CASE HISTORY – December 2007

Cerebral venous thrombosis


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Cerebral venous thrombosis (CVT) is a relatively rare vascular pathology that constitutes approximately 0.5% of all strokes. The purpose of this article is to review the risk factors, clinical findings, diagnosis and current treatment options associated with CVT. CVT can occur at any age. Up to 50% of the patients present in the subacute stage of the disease. The causes of CVT can be either local or systemic and are often combined. In 35% of cases the etiologic factor remains unidentified. The most universal symptom of the disease is headache, which could also be the first and only symptom. It occurs in 70–90% of cases. The clinical presentation of CVT can be extremely heterogenous. Therefore it is important to suspect the diagnosis on the basis of clinical signs.
Radiological investigations play an important role in the diagnosis of CVT. In many cases the first study is a head CT scan, which reveals either an intracerebral hemorrhage, stroke, cerebral oedema or a combination of the  previous. Of CT scans 25% show no pathology despite CVT. If CVT is suspected, either CT or MR angiography is performed allowing visualisation of the thrombosed venous sinuses.
Treatment options of CVT have been thoroughly addressed in the EFNS guidelines. After a certain diagnosis, treatment with intravenous heparin should be started immediately. The initial APTT value is measured and should be kept twice as high during treatment with heparin. Following the acute phase, anticoagulant therapy should be continued with oral administration of warfarin. The duration of anticoagulant use after discharge from hospital depends on the causing factor.
The prognosis of CVT is generally good but unexpected. Mortality is between 6–10%. Long term prognosis is affected by age, severity of symptoms at disease onset, seizures and venous stroke. Recurrence of CVT is dependent on various risk factors but is generally less than 10%.