What are the symptoms of Cerebral Venous Sinus Thrombosis (CVST)?

Symptoms of Cerebral Venous Sinus Thrombosis (CVST)

Headache is the most common symptom of CVST, occurring in nearly 90% of patients, typically diffuse and progressively worsening over days to weeks. 1

Primary Clinical Manifestations

CVST symptoms generally fall into two major categories:

1. Symptoms related to increased intracranial pressure:

   • Headache (90% of cases) - may be:
     • Diffuse and progressively worsening
     • Thunderclap-like in some cases
     • Migrainous in character
     • Isolated (without other symptoms) in up to 25% of patients
   • Papilledema
   • Diplopia (from sixth nerve palsy)
   • Visual disturbances
   • Nausea and vomiting

2. Symptoms related to focal brain injury (from venous ischemia/infarction or hemorrhage):

   • Focal neurological deficits (most commonly hemiparesis and aphasia)
   • Seizures (occurring in 40% of patients)
   • Altered consciousness
   • Sensory symptoms
   • Psychosis (when accompanied by focal neurological signs)
   • Bilateral motor signs including paraparesis (particularly with sagittal sinus thrombosis)

Location-Specific Symptoms

Symptoms vary based on the affected venous sinus 1:

• Superior sagittal sinus thrombosis:

  • Headache
  • Increased intracranial pressure
  • Papilledema
  • Motor deficits
  • Seizures
  • Scalp edema
  • Dilated scalp veins

• Lateral sinus thrombosis:

  • Headache
  • Pain in ear or mastoid region
  • Constitutional symptoms
  • Fever (especially with underlying ear infection)
  • Ear discharge
  • Increased intracranial pressure
  • Distended scalp veins
  • Hemianopia, contralateral weakness, and aphasia (with cortical involvement)

• Deep cerebral venous system thrombosis (16% of cases):

  • Rapid neurological deterioration
  • Altered consciousness without focal signs (with bilateral thalamic involvement)
  • Thalamic or basal ganglia infarction

Timing of Symptom Onset

The onset of symptoms in CVST is variable 1:

• Acute (<48 hours): 37% of patients
• Subacute (>48 hours to 30 days): 56% of patients
• Chronic (>30 days): 7% of patients

Diagnostic Challenges

CVST is often misdiagnosed due to:

• Varied and non-specific clinical presentation
• Isolated headache without other symptoms in 25% of cases
• Symptoms that mimic other neurological disorders 2
• Median delay from symptom onset to diagnosis is 7 days 1

Key Distinguishing Features

Several clinical features help distinguish CVST from other cerebrovascular diseases 1:

• Frequent seizures (40% of patients)
• Bilateral brain involvement
• Slowly progressive symptoms
• Headache as the predominant symptom
• Presence of risk factors (oral contraceptives, pregnancy, infection)

Warning Signs Requiring Urgent Evaluation

• Thunderclap headache
• Rapidly worsening neurological deficits
• Seizures
• Altered consciousness
• Papilledema with headache
• Bilateral motor signs

Early recognition of these symptoms is critical as prompt treatment significantly reduces mortality and improves outcomes 3, 4.