Cerebral venous sinus thrombosis
As sinus thrombosis is the occurrence of blood clots (thrombosis ) in the large venous confluences of the brain in the dura mater, venous sinuses of dura mater, respectively. Sinus thrombosis is a rare but dreaded cause of infarcts ( strokes ) of the brain.
Frequency
The exact incidence of sinus thrombosis is unknown. It is estimated that every year 3-5 new cases per 1 million population occur. Women are affected more often than men in a ratio of 3:1. The median age at diagnosis is 30-40 years.
Causes
Sinus thromboses are occasionally caused by purulent infections in the facial area, Nasennebenhöhlenvereiterung, mastoiditis or meningitis. In this case one speaks of a septic sinus thrombosis. Disease with increased blood clotting ( polycythemia, antithrombin deficiency, and others) may play a role. Pregnant are at increased risk. Some medications, such as contraceptives and corticosteroids are also disadvantageous.
Pathophysiology
The venous sinuses of the brain are thin walled and have little smooth muscle, no venous valves and no vasomotor innervation. In addition to the sine there is a deep venous system. In most cases, multiple sinus or sinus and deep cerebral veins are affected simultaneously with a sinus thrombosis. Unlike arterial occlusions that occur suddenly, venous thrombi form gradually by an imbalance of concurrent prothrombotic and thrombolytic processes. The blocked flow of blood causes the pressure to increase and may result in bleeding into the parenchyma or ventricles by themselves. Most common are the superior sagittal sinus and the lateral ( lateral ) sinus affected.
Symptoms
The symptoms of sinus thrombosis are ambiguous: headache, seizures and personality changes, as well as in advanced stages of paralysis, visual disturbances, and depressed consciousness to unconsciousness can also be observed in other diseases. In an inflammatory involvement of the cavernous sinus (about sinusitis, meningitis or trivial at first appearing inflammation in the eye or face area ), there is usually also a high fever.
- Early signs: Pressure pain in the nasal corner of the eye
- Blurred vision
- Severe headaches and neck pain, radiating to the arms / headache radiating from temple above the forehead to the other temple
- Edema of the nasolabial fold and lids
- Epileptic seizures
- Psychotic symptoms and personality changes
- High fever (septic temperatures)
- Paralysis
- Disorders of eye movement ( motility ) to vision loss
- Emergence of the eyes ( exophthalmos )
- Swelling of the conjunctiva ( chemosis )
- Numbness and depression of consciousness
- Intracranial pressure
- Death
Diagnostics
The clinical diagnosis of sinus thrombosis is difficult because there are no clear demonstrative clinical signs and symptoms that occur can also indicate other conditions such as an abscess, encephalitis or a malignancy. The clinical suspicion of thrombosis can be supported by a determination of D -dimer levels in the blood serum, but not proven. In thrombosis of the transverse sinus, the Griesinger character can occur.
Because of diagnostic difficulties solely on the basis of the clinic a cross-sectional imaging is recommended at an early stage of suspicion. Computed tomography or magnetic resonance imaging infarct zones and bleeding have been identified that do not correspond to known arterial supply areas. In the native computed the clot may represent light in the sinus without contrast agent. By contrast agents can be used both in computed tomography as well as magnetic resonance imaging the clot directly as a recess in the otherwise contrasting sinus usually be easily distinguished. They must be distinguished from recesses in the sinus, which are formed by Pacchionische granulations. Even the frequent anatomical variants, eg with asymmetric or one-sided landscaped transverse sinus must be considered. Another diagnostic method comes in exceptional cases, angiography only be considered if there are not reasonable suspicion of a sinus thrombosis the other methods mentioned above are available.
Therapy
Heparin in high doses, and later orally administrable anticoagulants such as phenprocoumon or warfarin; Intracranial pressure prevention, tranquilizers ( sedatives ) and anticonvulsants for epilepsy. The resolution ( thrombolysis ), or surgical removal of the thrombus is possible only in rare cases.