From the Guidelines
Yes, cerebral venous sinus thrombosis (CVST) can cause headache with acute psychosis. CVST is a serious condition where blood clots form in the venous sinuses of the brain, obstructing blood drainage and increasing intracranial pressure. Headache is the most common symptom of CVST, occurring in about 90% of cases, and is typically severe and progressive, as reported in the American Heart Association/American Stroke Association statement for healthcare professionals 1. Acute psychosis can develop as a neuropsychiatric manifestation of CVST due to brain tissue dysfunction from venous congestion, edema, and potential ischemia or hemorrhage. The psychotic symptoms may include hallucinations, delusions, disorganized thinking, and altered behavior.
When a patient presents with severe headache and new-onset psychosis, especially with risk factors such as oral contraceptive use, pregnancy, postpartum state, hypercoagulable conditions, or dehydration, CVST should be considered in the differential diagnosis. The ACR Appropriateness Criteria for altered mental status, coma, delirium, and psychosis suggest that patients with new onset psychosis who have suspected stroke, focal neurologic deficit, seizure, head trauma, or headache should undergo further evaluation, which may include neuroimaging 1.
Key points to consider in the diagnosis and management of CVST include:
- Prompt diagnosis through neuroimaging (MRI with venography or CT venography) is crucial
- Treatment typically involves anticoagulation with heparin followed by warfarin or direct oral anticoagulants for 3-12 months, depending on the underlying cause
- Delayed diagnosis can lead to serious complications including stroke, seizures, and even death, making early recognition of this potential connection between headache and psychosis essential. Therefore, it is essential to consider CVST in the differential diagnosis of patients presenting with headache and acute psychosis, and to promptly initiate diagnostic evaluation and treatment to improve outcomes and reduce morbidity and mortality.
From the Research
Cerebral Venous Sinus Thrombosis (CVST) and Headache with Acute Psychosis
- CVST is a rare cause of headache, but it should be considered in patients presenting with this common complaint 2.
- Headache is a common symptom of CVST, present in 68% of patients, and can be acute, sub-acute, or chronic in duration 3.
- The quality of headache in CVST can be throbbing, band-like, thunderclap, or other types, and can be unilateral, localized, or diffuse in location 3.
- While CVST can cause a range of symptoms, including headache, vomiting, and blurred vision 2, there is limited evidence to suggest a direct association between CVST and acute psychosis.
- However, CVST can cause venous hypertension, venous infarcts, hemorrhage, and seizures, which may lead to altered mental status or other neurological deficits 4, 5.
- In some cases, CVST may present with multifocal intracerebral hemorrhage and subarachnoid hemorrhage, which can have a poor clinical outcome 5.
- The treatment of CVST typically involves anticoagulation, even in patients with hemorrhage or subarachnoid hemorrhage, although the approach may need to be individualized in certain cases 6, 5.
Diagnosis and Treatment of CVST
- CVST is diagnosed by magnetic resonance venogram or computed tomography venogram of the brain 2.
- Anticoagulation with close monitoring is a safe first-line therapy for CVST, even in patients with hemorrhage on initial imaging 2.
- Endovascular strategies may be used to recanalize the sinuses in patients who demonstrate clinical deterioration while on heparin 4.
- The treatment approach for CVST may need to be tailored to the individual patient, taking into account factors such as the presence of hemorrhage or subarachnoid hemorrhage 5.