Symptoms of Cerebral Venous Sinus Thrombosis (CVST)
Headache is the cardinal symptom of CVST, occurring in nearly 90% of patients, and should be suspected when progressive and accompanied by signs of increased intracranial pressure such as papilledema or diplopia. 1, 2
Primary Clinical Manifestations
Headache (Most Common)
- Headache is present in almost 90% of CVST patients and can be the only manifestation in up to 25% of cases 1, 2
- The headache is typically diffuse and progressively worsens over days to weeks, distinguishing it from other primary headache disorders 2
- This progressive nature is a critical red flag that should prompt consideration of CVST, especially in high-risk populations 1
Seizures
- Seizures occur in 40% of CVST patients, presenting as either focal or generalized seizures 2
- Seizures represent a significant presenting feature and may be the initial manifestation in some patients 2, 3
Focal Neurological Deficits
- Hemiparesis and aphasia are the most common focal neurological signs when cerebral infarction or hemorrhage occurs due to venous thrombosis 1, 2
- These deficits arise from venous congestion leading to parenchymal damage and blood-brain barrier disruption 4
Signs of Increased Intracranial Pressure
Papilledema and Cranial Nerve Palsies
- Papilledema and diplopia (sixth nerve palsy) are common manifestations resulting from increased intracranial pressure 2
- Elevated opening pressure is present in more than 80% of CVST patients 1
- Ophthalmoscopic examination revealing bilateral papilledema should raise immediate suspicion for CVST 5
Altered Mental Status
- Altered mental status or decreased level of consciousness is a significant symptom, especially with deep venous system involvement 2
- Patients may present with altered sensorium ranging from confusion to deep coma 4, 6
- Loss of consciousness can be an initial presenting feature in severe cases 4
Additional Clinical Features
Associated Symptoms
- Nausea and vomiting frequently accompany the headache and increased intracranial pressure 7, 3
- Ataxia, speech impairment, and cranial nerve palsies may be present depending on the location of thrombosis 3
- Fever may be present, particularly when there is an underlying infectious or inflammatory process 7
Clinical Pitfalls and Caveats
The most common pitfall is dismissing CVST as "just another headache" because the presentation can be non-specific, particularly in young patients without apparent risk factors 5. The key distinguishing features are:
- Progressive worsening over days to weeks rather than acute onset 2
- Combination of headache with any focal neurological signs, seizures, or papilledema should trigger immediate imaging 1, 2
- High index of suspicion is required in young women on oral contraceptive pills presenting with severe neurological dysfunction 7
- Comatose patients with intracranial hemorrhage on imaging carry the highest risk of fatal outcome 6