From the Guidelines
Isolated cortical venous thrombosis (ICVT) is associated with several risk factors and etiologies, including hypercoagulable states, pregnancy, oral contraceptive use, malignancy, and local factors such as head trauma and neurosurgical procedures, and treatment typically involves anticoagulation with heparin initially, followed by warfarin or direct oral anticoagulants for 3-6 months, as supported by the most recent and highest quality study 1. The primary risk factors for ICVT include:
- Hypercoagulable states such as factor V Leiden mutation, protein C and S deficiencies, antithrombin III deficiency, and antiphospholipid syndrome
- Pregnancy and the postpartum period
- Oral contraceptive use
- Malignancy
- Dehydration
- Systemic inflammatory conditions like lupus or Behçet's disease
- Local factors such as head trauma, neurosurgical procedures, central nervous system infections, and local inflammatory processes
- Certain medications such as high-dose steroids, chemotherapeutic agents, and immunosuppressants Unlike larger sinus thromboses, ICVT may present more subtly with focal neurological deficits, seizures, or headache without the typical signs of increased intracranial pressure. Diagnosis requires high clinical suspicion and specialized neuroimaging, as conventional CT or MRI may miss these smaller thromboses, as noted in 1 and 1. The treatment of ICVT involves anticoagulation to prevent propagation of the thrombus and reduce the risk of recurrent venous thromboembolism, as recommended in 1. The duration of anticoagulation may extend to 12 months or indefinitely depending on underlying risk factors and whether they are transient or permanent. It is essential to individualize treatment based on the patient's specific risk factors and clinical presentation, as emphasized in 1.
From the Research
Isolated Cortical Venous Thrombosis Risk Factors
- Infection, pregnancy or puerperium, and oral contraceptive use are common risk factors for isolated cortical venous thrombosis (ICVT) 2
- ICVT shares the same group of predisposing conditions typical of other cerebral vein thromboses (CVT), which are more prevalent in women 3
- The most common symptoms of ICVT are headache, seizures, and focal neurological deficits 2
Etiologies
- Isolated cortical venous thrombosis is a rare condition representing approximately 6% of cerebral vein thromboses (CVT) 3
- Anatomical variations in cortical veins and the lack of a gold standard imaging feature make the diagnosis of ICVT challenging 4
- The Vein of Trolard followed by superficial middle cerebral vein (SMCV) are the most commonly involved in ICVT 4
Diagnosis and Treatment
- MRI and conventional angiography are the most frequently used diagnostic modalities for ICVT 2
- Anticoagulation is the most widely used therapy for ICVT, with direct oral anticoagulants (DOACs) showing similar efficacy and safety compared to vitamin K antagonists (VKAs) 5
- Correction of predisposing factors for venous thrombosis and anticoagulation is the therapy of choice for most patients with ICVT 3