From the Guidelines
Venous sinus thrombosis should be suspected in patients presenting with severe, progressive, and unresponsive headaches, especially when accompanied by focal neurological deficits, seizures, or altered mental status, as stated in the most recent guidelines 1. The clinical presentation of cerebral venous sinus thrombosis (CVT) can be highly variable, making it a diagnostic challenge. Key risk factors that should raise suspicion include:
- Pregnancy or postpartum state
- Oral contraceptive use
- Hypercoagulable states
- Dehydration
- Local infections (like mastoiditis or sinusitis)
- Recent head trauma or neurosurgical procedures These risk factors, combined with symptoms such as unusual headaches, seizures, or altered mental status, should prompt consideration of CVT, as noted in recent studies 1.
The onset of CVT is typically subacute, developing over days rather than hours. Papilledema on fundoscopic examination suggests increased intracranial pressure and should prompt consideration of this diagnosis. Nausea, vomiting, and visual disturbances may also be present. When CVT is suspected, urgent neuroimaging with MRI and MR venography is recommended for diagnosis, as CT scans may miss early thrombosis, according to the American College of Radiology 1.
It is essential to note that the diagnosis of CVT is typically based on clinical suspicion and imaging confirmation, as stated in the American Heart Association/American Stroke Association guidelines 1. Early diagnosis is crucial, as prompt anticoagulation therapy with heparin followed by warfarin or direct oral anticoagulants for 3-12 months (depending on the underlying cause) significantly improves outcomes and reduces mortality. The most recent guidelines emphasize the importance of initial imaging evaluation, focusing on the direct identification of clot and assessment for complications such as venous infarction and hemorrhage 1.
From the Research
Cerebral Venous Sinus Thrombosis Suspicion
Cerebral venous sinus thrombosis (CVST) should be suspected in various clinical scenarios, including:
- Patients presenting with sudden onset headaches, particularly those with thrombotic risk factors, such as the use of oral contraceptives, intracranial infections, and malignancy 2
- Individuals with a history of trauma, as traumatic cerebral venous sinus thrombosis is a rare but potentially devastating complication of head trauma 3, 4
- Patients with antiphospholipid syndrome (APS), as CVST is a rare but serious manifestation of venous thrombosis in APS patients 2
- Those presenting with symptoms such as headache, vomiting, blurred vision, loss of consciousness, seizures, and coma, which can be indicative of CVST 3
Clinical Presentation and Risk Factors
The clinical presentation of CVST can be non-specific and variable, with four major syndromes described:
- Isolated intracranial hypertension
- Seizures
- Focal neurological abnormalities
- Encephalopathy 5 Risk factors for CVST include:
- Female sex
- Intracranial hemorrhage
- Infection
- Cancer
- Trauma, particularly in pediatric populations 4
- Oral contraceptives
- Intracranial infections
- Malignancy 2
Diagnosis and Imaging
The diagnosis of CVST is confirmed through neuroimaging, with non-enhanced CT (NECT) of the head being the most frequently performed imaging study in the emergency department 5 Features of CVST on NECT can be divided into direct signs (demonstration of dense venous clot within a cerebral vein or a cerebral venous sinus) and indirect signs (such as cerebral edema or cerebral venous infarct) 5 CTV and MRI/MRV can also be used to confirm the diagnosis and provide a better description of parenchymal abnormalities 5