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The syndrome of intracranial venous and sinus Scanning age-related incidence graphs9,10 reveal
thrombosis - termed as cerebral venous thrombosis three peaks that are as follows:
(CVT) was recognised in early part of 18th century
1. Infants and young children : Probably explained
when Ribes1 (1825) described, in a 45 yrs old man
on the basis of greater prevalence of dehydration-
suffering from disseminated malignancy, the clinical
associated disease, malnutrition (marasmus) and
and autopsy spectrum of superior sagittal sinus
infections of central nervous systems e.g., pyogenic
thrombosis. The first ever description of superior
meningitis, etc.
sagittal sinus thrombosis occurring in puerperium was
by Abercrombie in 1828 2 . Kalabagh in his 2. Young Premenopausal Women : Frequent use
monograph on CVT stated that aseptic thrombosis is of oral contraceptives in developed countries is
not an uncommon entity especially in children, an important aetiologic factor; while in developing
puerperium, and elderly3. With the advent of three countries, pregnancy and puerperium are the
dimensional M.R. Flow Imaging it has been shown common causes.
that the prevalence of CVT is more common than 3. Elderly : Greater prevalence of malignancies,
reported previously and carries a less serious malnutrition and dehydration-associated disorders
prognosis4. explain the frequency of CVT in elderly.
Exact incidence of CVT is still under debate because
of scarcity of scientifically planned epidemiological Applied Anatomy 12,13
studies in the available literature. Hospital data has
Cerebral venous circulation exhibits following
been utilised to determine its prevalence in the
anatomical characteristics that influence clinical profile
community. According to British Registrar General5,
and management of CVT :
average mortality from CVT in U.K. during 1952-
1961, was 0.4/106/per year. On assumption that a) Cerebral veins and sinuses have neither any valves
mortality rate from CVT is 10%, it’s prevalence in U.K. nor tunica muscularis. Absence of valves permits
is likely to be 4.0/106/per yr. On the other hand blood flow in various directions while absence of
aseptic CVT occurring in pregnancy and puerperium tunica muscularis permits veins to remain dilated.
has been reported very frequently from Indian b) Intercommunication between various venous
subcontinent. While studying stroke in the young, sinuses either via communicating veins (vein of
Indian studies6,7,8 revealed that CVT constitutes 10- Trolard, & Vein of Labbe) or through merger into
15% of stroke in the young and was the commonest each other especially at torcular Herophili,
cause of stroke in pre-menopausal women. explains lack of correlation between the severity
Sirinivasan7 encountered 50 cases of severe CVT of underlying pathology and infrequent clinical
amongst 1000 deliveries performed per year. It has symptomatology. Even recovery that is complete
been estimated that the prevalence rate in developing or with minimal sequelae, is explained by this fact.
countries is approximately 10 times more than that
in developed countries. In pre-antibiotic era, post- c) Venous sinuses are located between two rigid
infective CVT was more prevalent while in post- layers of duramater. This prevents their
antibiotic era, aseptic CVT has taken its place. compression when intracranial pressure rises.
* Former Director and Head of Department of d) Emissary veins from scalp, face, paranasal sinuses
Medicine, Rohtak Medical College, Rohtak, and ears, etc., diploic veins, and meningeal veins
Haryana. drain into cerebral venous sinuses either directly
** Professor of Medicine and Head of Neurology or via venous lacunae. This explains the frequent
Division (Retd.), Rohtak Medical College, Rohtak; occurrence of CVT as a complication of infective
Senior Consultant in Neurology, Moolchand K.R. pathologies in the catchment areas, e.g.,
Hospital, New Delhi. cavernous sinus thrombosis in the facial infections,
lateral sinus thrombosis in chronic otitis media b) Changes in blood flow, e.g., stasis or
and sagittal sinus thrombosis in scalp infections. hyperviscosity of blood as in dehydration, C.H.F.,
polycythaemia.
e) Superficial cortical veins drain into superior sagittal
sinus against the blood flow in the sinus, thus c) Changes in coagulability of blood, e.g.,
causing turbulation in the blood stream that is thrombocythaemia, protein S & C alterations,
further aggravated by the presence of fibrous Antithrombin deficiency, antiphospholipid
septa present at inferior angle of the sinus. This antibodies, etc.
fact explains greater prevalence of superior
In view of the above, many pathological conditions
sagittal thrombosis.
which are associated with CVT, have been described.
f) Arachnoid villi are located in the walls of superior More commoner ones are shown in the Table II.
sagittal sinus and drain CSF into the sinus. So,
Table II : Aetiologic Causes of CVT
thrombosis when it develops in the sinus, especially
in the posterior segment, blocks villi and leads to a) Hypercoagulable Conditions.
intracranial hypertension and papilloedema. Pregnancy & Puerperium
Oral Contraceptives15
g) Deep cortical veins, like arterial circle of Willis, Anti-thrombin III deficiency16
also form a venous circle around mid-brain, Antiphospholipid Syndrome16
comprising of basal vein of Rosenthal formed by Protein C & S alterations16
the merger of anterior and middle cerebral veins, Factor V Leiden and factor II gene mutations17
formed by the drain into internal cerebral vein b) Changes in vessel wall.
posteriorly that merges into the vein of Galen. Malignancy
These basal veins become engorged in superior Infections : local-chronic-otitis media, nasolabial and/or
sagittal sinus thrombosis and can be facial infections, pyogenic meningitis
demonstrated by venous transcranial doppler – Systemic, e.g., gram negative septicaemia, fungal infections
etc.
ultrasonography in 80% cases14.
c) Changes in blood flow/viscosity.
h) Cerebral venous system can be classified into two Marasmus
major groups: Malnutrition
1. Superficial system comprising sagittal sinuses Dehydration
and cortical veins draining superficial surfaces Congestive heart failure
of both cerebral hemispheres. Hyperviscosity syndrome
2. Deep system comprises lateral sinus, straight
sinus, and sigmoid sinus alongwith draining A. Post-infective CVT18,19,19A
deeper cortical veins.
In pre-antibiotic era, pyogenic infections in the
i) Superior sagittal sinus is the commonest sinus to catchment area were the commonest cause of
be involved in aseptic CVT (Table I)3. CVT. Infective organism reaches the draining sinus
Table I : Showing frequency of various sinuses via emissary veins. Though any sinus can be
involved in aseptic CVT involved, still, commonly involved in order of
frequency, are cavernous sinus, lateral sinus and
Superior sagittal sinus 72%
superior sagittal sinus. With the advent of
Lateral sinus (combined) 70%
antibiotics, incidence of post-infective CVT has
Straight sinus 13% markedly reduced but still otitic hydrocephalus as
a result of lateral sinus thrombosis is a common
Aetiology sequelae of chronic suppurative otitis media.
CVT like venous thrombosis at other sites in the body,
can develop because of : B. CVT in Premenopausal Women19,20,21,25
a) Changes in the vessel walls (phlebitis or a. Post-gestational & post-puerperal CVT. This
phlebopathy) e.g., malignant infiltration, post- entity though prevalent globally, has been
infective phlebitis, etc. described more often from Indian