Cerebral venous thrombosis

We discussed a case of a middle-aged man with uncontrolled diabetes, who presented with acute-subacute fevers, headache, L neck pain, L retroauricular pain, and was found to have L ophthalmoplegia, acute L eye swelling due to MRSA bacteremia, left skull base MRSA osteomyelitis, and septic cavernous sinus thrombosis.

We reviewed various frameworks for secondary headache.
Thunderclap headache = Abrupt onset and reaches its max intensity within 1 minute or less of onset

Cerebral venous thrombosis is a rare (1%) cause of strokes. It usually affects younger patients (20-50 y/o) with a female > male predominance.

In septic cerebral vein thrombosis, thrombosis most commonly arises from contiguous spread of infection (nasal, sinus, dental) into the veins/sinuses.

Risk factors for cerebral venous thrombosis include:

  • Thrombophilia e.g. hx of prior VTE, oral contraceptives, obesity, pregnancy, autoimmune diseases (lupus, IBD, antiphospholipid), nephrotic syndrome
  • Head and neck infections e.g. mastoiditis, sinusitis, otitis media, meningitis, cerebral abscess, Lemierre’s syndrome
  • Mechanical causes e.g. trauma (at the skull base or jugular foramen), NSGY procedures, jugular vein procedures

Clinical manifestations to definitely watch out for include:

  • Headache: acute to subacute, can be thunderclap headache
  • Fevers
  • Focal neuro symptoms: CN III, IV, VI palsies, paresis, dysarthria, diplopia…depending on where the clot is
  • Seizure
  • Encephalopathy

Treatment goals:

  • Recanalize the occluded vein
  • Prevent thrombus propagation
  • Treat the underlying prothrombotic state

Treatment:

  • Heparin (unfractionated or LMWH)
  • Intracerebral hemorrhage is NOT a contraindication to anticoagulation.

References:

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