What are the typical features and treatment of cerebral venous sinus thrombosis?

Typical Features of Cerebral Venous Sinus Thrombosis (CVST)

Headache is the most common symptom of CVST, occurring in nearly 90% of patients, and is typically diffuse and progressively worsens over days to weeks. 1 CVST presents with a combination of symptoms related to increased intracranial pressure and focal brain injury from venous ischemia or hemorrhage.

Clinical Presentation

Common Symptoms

• Headache (90% of cases) - diffuse, progressive, and may occasionally present as thunderclap headache 1
• Seizures (40% of patients) - both focal and generalized 1
• Focal neurological deficits - most commonly hemiparesis and aphasia 1
• Papilledema and diplopia (sixth nerve palsy) due to increased intracranial pressure 1
• Altered mental status - especially with deep venous system involvement 1

Timeline of Symptom Onset

• Acute (<48 hours): 37% of patients 1
• Subacute (>48 hours to 30 days): 56% of patients 1
• Chronic (>30 days): 7% of patients 1

Location-Specific Manifestations

Superior Sagittal Sinus (Most Common)

• Headache and increased intracranial pressure 1
• Papilledema 1
• Motor deficits and seizures 1
• Scalp edema and dilated scalp veins 1
• Bilateral motor signs including paraparesis 1

Lateral Sinus

• Constitutional symptoms, fever (especially with underlying middle ear infection) 1
• Ear discharge and pain in ear/mastoid region 1
• Hemianopia, contralateral weakness, and aphasia 1

Deep Cerebral Venous System (16% of cases)

• Rapid neurological deterioration 1
• Altered consciousness without focal deficits 1
• Thalamic or basal ganglia infarction 1
• Bilateral thalamic involvement 1

Distinguishing Features from Other Cerebrovascular Diseases

• High frequency of seizures (40% of patients) 1
• Bilateral brain involvement, especially with deep venous system thrombosis 1
• Ischemic lesions that cross arterial boundaries (particularly with hemorrhagic component) 1
• Slowly progressive symptoms with delayed diagnosis (median 7 days from symptom onset to diagnosis) 1

Diagnostic Findings

Laboratory Tests

• D-dimer may be elevated, but a normal level doesn't exclude CVST (especially with limited clot burden) 1
• Routine blood studies (CBC, chemistry, PT, aPTT) should be performed 1
• Screening for prothrombotic conditions (contraceptives, inflammatory disease, infection) 1

Imaging

• Non-contrast CT is often normal (abnormal in only 30% of cases) 1
• CT may show hyperdensity of cortical vein/dural sinus or "empty delta" sign on contrast-enhanced CT 1
• MRI with MR venography is more sensitive than CT for detecting CVST 1
• Ischemic infarction with hemorrhagic component crossing arterial boundaries is suggestive of CVST 1

Common Pitfalls in Diagnosis

• Isolated headache without focal neurological findings (25% of patients) 1
• Isolated mental status changes, especially in elderly and with deep venous system thrombosis 1
• Normal CT scan, especially early in the clinical course 1
• Delayed diagnosis (median delay from symptom onset to diagnosis: 7 days) 1

Risk Factors

• Prothrombotic conditions 1
• Oral contraceptive use 2
• Pregnancy and puerperium 2
• Infection (particularly common in developing countries) 2
• Dehydration 1

Early recognition of these typical features is crucial as prompt diagnosis and treatment significantly impact morbidity and mortality outcomes in patients with CVST.