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What Is Cerebral Venous Sinus Thrombosis

Living With Cerebral Venous Sinus Thrombosis

What is cerebral venous sinus thrombosis (CVST)?

What you need to do to recover and then stay healthy after CVST will depend on how the stroke affected your brain. Everyone can benefit from a healthy diet and exercise.

You may also need to participate in a special rehabilitation program or physical therapy, if you have lost some movement or speech.

Other possible effects of the stroke, such as headaches or changes in vision, can be treated by specialists.

If you have had this type of stroke, you may need to avoid certain types of medicines, such as oral contraceptives. These can increase your risk for blood clots.

Deterrence And Patient Education

In patients with a known thrombophilia, treating with long term anticoagulation can reduce the likelihood of recurrent VST. Patients need to be educated on the importance and rationale of continued anticoagulation. The decision to anticoagulate should be made in consultation with the patient and how their predisposing thrombophilia puts them at risk. Certain syndromes such as antiphospholipid antibody syndrome have shown to have dramatically high rates of recurrent venous thrombosis than other causes.

When Should I See My Healthcare Provider

Youll need to see your healthcare provider regularly while youre taking anticoagulants. Contact your healthcare provider if you miss a dose of warfarin.

You may need to have another CT or MRI with contrast three to six months after you have a cerebral venous sinus thrombosis to follow up on the status of your cerebral venous blood clot.

When should I go to the ER?

  • Bleeding that you cant stop.
  • Severe headache.

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What’s Causing This Clotting

It is not yet known why rare blood clots are occurring in some patients who receive the J& J vaccine. The six people who experienced clots were all women between the ages of 18 and 48, with symptoms developing six to 13 days after they received the shot, the FDA and CDC said. They had what’s called a cerebral venous sinus thrombosis, or CVST, as well as low levels of blood platelets. The New York Times reports one of the women died and a second woman is hospitalized in critical condition.

Until now concern about the unusual blood clots has centered on the vaccine from AstraZeneca, which has not yet received authorization in the U.S. Last week, European regulators said they found a possible link between the shots and a very rare type of blood clot that occurs together with low blood platelets, one that seems to occur more in younger people.

The J& J and AstraZeneca vaccines are made with the same technology. Unlike the Pfizer and Moderna vaccines, which train the body to recognize the spike protein that coats the outer surface of the coronavirus, the J& J and AstraZeneca vaccines use a cold virus, called an adenovirus, to carry the spike gene into the body. J& J uses a human adenovirus to create its vaccine while AstraZeneca uses a chimpanzee version.

How Is Cerebral Venous Sinus Thrombosis Treated

dural venous sinuses

The main treatment for CVST is the anticoagulation drug heparin. Heparin and other anticoagulantsor blood thinnersare used to treat CVST because they help to prevent new blood clots from forming in blood vessels throughout the body, including the venous sinuses of the brain, and can keep existing clots from getting larger. Blood thinners, however, cannot dissolve existing clots. Heparin is delivered to the body intravenously or via injection.

If patients do not improve upon administration of heparin or another blood thinner, the doctor may administer thrombolytic enzymes, which can dissolve existing blood clots. Because they may cause hemorrhage, these medications are typically used only in severe cases. Alternatively, a surgeon may perform a procedure known as a thrombectomy to remove the blood clot. The goal of thrombolytic enzymes and thrombectomy is the same: to remove the blood clot and restore blood flow.

Once the acute phase of CVST has been controlled, doctors will transition the patient to an oral blood thinner, such as warfarin. Anticoagulation therapy is continued to prevent recurrence of CVST or other clotting disorders. Patients will typically stay on oral blood thinners for three or more months. Pregnant women, however, should not take warfarin because it may cause birth defects.

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Search Strategy And Selection Criteria

We searched PubMed, Medline and Cochrane Library, from 1995 to May 2020 using the search OR ) OR OR )) and other relevant terms including aetiology, pathogenesis, risk factors, diagnosis, therapy, treatment, therapeutics, management, anticoagulant, endovascular, decompressive craniectomy, prognosis. We limited the search to human studies and those published in English. This search was supplemented by reviewing additional references from included studies.

How Do I Take Care Of Myself

After youve had a cerebral venous sinus thrombosis, your healthcare provider will want to keep you from having another blood clot. This means youll need to take an anticoagulant or blood thinner like warfarin.

This can protect you from a dangerous clot, but can put you at risk of bleeding from everyday cuts, as well. Youll want to be careful when using knives and consider switching to an electric razor, which may be safer than a razor with a blade.

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Headache Mechanism In Sle: Neuroinflammation And Hypercoagulability

Neuroinflammatory events involving activation of microglia and astrocytes also occur during the process of cortical spreading depression which is the same pathophysiology of migraine with aura .12,13 Several preclinical studies have revealed that CSD not only induces glial cell activation but also increases the expression of pro-inflammatory cytokines, adhesion and chemokines as well as the expression of toll-like receptors . Neurogenic inflammation involving the dural and wattle vessels and also can induce disorders of the blood vessel wall that cause hypercoagulability.31 This causes several processes such as extravasation of plasma proteins due to increased meningeal vascular permeability and activation of immune cells, namely mast cells and macrophages.

In this patient there is thrombosis in the vein which can be caused by hypercoagulable conditions and will cause blockage of venous system resulting in increased intracranial pressure . The complex interaction between endothelial cells and Lupus Antibody will trigger inhibition of proteins C and S that can cause hypercoagulable state which are responsible for the occurrence of thrombosis.25 Impaired fibrinolysis, antithrombin III, hyperfibrinemia, or changes in coagulation may also lead to thrombosis.14,15,25

Neuroimaging And Other Examinations

Cerebral Venous Sinus Thrombosis (CVST) | With Dural Venous Sinuses Anatomy

A total of 43 patients were subjected to computed tomography , magnetic resonance imaging , magnetic resonance vein angiography, magnetic resonance venography or magnetic resonance artery angiography . Patients in this sample had involvement of a number of regions . The binomial test revealed that involvement of the superior sagittal sinus and transverse sinus was significantly more common than involvement of the straight sinus/inferior sagittal sinus, cerebral infarction, or involvement of the vein of Galen . However, the proportions of patients with these findings were not significantly different from those of patients with sinus sigmoideus or ICH.

Additionally, 6 patients exhibited papilledema, and 4 patients had an unclear boundary of the optic nerve head. The lowest and highest cerebrospinal fluid pressures were 105cm H2O and 400cm H2O.

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What Is Unique About The Cerebral Venous Sinus Thrombosis Cases Associated With The Johnson & Johnson Covid

The form of CVST experienced by the 6 women who received the Johnson & Johnson vaccine differs from the usual case of CVST. While the women experienced blood clot in the cerebral venous sinuses, they also had a condition known as thrombocytopenia, or lower than normal levels of platelets.

Platelets, known as thrombocytes, are blood cells that play an important role in the formation of blood clots in blood vessels. When people have thrombocytopenia, they are prone to excessive bleeding. Because they have low levels of platelets, they tend to have difficulty forming clots.

The blood clotting condition experienced by these women who received the Johnson & Johnson vaccine is known as thrombosis with thrombocytopenia syndrome or vaccine-induced immune thrombotic thrombocytopenia . TTS can cause blood clotting in common sites, such as deep vein thromboses or pulmonary embolisms, but it can also lead to clotting in atypical sites, including the cerebral venous sinuses.

Between March and August 2021, a total of 54 cases of TTS had been identified out of 14.1 million Johnson & Johnson vaccine shots administered. Of these cases, 29 had CVST, which resulted in 7 deaths. TTS most commonly affects women between 30 and 49 years of age. There is about 1 case for every 100,000 doses given in this age group. In all cases, symptoms of TTS began within 18 days of receiving an initial dose of the Johnson & Johnson vaccine.

Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis
Other names Cerebral venous and sinus thrombosis, sagittal sinus thrombosis, dural sinus thrombosis, intracranial venous thrombosis, cerebral thrombophlebitis
Dural veins
Low molecular weight heparin

Cerebral venous sinus thrombosis , cerebral venous and sinus thrombosis or cerebral venous thrombosis , is the presence of a blood clot in the dural venous sinuses , the cerebral veins, or both. Symptoms may include severe headache, visual symptoms, any of the symptoms of stroke such as weakness of the face and limbs on one side of the body, and seizures, which occur in around 40% of patients.

The diagnosis is usually by computed tomography or magnetic resonance imaging to demonstrate obstruction of the venous sinuses. After confirmation of the diagnosis, investigations may be performed to determine the underlying cause, especially if one is not readily apparent.

Treatment is typically with anticoagulants such as low molecular weight heparin. Rarely, thrombolysis or mechanical thrombectomy is used, although evidence for this therapy is limited. The disease may be complicated by raised intracranial pressure, which may warrant surgical intervention such as the placement of a shunt.

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What Are The Symptoms Of Cerebral Venous Sinus Thrombosis

CVST can cause a number of symptoms including:

  • Nausea, vomiting
  • Weakness or impaired control of one side of the body, both sides of the body, or one leg or one arm
  • Difficulty speaking
  • Blurred or double vision brief periods in which vision becomes gray or black

A patient may experience one or several of these symptoms. While symptoms may appear suddenly, in general they develop over the course of a week or longer. In about a third of cases, headache is the only symptom.

Magnetic Resonance Imaging And Magnetic Resonance Venography Scans

Sinus and Cerebral Vein Thrombosis

An MRI scan uses magnetic fields and radio waves to build a detailed picture of the inside of a persons body.

Doctors may also use MRV during an MRI scan. For MRV, a healthcare professional injects a special dye into a persons blood vessels. This dye shows up on imaging scans and helps show any blockages.

MRI scans are more sensitive than CT scans and, when combined with MRV, are the gold standard for diagnosing CVT.

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How Can I Reduce My Risk

If you had a CVST while you were pregnant, an anticoagulant may lower your risk of thrombosis for future pregnancies.

Oral contraceptives are one cause of cerebral venous sinus thrombosis. Not using oral contraceptives can help reduce your risk of this condition. You can use contraceptives that contain only progestin instead.

Smoking, combined with oral contraceptive use, increases the risk of CVST, too. Avoiding both of these can help prevent CVST.

How To Spot And Treat Cerebral Venous Sinus Thrombosis

We were wrapping up a peaceful shift, as peaceful as it can be for a Level 1 trauma center, when we heard the dreaded overhead page, Medical alert to red 3.

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We entered the room to find a 52-year-old female with the chief complaint of posterior headache for one week, migrating, variable in intensity, but constant and associated with nausea. Well, why was this a medical alert again? The triage nurse added, Weakness, numbness and tingling to the left upper extremity, onset yesterday morning dropped tea cup from left hand slight unsteadiness in left leg, onset yesterday. The patient added, I have numbness around my mouth, and I think my vision is off, but thats been forever! Its probably nothing. I dont want to waste your time.

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When To Seek Medical Advice

  • a severe headache that is not relieved with painkillers or is getting worse
  • a headache that feels worse when you lie down or bend over
  • a headache that’s unusual for you and occurs with blurred vision, feeling or being sick, problems speaking, weakness, drowsiness or seizures
  • eye pain or swelling of one or both eyes
  • a rash that looks like small bruises or bleeding under the skin
  • shortness of breath, chest pain, leg swelling or persistent abdominal pain

While it’s highly unlikely to be the result of cavernous sinus thrombosis, these symptoms need to be investigated.

In very rare cases, cavernous sinus thrombosis can occur after having some types of coronavirus vaccine. If this happens, symptoms can appear between 4 days and 4 weeks after vaccination.

After an examination, you may be referred for tests, including a CT scan, an MRI scan and blood tests.

What Makes Yale Medicines Approach To Cerebral Venous Sinus Thrombosis Unique

Cerebral Venous Sinus Thrombosis, CVST, Animation

While headache is seen in most patients with CVST, it is also a very common symptom seen in many disorders. Clinicians at Yale Medicine are trained to have a high index of suspicion for CVST in the appropriate clinical circumstance , says Dr. Bona. This training is especially important as early diagnosis with early treatment will result in better long-term outcomes.

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Preventing Further Venous Thrombotic Events

Initial anticoagulation with LMWH is followed by longer-term anticoagulation to prevent further venous thrombotic events the risk of recurrent CVT is about 27% per year, and the risk of other venous thrombosis is about 47% per year. Current guidelines recommend using oral vitamin-K antagonist at standard-intensity 2.5, range 2.03.0) for between 3 and 12 months. The optimal duration of anticoagulation in CVT is uncertain because of the lack of randomised trials or prospective studies, and, in practice, it is decided based on the underlying risk factors for recurrence and bleeding. However, the following suggested scheme is supported by expert opinion and guidelines: patients with one episode of CVT and transient risk factors , infections, trauma, surgical interventions) should receive anticoagulation for 36 months patients with one episode of CVT of unknown cause should continue anticoagulation for 612 months and those patients with two or more CVTs are usually recommended to have lifelong anticoagulation. These sometimes difficult decisions should involve discussion with haematology. A study comparing the efficacy and safety of short-term versus long-term anticoagulation after CVT is ongoing.

Prognostic score for CVT

What Is Cerebral Venous Sinus Thrombosis J& j Covid Vaccine Paused Over Blood Clots

Top American health agencies have recommended the rollout of the Johnson & Johnson vaccine be paused as experts investigate six reported cases of a “rare and severe” type of blood clot in people who received the shot.

Officials from the Centers for Disease Control and Prevention and the Food and Drug Administration confirmed in a joint statement on Tuesday that the handful of known cases were linked to a condition called cerebral venous sinus thrombosis.

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How Is Cvst Treated

According to Johns Hopkins Medicine, treatments are conducted in a hospital setting, including the use of antibiotics , controlling pressure inside the head, anticoagulants to stop blood from clotting and possibly even surgery.

It listed some of the potential complications as vision problems, nerve pressure, brain injuries, developmental delays, difficulty moving parts of the bodyand death.

The U.S. health agencies said treating CVST is usually based around an anticoagulant drug, but warned that use inside a vaccine center setting could be dangerous.

Anatomy Of The Cerebral Venous System

Cureus

Cerebral venous system is divided into the superficial and deep venous system . They are a group of venous channels located intracranially between the endosteal and meningeal layers of the dura mater. Unlike systemic veins, cerebral veins lack valves and do not follow cerebral arterial territory. The superior sagittal sinus, in particular, also drains the cerebrospinal fluid from the subarachnoid space.

The superficial system comprises the dural sinuses and cortical veins. It drains the cerebral cortex and superficial white matter. The 2 major dural sinuses include the superior sagittal sinus that drain dorsolateral area and the cavernous sinus that drain the anteroventral region. The superior sagittal sinus drains into the transverse sinus which then drains into the straight sinus. The cavernous sinus drains into the transverse sinus posterolaterally and sigmoid sinus inferolaterally, along the superior and inferior petrosal sinuses, respectively. The superficial cortical veins are the superiorly draining veins and the inferiorly draining veins .

The deep system includes straight, lateral, and sigmoid sinus, as well as drain the deeper cortical veins . These vessels drain the basal ganglia, thalamus, the upper brain stem, and deep brain white matter. Both the superficial and deep venous systems eventually drain into the internal jugular veins .

Fig. 1.

Anatomy of cerebral venous system. The figure was reproduced with permission from the Radiology Assistant Web site .

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