Does transverse sinus thrombosis cause seizures and how should it be managed?

Transverse Sinus Thrombosis and Seizures

Yes, transverse sinus thrombosis can cause seizures, which occur in approximately 40% of cerebral venous thrombosis (CVT) cases, and these seizures can resolve with appropriate treatment including anticoagulation even in the presence of hemorrhagic complications. 1

Seizure Occurrence in Transverse Sinus Thrombosis

Incidence and Characteristics

• Seizures are a frequent complication of CVT, occurring in 40% of patients, distinguishing venous thrombosis from arterial stroke 1
• The incidence of acute symptomatic seizures (within first 14 days) ranges from 6.9-76%, with post-CVT epilepsy (after 14 days) occurring in 4-16% of cases 2
• Both focal and generalized seizures can occur, with generalized tonic-clonic seizures commonly observed 1, 3

Mechanism and Predictors

• Seizures result from venous congestion causing cortical irritation, venous ischemia, or hemorrhagic transformation 1
• Key predictors for acute seizures include: loss of consciousness, focal neurological deficits, supratentorial lesions, and involvement of superior sagittal sinus, straight sinus, or cortical veins 2
• Transverse sinus thrombosis specifically can cause seizures when associated with cortical vein involvement or hemorrhagic complications 1, 3

Management Approach

Anticoagulation Remains First-Line Even With Hemorrhage

• Therapeutic anticoagulation with heparin should be initiated and continued even when intracranial hemorrhage develops from venous congestion 1, 4
• The AHA/ASA guidelines explicitly recommend continuing anticoagulation in CVT patients who develop hemorrhage, as this represents venous congestion rather than arterial bleeding 1
• A retrospective study showed complete recovery in 52% of CVT patients with hemorrhage who received heparin, compared to only 23% complete recovery (with 69% mortality) in those who did not receive anticoagulation 1

Seizure Management

• Antiepileptic drugs should be initiated after the first seizure in patients with supratentoral lesions or focal neurological deficits 2
• Primary prophylaxis with antiepileptics in the acute phase without seizures is not routinely indicated 2
• Lacosamide or levetiracetam are commonly used agents for acute seizure management in this setting 1

Critical Decision Points for Anticoagulation Interruption

• Anticoagulation should only be discontinued if there is hemorrhage expansion with mass effect causing herniation signs (bilateral extensor posturing, dilated pupils, acute deterioration) 1
• In such cases, hyperosmolar therapy (mannitol, hypertonic saline) should be initiated immediately while considering surgical evacuation 1
• Once mass effect is controlled surgically, anticoagulation can be resumed 1

Prognosis and Resolution

Excellent Recovery Potential

• Among patients with CVT complicated by hemorrhage and seizures, 81% achieved complete neurological recovery with appropriate treatment 1
• Seizures typically resolve as the venous thrombosis is treated and venous drainage is restored 3
• Recanalization of the thrombosed sinus correlates with clinical improvement and seizure resolution 3

Common Pitfalls to Avoid

• Do not withhold anticoagulation due to presence of intracranial hemorrhage - this is venous congestion bleeding, not arterial, and requires anticoagulation for resolution 1
• Do not miss the diagnosis in patients with isolated headache and papilledema - this occurs in up to 25% of CVT cases and represents a major diagnostic challenge 1, 5
• Consider CVT in any young patient with unexplained intracerebral hemorrhage, as this may be the presenting feature 4
• Bilateral symptoms or bilateral motor deficits should immediately raise suspicion for sagittal or transverse sinus involvement, as this pattern is characteristic of venous pathology 1, 5