04. tbl. 99. árg. 2013
Cerebral sinus thrombosis – an uncommon but important differential diagnosis to headache, stroke and seizures. Cases and overview
Thrombosis of the cerebral veins and sinuses is an unusual but important cause of increased intracranial pressure and stroke, especially in the young and middle aged. Pregnant women, especially during the puerperium, and individuals with thrombophilia are a special risk group. What makes the diagnosis difficult is the vast range of symptoms including: headache, nausea, vomiting, blurry vision, reduction of consciousness, aphasia and motor and sensory disturbances. We present four cases which reflect the diverse clinical presentation of the disease.
Sveinsson OA1, Kjartansson O2, Valdimarsson EM3
1Department of Neurology Karolinska Hospital, Stockholm, Sweden, 2Department of radiology, Landspítali, National University Hospital of Iceland, Reykjavík, Iceland, 3Department of neurology, Landspítali, National University Hospital of Iceland, Reykjavík, Iceland.
Table I. Overview of the brains most important veins and sinuses.
Table II. Known causes and risk factors for cerebral sinus venous thrombosis
Genetic thrombophilia |
Factor V Leiden mutation |
Antithrombin mutation |
Protein C and protein S deficiency |
Aquired thrombophilia |
Hormonal contraception |
Pregnancy and puerperium |
Elevated homocystein in blood |
Nephrotic syndrome |
Anti-fospholipid syndrome |
Inflammatory diseases |
Sarcoidosis |
Systemic lupus erythromatosis |
Wegeners disease |
Bechet syndrome Inflammatory bowel disease |
Infections |
Infections of the ear, nose and throat area (sinusitis, mastoiditis and middle ear) |
Meningitis |
Drugs |
Hormone replacement therapy |
Corticosteroids |
Hormonal contraception |
Asparginase |
Miscellaneous |
Anemia |
Dehydration |
Cancer |
Head trauma |
Medical procedures in the head and neck area |
Picture 1a). MRI (FLAIR). Images in the upper row show thrombi in the transverse and superior sagittal sinus (arrows). Images in the lower row show that the thrombi have resolved, six months later.
Picture 1b). Magnetic resonance venography. Images in the upper row show lack of flow in the superior sagittal and transverse sinus on the right side. Images in the lower row show normal flow, six months later.
Picture 2. Sagittal CT image in midline shows good contrast enhancement in v. cerebri interna, v. galeni, sinus sagittalis inferior and sinus rectus but no enhanchment in sinus sagittalis superior.
Picture 3. a) An unenhanched sagittal CT image in midline shows cerebral vein thrombosis as a hyperdense v. cerebri magna, sinus sagittalis inferior and sinus rectus. b) An enhanched sagittal CT image in midline shows no cerebral vein thrombosis as a contrast filling defect in the v. cerebri magna, sinus sagittalis inferior and sinus rectus.
Picture 4. Shows the largests sinuses of the brain and the frequency of sinus venous thrombosis in each sinus, respectively. Published with permission from The New England Journal of Medicine.