What are the typical presenting symptoms of cerebral venous sinus thrombosis?

Symptoms of Cerebral Venous Sinus Thrombosis

Headache is the cardinal symptom of cerebral venous sinus thrombosis, 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

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 2
• The headache is typically diffuse and progressively worsens over days to weeks, distinguishing it from other acute headache syndromes 1
• Consider CVST in any patient with progressive headache, particularly when accompanied by signs of increased intracranial pressure 2

Seizures (Second Most Common)

• Seizures occur in 40% of patients, presenting as both focal and generalized types 1, 3
• Seizures are particularly common when cortical vein thrombosis leads to hemorrhagic infarction 3

Focal Neurological Deficits

• Hemiparesis and aphasia are the most common focal deficits when cerebral infarction or hemorrhage occurs due to venous thrombosis 2, 1
• These deficits occur when venous congestion progresses to venous infarction 3

Signs of Increased Intracranial Pressure

• Papilledema is present in more than 26-80% of patients and represents elevated intracranial pressure 2, 1, 4
• Diplopia from sixth nerve palsy is a common manifestation of increased intracranial pressure 1
• Elevated opening pressure on lumbar puncture is found in more than 80% of patients 2

Altered Mental Status

• Altered mental status is particularly significant with deep venous system involvement, including mental obtundation, bradyphrenia, or apathy 1, 5
• Deep cerebral venous sinus thrombosis often presents early with neuropsychological deficits, which aids in distinguishing this subtype 5

Associated Symptoms

• Nausea and vomiting are common accompanying symptoms, present in up to 90% of patients 4
• Visual abnormalities including impaired vision and altered spatial sensation may occur 6
• Fever may be present in 38% of cases, often indicating an underlying infectious etiology 4

Clinical Pitfalls and Key Points

• CVST presents with non-specific symptoms that can delay diagnosis, requiring a high index of suspicion 6, 7
• The presentation varies significantly based on which venous structures are involved—deep venous system involvement causes more prominent mental status changes, while cortical vein thrombosis more commonly presents with seizures and focal deficits 3, 5
• Bilateral thalamic lesions on imaging suggest deep venous system involvement and correlate with altered mental status 1
• The combination of progressive headache, seizures, focal neurological deficits, or altered consciousness should prompt immediate consideration of CVST 6