Can Cerebral Venous Sinus Thrombosis (CVST) present with dizziness without headache?

Can Cerebral Venous Sinus Thrombosis (CVST) Present with Dizziness Without Headache?

Yes, CVST can present with dizziness without headache, though this is an atypical presentation that requires high clinical suspicion to diagnose correctly.

Clinical Presentations of CVST

CVST typically presents with various clinical manifestations, but its presentation can be subtle and nonspecific:

• Headache is the most common symptom, present in nearly 90% of patients 1
• However, isolated headache without focal neurological findings occurs in only up to 25% of patients 1
• Atypical presentations without the classic headache can include:
  • Somnolence or confusional states 1
  • Isolated mental status changes 1
  • Focal neurological deficits (hemiparesis, aphasia) 1
  • Seizures 1
  • Increased intracranial pressure symptoms 1

Dizziness as a Presentation of CVST

While dizziness is not explicitly mentioned as a common isolated symptom of CVST in the guidelines, several factors support that it can occur:

• CVST can affect various venous sinuses, with different clinical manifestations depending on location 1
• Lateral sinus thrombosis can present with symptoms that may include dizziness, especially when there is increased intracranial pressure 1
• The American College of Radiology notes that venous abnormalities like venous sinus thrombosis can cause various symptoms that may be misattributed to other conditions 2

Diagnostic Challenges

CVST is often misdiagnosed initially because:

• Clinical presentations are diverse and may not follow typical stroke patterns 1
• Symptoms can be subtle or nonspecific 1, 3
• Symptoms may develop gradually over days to weeks 1
• Isolated symptoms without the classic headache make diagnosis particularly challenging 1

Diagnostic Approach for Suspected CVST

When CVST is suspected, even with atypical presentations like isolated dizziness:

1. Imaging is essential:

   • MRI with MR venography is the most sensitive diagnostic tool 1
   • CT with contrast may show the "empty delta" sign in some cases 1
   • D-dimer testing may help identify patients with low probability of CVT, but normal D-dimer should not preclude further evaluation if clinical suspicion is high 1

2. Risk factor assessment:

   • Prothrombotic conditions (genetic or acquired) 1
   • Oral contraceptives, pregnancy, puerperium 1
   • Infections (particularly parameningeal) 1
   • Malignancy 1
   • Dehydration 1
   • Inflammatory conditions 1

Common Pitfalls in Diagnosis

• Mistaking CVST for other causes of dizziness such as benign paroxysmal positional vertigo (BPPV) or vestibular neuritis 1
• Failing to consider CVST in patients without the classic headache 1
• Relying solely on non-contrast CT, which has limited sensitivity for CVST 1
• Dismissing the possibility of CVST in patients with normal D-dimer levels 1

Management Considerations

If CVST is diagnosed, prompt treatment is crucial:

• Anticoagulation with heparin (unfractionated or low molecular weight) is the main intervention in the acute phase 3
• For patients with severe symptoms or who deteriorate despite anticoagulation, local thrombolysis or thrombectomy may be considered 3
• Long-term anticoagulation is typically continued for 3-12 months depending on underlying risk factors 4

Conclusion

While headache is the most common symptom of CVST, atypical presentations including isolated dizziness without headache can occur. Clinicians should maintain a high index of suspicion for CVST in patients with unexplained dizziness, especially when risk factors are present, as early diagnosis and treatment significantly improve outcomes.