Thread by @AaronLBerkowitz, A lot of talk about #CVST Rare to have neuro in the [...]

A lot of talk about #CVST Rare to have neuro in the news, so here's a quick #neurology #Tweetorial on cerebral venous sinus thrombosis.

#MedEd #MedTwitter #neurotwitter @CPSolvers @rabihmgeha @DxRxEdu #EndNeurophobia

I will focus on the condition/neurology, not the possible association w/vaccine or hematology. I leave that to experts like @shemarmoore and her excellent thread here: https://twitter.com/acweyand/status/1382156548571590657

https://twitter.com/acweyand/status/1382156548571590657

First, what are the cerebral venous sinuses?

They are the final pathway of venous drainage from the brain into the jugular veins.

They are formed from folds in the dura.

The superior sagittal sinus runs in interhemispheric fissure, leads back to the transverse sinuses in tentorium, which pass by way of sigmoid sinuses into jugular veins. Straight sinus joins transverse sinuses and superior sagittal sinus at torcula (which means wine press!)

The most famous sinus is the cavernous sinus, through which CN 3, 4, 6, V1/V2, and carotid pass…I think that’s the only place in the body in which an artery passes through a vein!? right @AvrahamCooperMD ?
But cavernous sinus thrombosis is super rare https://twitter.com/AaronLBerkowitz/status/1272306877938855937

https://twitter.com/AaronLBerkowitz/status/1272306877938855937

When I teach #neurology for the non-neurologist, I like to make medical metaphors:
Stroke = heart attack of brain
Seizure = brain arrhythmia
ICP headache worse when supine = brain orthopnea

So what's CVST? DVT of the brain!
What do you think @cpsolvers @rabihmgeha @DxRxEdu ?

The DDX includes any cause of a hypercoaguable state (inherited, acquired, malignancy, post-partum)...

but also local processes such as head trauma, intracranial infections (meningitis, sinusitis, otitis, etc.…

see list here from https://www.amazon.com/Lange-Clinical-Neurology-Neuroanatomy-Localization-Based-ebook/dp/B01N8S6KVF

How does CVST present?

- Sx/signs of

ICP: Headache, blurred vision (papilledema), double vision (from pressure on CN6), seizures; if severe

level of consciousness.

- Stroke or hemorrhage with corresponding focal deficits (Cortical vein thrombosis can->convexal SAH).

VST = a rare cause of cerebrovascular events, < 1%! One of my amazing mentors Steve Feske @harvardneuromds once said “with any stroke/hemorrhage, always ask "could this be venous?” or you’ll never remember to think of it and you’ll miss it!"

How's that for a pearl!?

when to consider VST in pt w/ intracerebral hemorrhage?
A few radiology clues
- Location adjacent to a sinus
- Edema out of proportion to hemorrhage (most spontaneous ICH have relatively little edema around them)
more in GIF
other neuroradiology clues to VST @tabby_kennedy?

On non con head CT look for CORD SIGN (hyperdense sinus)

If contrast given, look for empty delta sign (lack of filling at confluence of sinuses)

If suspicion for CVST, get CTV or MRV and look for filling defect . If scan was already ordered without these, can look for filling defect on post-contrast sequences or clot on GRE/SWI (will be dark)
see below and https://n.neurology.org/content/82/22/e188

Treatment is LMWH or heparin acutely (even if ICH present!), dagibitran or warfarin subsequently https://jamanetwork.com/journals/jamaneurology/fullarticle/2749167
Months if provoked/temporary cause vs need for long term AC
(Note thread from @acweyand above re: complexities of mgt if concurrent coagulopathy)

Safety and Efficacy of Dabigatran vs Warfarin After CVT

This randomized clinical trial conducted in 9 countries compares the use of dabigatran with warfarin in stroke prevention among patients who just experienced cerebral venous thrombosis.

https://jamanetwork.com/journals/jamaneurology/fullarticle/2749167

In severe/extreme cases, catheter based therapies may be considered. Some data reviewed in context of this clinical reasoning case from @AANMember @RoyStrowdMD section my colleagues and i wrote up when residents @harvardneuromds
https://n.neurology.org/content/neurology/82/22/e188.full.pdf
(check out the images)!

Also must manage complications:
- elevated ICP
- seizures
- supportive care
@caseyalbin surely would have more to teach us about these!