the cortical sinuses and veins, in- isointense on T1 and iso- or hyperintense on T2 sequenc-
creased collateral venous drainage, as well as enhance- es. Four months later, no abnormalities on T1 and subtle
ment of sinus walls in these patients [40]. CT venography abnormalities on T2 sequences can be detected [42–44]
(CTV) has an overall sensitivity of about 95% and may be (Fig. 4). The MRI appearances in the acute form occur
useful for patients with a subacute or chronic presenta- due to an increased amount of deoxyhemoglobin in the
tion [5]. Studies support the use of CTV for the diagnosis thrombus, and the changes seen with the subacute form
of cerebral sinus thrombosis and show it has less diagnos- is due to an increased concentration of methemoglobin
tic value for cortical vein thrombosis [41]. CTV is a rapid [8]. The absence of changes in the T1 signal sequence and
and reliable option, especially in those patients with con- normal flow pattern on the T2 sequence makes diagnosis
traindication to perform an MRI. particularly difficult in the acute form of the disease [45].
Gradient-echo T2 and susceptibility-weighted imaging circulation. There is an abrupt stopping of cortical veins
sequences help identify a thrombus as a hypointense area with surrounding tortuous and dilated collateral “cork-
and can be useful in the detection of acute CSVT. Suscep- screw” vessels [10].
tibility-weighted sequences are also beneficial for the di-
agnosis of an isolated cortical vein involvement [46]. Advantages and Disadvantages of Diagnostic
MRV is a noninvasive diagnostic modality used for the Modalities
diagnosis of CSVT suggested by the absence of normal A comparison of the various imaging modalities in-
flow in a vein or sinus. A contrast-enhanced MRV is con- cluding CT/CTV, MRI/MRV, and a digital subtraction
sidered more sensitive to time-of-flight MRV for the de- angiography is summarized in Table 2.
tection of thrombus in smaller veins [47].
The authors declare that they have no conflict of interests. All authors have been involved in the preparation of this man-
uscript. All authors have read and approved the manuscript. The
corresponding author has full access to data and has the right to
publish this data.
Funding Sources
References
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S, Alcala-Cerra G, Rafael Moscote-Salazar L. philic abnormalities, oral contraceptives, and Sakaki T. Impact of anatomical difference of
Cerebral sinus venous thrombosis. J Neurosci risk of cerebral vein thrombosis: a meta-anal- the cerebral venous system on microcircula-
Rural Pract. 2013;4(4):427–38. ysis. Blood. 2006;107(7):2766–73. tion in a gerbil superior sagittal sinus occlu-
2 Guenther G, Arauz A. Cerebral venous 15 Zuurbier SM, Arnold M, Middeldorp S, sion model. Acta Neurochir. 2000;142(1):75–