Cerebral venous thrombosis: a moroccan retrospective
study of 30 cases
Zouhayr Souirti1,&, Ouafae Messouak1, Faouzi Belahsen1
1Neurology Department, University Hospital of Fez, Morocco
Zouhayr Souirti, Neurology Department, University Hospital of Fez, Morocco
Cerebral venous thrombosis (CVT) is a rare form of stroke, diagnosis and management
can be difficult because of the diversity of clinical presentation and causes.
The prognosis is shown to be better than arterial thrombosis. Magnetic
(MRI) and MR Venograpgy (MRV) are currently important tools for the diagnosis.
We studied 30 cases of CVT diagnosed in the department of neurology
at the University Hospital
Fez (Morocco). Patients diagnosed with CVT signs between January 2003 and
October 2007 were included in the study. Cerebral CT-scan was performed
in 27 cases (90%) while the MRI examination was done in 18 patients (67%);
and most patients (90%) received
anticoagulant therapy. The mean age of our patients was of 29 years (age range
between 18 days and 65 years). A female predominance was observed
(70%). The clinical
presentation of patients was dominated by: headache in 24 cases
(80%), motor and sensory disability in 15 cases (50%), seizures in 10 cases (33%)
, consciousness disorder in 10 cases (33%). CVT was associated to post-partum
in 10 cases (33%), infectious origin in 8 cases (26%), Behçet disease
in 2 cases (7%), pulmonary carcinoma in 1 case, thrombocytemia in 1 case and
in 7 cases (23%).
The evolution was good in 20 cases (67%), minor squelaes were observed in 6 patients
(20%), while major squelaes were observed in 2 cases. Two cases of death were
registered. The CVT is a pathology of good prognosis
once the diagnosis
promptly established and early heparin treatment initiated.
CVT is a rare origin of stroke. This pathology was considered an infectious
disease for a long period. In addition, it was assumed to be affecting the
superior sagittal sinus dragging to death. Anticoagulants were contraindicated
the diagnosis was established at the autopsy stage. Currently, CVT is a disease
with various clinical presentations and etiologies. MRI and MRV are the key
diagnosis tools. Heparin is the first-line treatment. The prognosis is better
compared to arterial thrombosis with mortality well below 10%. The goal of
this study which took place at the University Hospital of Fez, Morocco is to
describe and discuss different features of this pathology including
frequency, clinical model, diagnosis and outcome.
We studied 30 cases colligated in the department of neurology of the University
Hospital of Fez (Morocco). Patients were recruited from
January 2003 to October 2007 (58 months). All patients demonstrating
of CVT were included. The cerebral CT-scan was performed in 27 patients (90%).
The period between onset and CT scan varied from 1 day to 45 days. The MRI
examination was achieved in 17 patients (56%). Ninety percent of patients (90%)
received anticoagulant therapy. Considering the CT scan without injection of
contrast agents, the inclusion criteria was spontaneous hyperdensity or
cord sign; while contrast agents was injected the empty delta sign and empty
lateral sinus sign were the inclusion criteria. On MRI, inclusion criteria
were hypersignal on T1 and T2 sinuses (Figure
1), abnormal defect
or rupture of the sinus in MRV except two cases of deep cerebral venous thrombosis
presented indirect signs of thrombosis of deep veins. The MRI T1 and T2 weighted
were done in axial, sagittal and coronal slices. Axial FLAIR and echoplanar
susceptibility-weighted (T2*), and T1 with gadolinium injection were also achieved.
Our patients have had the MRI and MRV between 5th and 30th day
of onset. The diagnosis of sinus thrombosis was based on hyperintense signal
on T1 and isointense or hyperintense signal on T2, and by the absence of flow
on MRV. The diagnosis using the CT scan was based on the presence of: empty
delta sign or empty lateral sinus sign.
The CT scan was sufficient for establishing the diagnosis in 13 cases (43%). Hence, the MRI examination was not performed for these patients. The MRI examination was achieved directly and without earlier CT-scan in 3 patients (10%). Fourteen patients (47%) have benefited of both CT scan and MRI.
The mean age of our patients was 29 years old, ranging from 18 days to 65 years
old. High predominance of female involvement was noticed with sex ratio of
2.3. The average period between the onset of symptoms and consultation was
18 days. The Table
1 summarizes patients' data.
The mode of onset of symptoms was subacute in 50% of cases, acute in 47% and
progressive in one case (3%). The clinical presentation was variable, but the
most common symptoms were headaches in 24 cases (80%), motor and sensitive disability
in 15 cases (50%), seizures in 10 cases (33%) including two cases of status epilepticus,
consciousness disorder was noticed in 10 cases (33%) and fever (40%) (Figure 2
Biological and Radiological Examinations
The biological examination showed anemia in 13 cases (43%), hyperleucocytosis
in 8 cases (27%), raised erythrocyte sedimentation rate in 11 cases (37%), thrombophilia
was recorded in four patients including low S-protein in three cases and C-protein
in one case. The CT-scan showed direct signs such as empty lateral sinus in 11
(37%) (Figure 3
cord sign in six cases (20%), empty delta sign in
cases (23%). The indirect signs were cortical hypodensity in 10 cases (33%),
hypodensity in 12 cases (40%), parenchymal hematoma (1 case), enhancement of
wall sinuses after contrast agent injection in 9 cases (30%), multiple and grouped
hyperdensities in six cases (20%).
14 patients benefited both CT scan and MRI examinations. The CT scan performed
diagnosis in five cases (35%), confirmed by MRI associated with MRV. The CT scan
was normal in three cases (21%). The MRI associated with MRV was more efficient
in demonstrating the lesion compared to CT in 9 patients (65%) (Table
CT-scan and/or MRI including the MRV showed the CVT in the sagittal superior
sinus (SSS) in 15 cases (50%), right lateral sinus (RLS) in 12 cases (40%), left
lateral sinus (LLS) in 3 cases (10%), cavernous sinus (CS) involvement in 5 cases
(16%), deep cerebral vein in two cases (7%), and cortical cerebral vein in one
case. The diagnosis of cortical cerebral vein thrombosis was also demonstrated
a hyposignal on echo-planar susceptibility weighted (T2
images (Figure 4
The diagnosis of deep cerebral vein thrombosis was
indirect signs on MRI, and theses cases have shown normal deep venous system
on MRV images.
All patients underwent systematically an investigation of the thromboembolic
antecedent, clinical examination, blood cells enumeration, prothrombin time (PT),
activated partial thromboplastin time (APTT), erythrocyte sedimentation rate
(ESR) and a thoracic x-ray. The post-partum was the most frequent cause of CVT
in our series consisting of 10 cases (33%); infectious origin was seen in 8 cases
(26%), four cases of otomastoiditis, three cases of severe staphylococcal of
the face and these patient have had delayed treatment, one case of ethmoiditis,
one case of miliary tuberculosis; Behcet disease in 2 cases (7%); pulmonary carcinoma
in 1 case; essential thrombocytemia in 1 case and thrombophilia in one case (deficiency
in protein C) (Figure 5
Finally, in 7 cases
(23%), the etiology of the CVT could not be established.
The treatment of intracranial hypertension was based on carbonic anhydrase inhibitor
or mannitol (63%), and the lumbar puncture was performed to remove the cerebrospinal
fluid (23%). Most of our patients (90%) received heparinotherapy (low-molecular-weight
heparin 68% or standard heparin 32%) followed by oral anticoagulant for 6 months.
Four patients (10%) did not receive heparin, two have had a thrombosis of the
cavernous sinus complicated by a carotid aneurysm; hence the anticoagulation
was contraindicated. The third patient was a newborn of 18 days.
Antibiotherapy was administrated to patients with infectious origin (47%). Antiepileptics
(27%) were prescribed for cases of seizures. We used steroids (prednisone 1mg/kg/day)
in two cases of Behcet disease. Allopurinol (300mg/day) and hydroxycarbamid
(1000mg/day) were used in cases of essential thrombocytemia. Two patients with
severe disorder of consciousness were hospitalized in reanimation department;
one of them has died in this department. The surgery was not the treatment of
choice in any of the reported cases.
After treatment, a full recovery was noticed in 18 cases (60%). Sequelae were
observed in 8 patients (27%), these consisted of blindness in one case associated
to cavernous sinus thrombosis complicated by severe staphylococcal of the
face. Hemiparesis was noticed in 3 cases, tetraplegia associated to cognitive
dysfunction was recorded in case of deep cerebral veins thrombosis. Epilepsy
in a case stabilized using carbamazepin; ophtalmoplegia after a cavernous
sinus thrombosis; pyramidal hypertonia in the newborn of 18 days. Three patients
died (10%) including one patient in the post partum, one of cavernous sinus
and one idiopathic.
Cerebral venous thrombosis is a rare type of stroke that might occur at any age.
The diagnosis of CVT requires a visualization of the thrombosis, which is commonly
demonstrated by cerebral MRI and MRV. The CT-scan might be helpful but does
not allow establishing the diagnosis.
CVT affects about five people per
million per year and represents 0.5 % of all stroke [1
CVT might occur in any stage of life. Most authors agree on the
predominance of CVT in young subjects, this was also revealed
in our study. Similar agreement
was found for the gender ratio [1
]. In our
series, we found a sex ration of 2,3.
The female predominance
is explained by the high frequency of CVT in the post-partum.
The clinical presentation is determined by the patient age, the
delay between the onset and the hospitalization, the location
of the thrombosis and the occurrence of cerebral parenchymal lesions.
Headaches represent the main and
first symptom of CVT retrieved in most studies. CVT with
isolated headache is possible, without
hypertension, subarachnoid haemorrhage, or meningitis signs and
Other symptoms are partial and generalized seizures, motor or sensitive
deficits, altered consciousness, and papilloedema which might be
associated to other symptoms [4
Motor or sensitive deficit, altered consciousness and seizures
are frequent in our study and agrees with earlier study (Einhäupl
1990), this was mostely related to delayed patients consultation.
The 18 days newborn patient has shown a generalized seizures and
hyporeactivity as main symptoms of the SSS thrombosis. The case
number 20 has shown isolated cortical cerebral vein thrombosis
revealed by motor deficit without seizures association.
In SSS thrombosis, signs are dominated by the unilateral or bilateral motor deficit
seizures and consciousness disorder. On the other hand, the isolated intracranial
hypertension syndrome is not frequent in SSS thrombosis. However, CVT of the
LS is often revealed by an isolated intracranial hypertension syndrome. When
the left LS is affected, an aphasia occurs, thereafter, a patient
with Wernicke aphasia and partial seizures.
The clinical manifestations of deep CVT are more severe, it often presents with
coma and bilateral motor deficit. These manifestations have been noticed in
number 18, while the case number 29 presented only a unilateral motor deficit.
Seizures are more frequent during the CVT comparing to the other types of stroke.
Seizures occur mainly in cases of parenchymal lesions, SSS thrombosis and in
patients having motor or sensitive deficit [5
Most of the routine blood assessment does not have diagnostic value for CVT.
However, they may help establish its etiology. Several
studies confirmed the elevation of the D-dimers during the CVT but their predictive
negative value seems only interesting for patients having signs of encephalic
reach. Therefore, an absence of D-dimers elevation in case of isolated headache
can not rule out CVT [6
In our study, the cerebrospinal fluid (CSF) mostly showed abnormal composition and elevation of the intracranial pressure. The CSF assessment revealed associated purulent meningitis in two patients, meningitis with an increased number of lymphocytes and red cells, an isolated elevation of red cells at two patients. However, we did not find any elevation of proteins in CSF. The opening pressure was elevated in all patients except the cases of cavernous sinus thrombosis. It varies between 19 and 48 cm H2O.
Detailed CT scan findings have been described in earlier literature [7-10
]. The CT scan without and with of contrast agent injection remains the first exam achieved whenever a CVT is suspected. It provides the diagnosis proof and allows showing the direct signs of CVT. However, up to 20% CVT cases have shown a normal CT [11
], more frequently they are patients with isolated intracranial hypertension. Therefore, a CVT diagnosis has to be systematically discarded before retaining an idiopathic intracranial hypertension diagnosis [12
]. However, the CT scan sensitivity was 30% in Ameri study [14
]. The empty delta sign (the frequent direct sign) was found in six patients (23%) compared to 20% found in the literature [15
]. The empty lateral sinus sign is the equivalent of the empty delta sign. This seemed to be underestimated in the literature [16
], whereas it represents the first direct sign in our study and was found in 11 patients (37%). It is necessary to differentiate it from hypoplasic sinus mainly the left lateral sinus. A special attention must be allocated to the signs of the transverse sinus on the mastoid in images before contrast agent injection.
Indirect signs are more frequent and less specific compared to direct signs in
different studies. This was also confirmed in our study (85%). Most often, the
CT-scan shows thrombosis consequences on the cerebral parenchyma under the shape
of a hypodensity (oedema or venous infarction), or a hyperdensity bound to a
haemorrhage going from some small patches to a real intraparenchymal haematoma.
is frequently hemorrhagic (10 to 50% of cases in the literature) [17
In our study, the CT scan was sufficient to diagnose 50% of cases at the admission.
Currently, the gold standard in the disagnosis of CVT is to combine MRI and
MRV for visualizing the thrombosed vessel. The indirect signs of CVT
MRI are similar
to those in the CT scan since they are not specific; both might withdraw 25%
cases. The sensitivity of the MRI associating the MRV is 90% in Lafitte study
The MRI and the MRV allowed the diagnosis in all cases of our series (56%). The
MRI alone is limited by flow artifacts that can lead to false positives and the
absence of hyperintense signal on T1 and T2-weighted images at the onset of acute
]. During the first 3 to 5 days the thrombosed
sinus is isointense on T1 and hypointense on T2, and thus very difficult to differentiate
from normal veins. All MRI examinations have been achieved after the 5th day
of the onset. For all cases; (except those with deep veins thrombosis, cortical
veins thrombosis and the cavernous sinus thrombosis); the thrombosed sinus was
hyperintense on T1 and hyper or isointense on T2. MRV done alone cannot discriminate
hypoplasia than lateral sinus thrombosis [20
]. It is illustrated
by one case (case number 5) that shows an amputation of the hypoplasic LLS confirmed
by morphological T2 and T1 sequences. The cortical or deep vein thrombosis might
be misdiagnosed even by MRI and MRV. This fact occurred in one case presented
with a deep vein thrombosis (case number 18).
The diagnosis of isolated cortical vein thrombosis might be difficult, requiring
conventional angiography. In our series, conventional angiography investigation
was not used. The Echo-planar susceptibility-weighted images (T2*) are particularly
useful in isolated cortical venous thrombosis and during early stage of acute
CVT when T1 and T2 lack sensitivity [21
]. the diagnosis
of cortical venous thrombosis was performed by echo-planar susceptibility-weighted
images (T2*) at one patient (case number 20) (Figure 4
The thrombosis of the cavernous sinus was revealed in three cases by an absence of heightening of one or the two cavernous sinuses in the coronal T1 images after Gadolinium injection, it was the best to show the sinus thrombosis. Two patients had cavernous sinus thrombosis associated with intracavernous carotid aneurysm.
CVT is often multifactorial since several disorders might initiate or dispose
patients. In the International studies of the Cerebral Vein and Dural Sinus
Thrombosis (ISCVT), 44% of the patients had shown more than one origin and predisposing
factor including the congenital and genetic thrombophilia which was recorded
in 22% patients [22
]. In developped countries, non-infectious
origins such oral contraceptives, cancer, and thrombophilia are the most frequent
causes with a prevalence of 80% [4
The etiologies in our study was similar to the developing countries findings
]. Infections and post-partum
causes are the most frequent causes. Local infectious etiologies are observed
in seven cases including four cases of otomastoiditis, three cases of severe
of the face and one case of ethmoiditis. CVT in these cases may be explained
by the consultation delay of our patients. CVT represents 23.5% of the stroke
during pregnancy and postpartum [26
]. Several factors could
be associated to the postpartum CVT, these included caesarean section, arterial
hypertension, and anemia. On the other hand, eclampsia is not a risk factor.
Indeed no case of eclampsia has been counted in our study [27
In one case, CVT occurred after epidural analgesia. Oral contraceptives represent
12% in Biousse and Bousser study. In our context, we are convinced that some
cases are not diagnosed considering the increasing use of the oral contraceptives
in our environment. Hemostasis investigation includes congenital or genetic
thrombophilia (deficiencies in antithrombin III, protein C, and protein S and
having the factor
or prothrombin gene mutations, and antiphospholipid antibodies). We have investigated
thrombophilia in four cases; one case of deficiency in protein C, and
two cases in protein S were revealed. The protein S deficiency was not confirmed
by a second dosage. Congenital thrombophilia is certainly underestimated in
our study. CVT due to Behcet disease is frequent in Mediterranean countries,
but Behcet's cases seem less frequent in our study compared with Daif study.
The low frequency of Behçet disease might be explained by our limited cases.
CVT was idiopathic in 20% in agreement with literature data [28
Heparin (low-molecular-weight heparin or standard heparin) is the first-line
treatment even in presence of hemorrhagic infarction [29
In our study, 90% of patients benefited from anticoagulant treatment including
those with hemorrhagic infarction. Systemic or local thrombolysis may be used
in CVT when patients deteriorate despite adequate anticoagulation and other causes
of deterioration have been ruled out, thrombolysis or thrombectomy may be considered
in specialized centers [31
patients with isolated intracranial hypertension, a lumbar puncture for removing
the cerebrospinal fluid is required before starting heparin. If intracranial
pressure is severely raised, the general recommendations should be followed,
this starts with mannitol treatment to admission to an Intensive Care Unit with
intracranial pressure monitoring or even decompressive hemicraniectomy when a
risk of cerebral herniation exists. In our patients who consulted at a
important decrease of visual cuit,y we used carbonic anhydrase inhibitor
or mannitol or even steroids although they are not recommended by most authors
]. Antiepileptics and antibiotics are useful to treat
seizures and infection. One of our patient underwent a partial epilepsy which
was stabilized under carbamazepin. The advisable anticoagulant treatment duration
is 6 to 12 months.
For our patients, the mean duration of anticoagulation therapy was 6 months.
that death and severe sequelaes were observed in 15% of patients [22
In our study, the result was similar to ISCVT (13% vs 15%)with two cases of
severe sequelaes and two cases of death.
CVT is not uncommon in Morocco. Post-partum and infectious causes are more frequent
in this study. Behcet's disease etiology seems to be underestimated. The investigation
of the haemostasis should be a routine after each cerebral venous thrombosis.
MRI and Venous MR angiography are the key diagnostic tools. CT scan
should be more effective for establishing the CVT diagnosis. The outcome is
favorable using heparin treatment.
The authors declare no competing interests.
Souirti Z is the chief investigator and manager of the study. He drafted this
manuscript. Other authors are co-investigators. All authors read and approved
the final version of the manuscript.
Table 1: Patients data
Table 2: The 14 patients with both CT scan, MRI and MRV
Figure 1: (case
21) Sagittal MR T1 sequences without Gadolinium injection showing: hypersignal
of thrombosed SSS on the right (black arrows) (A), hypersignal of thrombosed
LLS on the left (white arrow) (B)
Figure 2: Principal
clinical signs of the 30 patients
Figure 3: (case
14) CT scan after contrast product injection, axial sequence of the posterior
fossa showing empty right lateral sinus (arrow)
Figure 4: (case
20): FLAIR MR cerebral axial sequences (on the left) showing a hypersignal at
level of the ascending frontal gyrus (arrow) and in T2* (on the right) showing
a hyposignal of a cortical vein (arrow) which is thrombosed
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