AKT · Neurology/Stroke & vascularlow yield

Cerebral venous sinus thrombosis

Thrombosis of a dural venous sinus → venous infarction/raised ICP

Overview

Thrombosis of the cerebral venous sinuses, causing raised ICP and venous infarction (which may be haemorrhagic). Easily missed — it presents with headache ± seizures/focal signs in a prothrombotic context (pregnancy/puerperium, COCP, dehydration, thrombophilia).

Recognise

Subacute headache (often the only feature), raised-ICP signs (papilloedema), seizures, focal deficits
Prothrombotic context: pregnancy/postpartum, COCP, dehydration, thrombophilia, malignancy
Cavernous sinus thrombosis: painful ophthalmoplegia, proptosis, chemosis

Red flags

Seizures, reduced GCS, venous haemorrhagic infarction, pregnancy/postpartum

Differentials & how to tell them apart

Subarachnoid haemorrhagethunderclap, arterial; CVST headache is subacute

Idiopathic intracranial hypertensionraised ICP without thrombosis — CVST must be excluded by venography first

Migraineno venographic thrombus, no prothrombotic context

Arterial strokefollows an arterial territory; CVST crosses territories

Investigations

CT venogram or MR venogram (the diagnostic test — shows the filling defect); non-contrast CT may show the dense sinus; D-dimer supportive; thrombophilia screen.

Management

Anticoagulate (LMWH → oral) — even with venous haemorrhagic infarction

1CT/MR venography to confirm. Anticoagulate with LMWH then oral anticoagulation.Gate: Anticoagulation is given EVEN when there is associated venous haemorrhagic infarction (the bleed is secondary to the clot) — unlike arterial ICH
2Treat the cause/risk factors; manage raised ICP and seizures; investigate for thrombophilia/malignancy.

Anticoagulation (LMWH then warfarin/DOAC) — even if there is venous haemorrhagic infarction

Key points

A subacute headache in a postpartum woman or on the COCP, especially with seizures or papilloedema, should prompt venous imaging. Anticoagulate despite venous bleeding.

Monitor & prognosis

Neuro status, ICP, anticoagulation; duration by provoked/unprovoked.

Good with prompt anticoagulation; worse with extensive thrombosis/coma.

Source: NICE CKS; stroke/neurology guidance