**3.1 Case Report of CVT – Application of local fibrinolysis in 24-year patient using HAK**

24-year-old female patient with a negative history, including pregnancy or thromboembolism used third-generation gestagen as oral contraceptives. The patient was admitted to Neurology ICU, suffering from a strong headache, localized retroaurically, lasting for the period of one week. During the previous two days, the pain was associated with vomiting. Neurological findings included IV-degree somnolence, apathy, dysarthria, nuchal rigidity with 12 points on the GCS (Glasgow Coma Scale) on admission. A CT examination and conventional DSA were carried out in the evening. Angiography showed a partial thrombotic closure of the superior sagittal sinus and complete closure of right-hand lateral and sigmoid sinus, Galen's vein and direct sinus with stagnation of venous drainage in thalamus and basal ganglia. CT examination confirmed hypodensity in the right side of the thalamus and basal ganglia, oedema in right-hand temporal-occipital area and a minor haemorrhage in the area of right lateral and sigmoid sinus.

### **Neurological examination**

The examination showed left-hand hemiparesis, divergent strabismus, bilateral miosis, nuchal rigidity and tachycardia 120/min. Oedema of the papillae was not present. Considering the progreding disorder of consciousness gradating into coma, the patient was intubated and left on artificial ventilation. Consequently, the patient was taken to Anaesthesiology-Resuscitation Department. We introduced anticoagulation treatment with dalteparine 1000 IU/hr and antibiotic therapy with amoxyciline with clavulanic acid 1,2 g/ 8 hrs and ciprofloxacine 100 ml/12 hrs. The ventilation was maintained with FiO2 0,3, tidal volume (Vt) 550 ml and positive end-expiratory pressure (PEEP) of 5 cm H20. ECG was normal, without any ischemic signs, frequency 120/min. Magnetic resonance and magnetic resonance venography (MRV) confirmed vasogenic inflation, blood hypovolemia of the right mesencephalum, right thalamus and basal ganglia, as well as thrombosis of deep cerebral veins and venous sinuses.

Cerebral Venous Thrombosis in Patients Using Oral Contraceptives 117

**A, B,** DSA (day 1) closure of sinus transversus, vena magna cerebri (Galen), vena cerebri interna and

**E,** MR venography – lateral image (day 4)- incomplete thrombosis of the sinus rectus, non-detectable

**F,** Sagittal view on MR – venography – thrombosis of the right-hand side sinus transversus and

**C,D,** T2- weighted images (day 4)- hyperaemia, or cerebral turgescence of right-hand side basal ganglia

vena basalis Rosenthali. Drainage of cortical venous collectors preserved.

Fig. 1. DSA, MRI + MR- venography- "Time of Flight-TOF"

flow in vena basalis Rosenthali.

sigmoideus and right vena jugularis interna.

and the thalamus, with an image of signal hypersensitivity, imitating cerebral ischemia.

#### **Laboratory examination**

Creatinine 63,6 umol/l, glucose 6,1 mmol/l, *coagulation*: INR 1,41, fibrinogen 4,69 g/l, D dimers elevated 6-fold, protein C 45%, free protein S 56%, APC resistance negative- 4,791, AT III- 74%, factor II 76%, factor VIII – 112% (% of the standard).

Despite the use of conventional anticoagulation treatment and anti-oedematous therapy according to the protocol, the serious brain stem symptoms progreded on the 5th day after admission, associated with a loss of vertical and horizontal oculocephalic reflexes. The patient was referred to interventional centre for endovascular treatment of cerebral venous thrombosis. After admission, a control DSA examination with three-dimensional venography (3D-XRV) was carried out, with reconstruction of the venous phase. We found an incomplete thrombotic closure of both venae cerebri internae, Galen's vein and direct sinus, as well as a complete thrombosis of the right transversal and sigmoid sinuses. On the basis of this imaging examination, we decided to proceed with a local thrombolysis with rt-PA.

#### **Technique of the procedur**

5F Terumo loader (Radiofocus, Tokyo) was inserted into the common femoral vein for the purpose of a venous approach, and another 5F Terumo loader was inserted retrogradely into common femoral artery for angiography imaging of the right-side carotid basin. Control position digital subtraction angiography was carried out with the 4F Vertebral Aqua - Tempo catheter (Cordis - Endovascular, JJ, Miami, FL), with 3D-Xra reconstruction of the venous phase, with the outcome of a complete thrombolysis of the basal Rosenthal's and Galen's veins, sinus rectus, sinus transversus, sinus sigmoideus and right jugular vein (Fig. 1). The patient received unfractionated Heparin in the dose of 5000 U i.a. Another 4F Vertebral Aqua – Tempo catheter was inserted into the right v. jugularis interna, using the Terumo 035´/260cm loader (Radiofocus, Tokyo, Japan), and subsequently smoothly through the thrombus up to the area of confluens sinuum (Fig. 2). We have initiated local continuous thrombolysis on the 5th day after admission, using the application of rtPA in the dose of 0,6mg/hr, with continuous application of UF Heparin in the dose of 700 IU/hr, to reach the therapeutic levels of anticoagulation therapy. Fibrinogen, aPTT, blood count and the count of thrombocytes were monitored in 6-hour intervals. The thrombolytic treatment lasted for a total of 48 hours.

*Control angiography* with 3D-XRA venography performed on the 7th day confirmed recanalization of both cerebri internae, basal Rosenthal's vein, Galen's vein, sinus rectus, transversal and sigmoid sinuses, as well as v. jugularis interna, with a rapid drainage into cortical collectors. Thrombolytic therapy was terminated after the restoration of venous flow. Control CT examination excluded bleeding complications, and subsequent MRI examination confirmed regression of hyperaemia in the area of thalamus and right basal ganglia.

During the following two days, the patient wakes from the comatose state, with further diminishing of clinical symptomatology in the following period. The NIHSS scale was scored at 4 points on the 7th day after the interventional procedure. During a follow-up check after one month, the patient is fully self-sufficient, with mRs – 0 points. The examination aimed at thrombophilic states verified heterozygous form of MTHFR: A/V 223 and homozygous form of PAI-I 4G/5G genotype mutation. The patient was introduced to anticoagulation treatment with warfarin, with periodical monthly INR check-ups. Subsequent neuro-psychological examination confirmed an excellent outcome: WAIS-R:IQ global test 141, verbal 128 and nonverbal 146 points, with Wechsler memory quotient MQ l0l, pointing towards high intellectual functions. The examination further confirmed a high psychomotor speed, optimal verbal expression and memory functions at three months after the treatment.

Creatinine 63,6 umol/l, glucose 6,1 mmol/l, *coagulation*: INR 1,41, fibrinogen 4,69 g/l, D dimers elevated 6-fold, protein C 45%, free protein S 56%, APC resistance negative- 4,791,

Despite the use of conventional anticoagulation treatment and anti-oedematous therapy according to the protocol, the serious brain stem symptoms progreded on the 5th day after admission, associated with a loss of vertical and horizontal oculocephalic reflexes. The patient was referred to interventional centre for endovascular treatment of cerebral venous thrombosis. After admission, a control DSA examination with three-dimensional venography (3D-XRV) was carried out, with reconstruction of the venous phase. We found an incomplete thrombotic closure of both venae cerebri internae, Galen's vein and direct sinus, as well as a complete thrombosis of the right transversal and sigmoid sinuses. On the basis of this imaging

5F Terumo loader (Radiofocus, Tokyo) was inserted into the common femoral vein for the purpose of a venous approach, and another 5F Terumo loader was inserted retrogradely into common femoral artery for angiography imaging of the right-side carotid basin. Control position digital subtraction angiography was carried out with the 4F Vertebral Aqua - Tempo catheter (Cordis - Endovascular, JJ, Miami, FL), with 3D-Xra reconstruction of the venous phase, with the outcome of a complete thrombolysis of the basal Rosenthal's and Galen's veins, sinus rectus, sinus transversus, sinus sigmoideus and right jugular vein (Fig. 1). The patient received unfractionated Heparin in the dose of 5000 U i.a. Another 4F Vertebral Aqua – Tempo catheter was inserted into the right v. jugularis interna, using the Terumo 035´/260cm loader (Radiofocus, Tokyo, Japan), and subsequently smoothly through the thrombus up to the area of confluens sinuum (Fig. 2). We have initiated local continuous thrombolysis on the 5th day after admission, using the application of rtPA in the dose of 0,6mg/hr, with continuous application of UF Heparin in the dose of 700 IU/hr, to reach the therapeutic levels of anticoagulation therapy. Fibrinogen, aPTT, blood count and the count of thrombocytes were monitored in 6-hour intervals. The thrombolytic treatment lasted for a total of 48 hours. *Control angiography* with 3D-XRA venography performed on the 7th day confirmed recanalization of both cerebri internae, basal Rosenthal's vein, Galen's vein, sinus rectus, transversal and sigmoid sinuses, as well as v. jugularis interna, with a rapid drainage into cortical collectors. Thrombolytic therapy was terminated after the restoration of venous flow. Control CT examination excluded bleeding complications, and subsequent MRI examination

confirmed regression of hyperaemia in the area of thalamus and right basal ganglia.

expression and memory functions at three months after the treatment.

During the following two days, the patient wakes from the comatose state, with further diminishing of clinical symptomatology in the following period. The NIHSS scale was scored at 4 points on the 7th day after the interventional procedure. During a follow-up check after one month, the patient is fully self-sufficient, with mRs – 0 points. The examination aimed at thrombophilic states verified heterozygous form of MTHFR: A/V 223 and homozygous form of PAI-I 4G/5G genotype mutation. The patient was introduced to anticoagulation treatment with warfarin, with periodical monthly INR check-ups. Subsequent neuro-psychological examination confirmed an excellent outcome: WAIS-R:IQ global test 141, verbal 128 and nonverbal 146 points, with Wechsler memory quotient MQ l0l, pointing towards high intellectual functions. The examination further confirmed a high psychomotor speed, optimal verbal

AT III- 74%, factor II 76%, factor VIII – 112% (% of the standard).

examination, we decided to proceed with a local thrombolysis with rt-PA.

**Laboratory examination**

**Technique of the procedur** 

**A, B,** DSA (day 1) closure of sinus transversus, vena magna cerebri (Galen), vena cerebri interna and vena basalis Rosenthali. Drainage of cortical venous collectors preserved.

**C,D,** T2- weighted images (day 4)- hyperaemia, or cerebral turgescence of right-hand side basal ganglia and the thalamus, with an image of signal hypersensitivity, imitating cerebral ischemia.

**E,** MR venography – lateral image (day 4)- incomplete thrombosis of the sinus rectus, non-detectable flow in vena basalis Rosenthali.

**F,** Sagittal view on MR – venography – thrombosis of the right-hand side sinus transversus and sigmoideus and right vena jugularis interna.

Fig. 1. DSA, MRI + MR- venography- "Time of Flight-TOF"

Cerebral Venous Thrombosis in Patients Using Oral Contraceptives 119

**K, L,** 3D-Xra digital rotational angiography with a complete recanalization of sinus rectus, vena magna

**Thirty-three-year-old** female patient with a negative history and negative allergic history, using third-generation hormonal contraceptives for a short period of one month was examined for a headache localised in the right-hand side occipital area, accompanied with repeated vomiting. After five days of cephalgias, the patient observed worsening of the visual acuity, namely in the right eye. The patient was admitted at Neurology department due to an epileptic seizure. The subsequent CT examination was described as negative. On admission, the patient complained about inappetence and overall sickness after using individual tablets of the contraceptive. On the 8th hospitalisation day, the patient suddenly lost consciousness, tonic stiffening of the limbs and jaw appeared, accompanied with sweating, and, having regained consciousness, the patient showed signs of overall confusion. Control CT examination was performed, with the image of squalid cortical areas and suspected subarachnoidal haemorrhage in the occipital area on the right, around

**M,** Control MRI – (1 month), with a minor venous infarction of pulvinar thalami on the right.

cerebri, vena basalis Rosenthali and venae cerebri internae.

**3.2 Case report – CVT with malignant course** 

Fig. 2. Continues.

**G,** Sagittal view on DSA (day 5) – thrombosis of sinus transversus and sigmoid. **H,** 3D-Xra digital rotational angiography, partial thrombosis, sinus rectus – "double railing" image, thrombosis of vena basalis Rosenthali. Closure of right sinus transversus and sigmoid. **I,**4F-Vertebral Tempo Cordis JJ catheter inserted into right-hand sinus transversus, into the area of confluens sinuum, through a soft thrombus for introduction of local thrombolysis. **J, Sagittal view** - DSA (day 7) – 48 hours of local thrombolysis - recanalization of the right-hand side sinus transversus and sigmoid.

Fig. 2. Interventional procedure + 3D-Xra control angiography and MRI after thrombolysis

**K, L,** 3D-Xra digital rotational angiography with a complete recanalization of sinus rectus, vena magna cerebri, vena basalis Rosenthali and venae cerebri internae.

**M,** Control MRI – (1 month), with a minor venous infarction of pulvinar thalami on the right.

Fig. 2. Continues.

118 Venous Thrombosis – Principles and Practice

**G,** Sagittal view on DSA (day 5) – thrombosis of sinus transversus and sigmoid.

thrombosis of vena basalis Rosenthali. Closure of right sinus transversus and sigmoid.

confluens sinuum, through a soft thrombus for introduction of local thrombolysis.

sinus transversus and sigmoid.

**H,** 3D-Xra digital rotational angiography, partial thrombosis, sinus rectus – "double railing" image,

**I,**4F-Vertebral Tempo Cordis JJ catheter inserted into right-hand sinus transversus, into the area of

**J, Sagittal view** - DSA (day 7) – 48 hours of local thrombolysis - recanalization of the right-hand side

Fig. 2. Interventional procedure + 3D-Xra control angiography and MRI after thrombolysis

#### **3.2 Case report – CVT with malignant course**

**Thirty-three-year-old** female patient with a negative history and negative allergic history, using third-generation hormonal contraceptives for a short period of one month was examined for a headache localised in the right-hand side occipital area, accompanied with repeated vomiting. After five days of cephalgias, the patient observed worsening of the visual acuity, namely in the right eye. The patient was admitted at Neurology department due to an epileptic seizure. The subsequent CT examination was described as negative. On admission, the patient complained about inappetence and overall sickness after using individual tablets of the contraceptive. On the 8th hospitalisation day, the patient suddenly lost consciousness, tonic stiffening of the limbs and jaw appeared, accompanied with sweating, and, having regained consciousness, the patient showed signs of overall confusion. Control CT examination was performed, with the image of squalid cortical areas and suspected subarachnoidal haemorrhage in the occipital area on the right, around

Cerebral Venous Thrombosis in Patients Using Oral Contraceptives 121

**N,** T1WI-MRI - axial scan with the image of hyperintense signal of sinus transversus thrombosis on the

**O,P** T1WI-MRI axial scan with the image of hyperaemia, or vasogenic inflation of the right temporal

**R,S,** TOF- MR venography with findings of sinus sagitalis superior, sinus transversus and sigmoideus thrombosis on the right, deep vein system - sinus rectus, v. magna cerebri, vv. cerebri internae, and v.

**Q,** T1WI-MRI – image of "analogous delta sign" at the thrombosis at the area of division of the

right and hyperaemia, or vasogenic dilatation of the right temporal lobe.

Fig. 3. MRI examination and MR venography - (TOF) – sub-acute stage

transversal sinus from confluens sinuum.

lobe.

basalis Rosenthali.

sinuses. Within further two hours, the patient lost consciousness, accompanied with meningeal symptomatology and left-side hemiparesis.

The patient was referred for MRI examination, which revealed a massive cerebral venous thrombosis of all cerebral sinuses, with a closure of the deep vein system drainage in the diencephalic area and around basal ganglia (Fig. 3). After subsequently performed examinations, the patient was intubated in semi-comatose state and transferred to the interventional centre for an emergency endovascular procedure.

#### **Interventional procedure**

Under general anaesthesia, through a cannulation of right-hand side common femoral vein, we inserted 4F sheath Terumo and applied UF-Heparin 5000 U i.a.. Through the sheath we inserted 4F Vertebral Aqua - Tempo (Cordis - Endovascular, JJ, Miami, FL) diagnostic catheter and proceeded with diagnostic angiography of the cerebral arteries. The AG revealed a significantly delayed capillary filling, and venous drainage of both hemispheres, as well as a complete thrombosis of sinus sagitalis superior, sinus transversus and sigmoideus on the right side, a complete closure of deep venous drainage - v. basalis Rosenthali, v. cerebri internae, v. magna cerebri and sinus rectus. We inserted a second 5F Terumo loader into the common femoral vein, and through it a second diagnostic Vertebral catheter, on Terumo loader (Radiofocus, Tokyo, Japan) we penetrated into v. jugularis interna on the right, through foramen jugulare into sinus sigmoideus and transversus on the right, up to the confluens sinuum area. We initiated the application of local thrombolysis in the dose of 1mg rt-PA/hr per 24 hours.

### **Therapy at the Anaesthesiology-Resuscitation Department**

Patient was left on controlled artificial lung ventilation, on antibiotics (amoxyciline with clavulanic acid i.v., at the dose of 1,2 g every 8 hours), parenteral infusion therapy with crystaloids, glucose, massive anti-oedematous therapy, continuous local thrombolysis.

#### **Laboratory examination**

Antithrombin III 88..67, Leukocytes 15,7; Erythrocytes 4,40; Haemoglobin 13,6, Haematocrit 0,357; Thrombocytes 291; APTT 180 vt., Quick 19,4; INR l,62; Fibrinogen 3,0.

#### **Control CT on the following day**

Significant progression of the cerebral oedema, faded basal cisterns, clouded structures of the mesencephalon, smoothened gyrification, clouded structure of the right basal ganglia, medium line without deviation, faded lateral ventricles, high density in sinus sagitalis superior and sinus rectus with proven thrombosis. Conclusion – manifestation of a diffusive oedema, together with thrombosis of cerebral sinuses.

#### **Neurological examination**

Patient without attenuation, on artificial lung ventilation without any spontaneous activity, no reaction to painful stimuli, stem reflexes not manifested, generalized hypotonic state with C5-C8, L2-S2 areflexia. Conclusion: areactive coma, without manifestation of stem reflexes, corresponding to cerebral death. The patient dies on basal therapy after 11 days of hospitalization.

#### **Pathology-anatomic finding**

see Fig. 4. The image confirms extensive cerebral venous thrombosis, cerebral oedema, mainly in the area of brainstem, without manifestations of intracerebral haemorrhage.

sinuses. Within further two hours, the patient lost consciousness, accompanied with

The patient was referred for MRI examination, which revealed a massive cerebral venous thrombosis of all cerebral sinuses, with a closure of the deep vein system drainage in the diencephalic area and around basal ganglia (Fig. 3). After subsequently performed examinations, the patient was intubated in semi-comatose state and transferred to the

Under general anaesthesia, through a cannulation of right-hand side common femoral vein, we inserted 4F sheath Terumo and applied UF-Heparin 5000 U i.a.. Through the sheath we inserted 4F Vertebral Aqua - Tempo (Cordis - Endovascular, JJ, Miami, FL) diagnostic catheter and proceeded with diagnostic angiography of the cerebral arteries. The AG revealed a significantly delayed capillary filling, and venous drainage of both hemispheres, as well as a complete thrombosis of sinus sagitalis superior, sinus transversus and sigmoideus on the right side, a complete closure of deep venous drainage - v. basalis Rosenthali, v. cerebri internae, v. magna cerebri and sinus rectus. We inserted a second 5F Terumo loader into the common femoral vein, and through it a second diagnostic Vertebral catheter, on Terumo loader (Radiofocus, Tokyo, Japan) we penetrated into v. jugularis interna on the right, through foramen jugulare into sinus sigmoideus and transversus on the right, up to the confluens sinuum area. We initiated the application of local thrombolysis in

Patient was left on controlled artificial lung ventilation, on antibiotics (amoxyciline with clavulanic acid i.v., at the dose of 1,2 g every 8 hours), parenteral infusion therapy with crystaloids, glucose, massive anti-oedematous therapy, continuous local thrombolysis.

Antithrombin III 88..67, Leukocytes 15,7; Erythrocytes 4,40; Haemoglobin 13,6, Haematocrit

Significant progression of the cerebral oedema, faded basal cisterns, clouded structures of the mesencephalon, smoothened gyrification, clouded structure of the right basal ganglia, medium line without deviation, faded lateral ventricles, high density in sinus sagitalis superior and sinus rectus with proven thrombosis. Conclusion – manifestation of a diffusive

Patient without attenuation, on artificial lung ventilation without any spontaneous activity, no reaction to painful stimuli, stem reflexes not manifested, generalized hypotonic state with C5-C8, L2-S2 areflexia. Conclusion: areactive coma, without manifestation of stem reflexes, corresponding to cerebral death. The patient dies on basal therapy after 11 days of

see Fig. 4. The image confirms extensive cerebral venous thrombosis, cerebral oedema, mainly in the area of brainstem, without manifestations of intracerebral haemorrhage.

0,357; Thrombocytes 291; APTT 180 vt., Quick 19,4; INR l,62; Fibrinogen 3,0.

meningeal symptomatology and left-side hemiparesis.

**Interventional procedure** 

the dose of 1mg rt-PA/hr per 24 hours.

**Laboratory examination** 

**Neurological examination** 

**Pathology-anatomic finding** 

hospitalization.

**Control CT on the following day** 

interventional centre for an emergency endovascular procedure.

**Therapy at the Anaesthesiology-Resuscitation Department** 

oedema, together with thrombosis of cerebral sinuses.

**N,** T1WI-MRI - axial scan with the image of hyperintense signal of sinus transversus thrombosis on the right and hyperaemia, or vasogenic dilatation of the right temporal lobe.

**O,P** T1WI-MRI axial scan with the image of hyperaemia, or vasogenic inflation of the right temporal lobe.

**Q,** T1WI-MRI – image of "analogous delta sign" at the thrombosis at the area of division of the transversal sinus from confluens sinuum.

**R,S,** TOF- MR venography with findings of sinus sagitalis superior, sinus transversus and sigmoideus thrombosis on the right, deep vein system - sinus rectus, v. magna cerebri, vv. cerebri internae, and v. basalis Rosenthali.

Fig. 3. MRI examination and MR venography - (TOF) – sub-acute stage

Cerebral Venous Thrombosis in Patients Using Oral Contraceptives 123

The outcomes of the therapy were excellent in seven patients receiving the basic treatment. The treatment included administration of a combination of low weight molecular heparin in the treatment dose and subsequent coverage with warfarin. In three patients with insufficient effect of LMWH, we used local thrombolysis Actilyse ® (rt-PA). One of the women died, despite acute thrombolysis and complex therapy. The results of coagulation tests (see Table 6) showed the presence of several thrombophilic risk factors in all women in our group. Homozygous form of the MTHFR-C677T gene mutation was detected in three patients, two patients had a mutation of the gene for PAI-1 in homozygous form. A combination of both homozygous forms was detected in one patient, the combination was present in heterozygous forms in two patients. The tests further detected an elevated level of factor VIII in three patients, and five of the patients showed a deficit of protein S, always in combination with mutations of the gene responsible for MTHFR-C677T, three of these were

The first clinical and pathological finding of cerebral venous thrombosis was described by Ribs in 1825 in a 45-year-old male patient with generalized malignant process. Without the possibility of angiography imaging, the diagnosis was determined on the basis of clinical findings – progreding headaches, oedema of the eye papilla, spasms, focal deficit, coma, and was most usually confirmed with pathology-anatomical findings of thrombosis in the area of dural sinuses, accompanied with haemorrhagic infarsation. In 2001, an important study "International Study of Cerebral Vein Thrombosis" - ISCVT was published; the study

Deep vein system, including vv. cerebri internae, v. basalis Rosenthali, v. magna cerebri and sinus rectus, responsible for the drainage of diencephalon, basal ganglia and deep structures of the white matter of hemispheres, is usually affected in 10% of cerebral venous thromboses. More serious clinical cases, including hemipareses and quadrupareses are caused by compression of capsula interna, with unilateral of bilateral infliction of the thalami or basal ganglia, and can be diagnosed with non-invasive examinations, e.g. CT or MRI under the image of the oedema or haemorrhagic infarction. Limitations of venous outflow result in cerebral hyperaemia, mostly detected on MRI in patients with CVT (3,4,5). The diagnosis of CVT in our group of patients was confirmed with MRI imaging, MR venography and subsequently also with digital subtraction angiography. Liang et al. confirm the importance of three-dimensional imaging of magnetic resonance MP-RAGE venography, supported with the use of contrast, in the diagnostics of thromboses in the area of dural sinuses. This method was also very useful in our patient group. (6) As an alternative diagnostic procedure for CVT it is also possible to perform CT venography, together with the subtraction of bone structures "Mathed Mask Bone Elimination" (MMBE). (7) 3D-Xra-digital rotation venography provides an excellent alternative, with the possibility of imaging the speed and direction of the flow in a normal section of the venous system, as

prospectively monitored data of 624 patients with this diagnosis. (2)

well as in partially thrombotized parts of dural sinuses and deep vein system.

The treatment of patients with intracranial venous thrombosis depends on the timeliness of the clinical suspicion of CVT and subsequent confirmation of the diagnosis with imaging techniques. Purdon Martin and Sheehan (1941) were the first to recommend anticoagulation therapy for the treatment of CVT. The treatment with heparin is currently considered as a treatment of choice in patients with CVT. (2) However, the effect of heparin may be too

present in homozygous form.

**5. Discussion** 

**T,U** Thrombosis of sinus sagitalis superior as seen after opening of the sinus and removal of the hard meninges

**V** Thrombosis of confluens sinuum and sinus rectus orifice, thrombosis of Labe collector on the right and cortical veins parietally on the left

**W** Thrombosis of perimesenphalic veins with hyperaemia in the area of medulla oblongata

Fig. 4. Pathology-anatomic finding
