QuestionSBA
QuestionChoice
Evidence suggests that low molecular weight heparin results in better outcomes than unfractionated heparin (UFH) for initial anticoagulation in cerebral venous sinus thrombosis. UFH may be considered in patients with renal impairment or those requiring very rapid reversal of anticoagulation, e.g. imminent surgical intervention
32100
c
Unfractionated heparin
QuestionChoice
Direct oral anticoagulants can be considered for longer-term prophylaxis of venous thromboembolism
32102
e
Dabigatran
QuestionChoice
In cerebral venous sinus thrombosis, recurrent seizures are more likely to develop in those who present with seizures and in those with supratentorial brain lesions on imaging. This would not be appropriate in the initial management, but may be considered later on for seizure prophylaxis
32099
b
Valproate
QuestionChoice
This patient has presented with cerebral venous sinus thrombosis, for which the initial management would be subcutaneous low molecular weight heparin
32098
a
Low molecular weight heparin
QuestionChoice
This may be considered after the acute stage for longer-term prophylaxis of further cerebral and extracerebral venous thrombosis (i.e. deep vein thrombosis, pulmonary embolism). It would not be appropriate to start warfarin acutely as it has prothrombotic activity on initiation
32101
d
Warfarin
Concept
Chapter
# Summary

Central Venous Sinus Thrombosis (CVST) is a rare but serious condition involving the occlusion of cerebral venous sinuses. It primarily affects younger individuals, with women at higher risk, particularly those of childbearing age. Risk factors include hormonal influences, prothrombotic conditions, systemic diseases, and local factors like trauma or infection. Symptoms are variable but often include headaches, neurological deficits, and seizures. Diagnosis is typically confirmed with imaging, such as CT venogram. Management involves anticoagulation therapy, usually starting with low molecular weight heparin and possibly transitioning to Warfarin, along with addressing underlying causes.

# Definition

Central Venous Sinus Thrombosis (CVST) refers to occlusion of venous vessels in sinuses of the cerebral veins

# Epidemiology

CVST has an incidence of approximately 3-4 cases per million people per year. Representing 0.5%-3% of all the types of stroke, affecting predominantly younger people. Women are affected more than men and mostly between the ages of 20 and 35. This is hypothesised to be due to pregnancy and the use of the COCP.

# Risk factors

Risk factors are similar to those for venous thromboembolism and include: 

- Hormonal factors (the pill, pregnancy, and the peri-partum period)
- Prothrombotic haematological conditions or malignancy
- Systemic disease (such as dehydration or sepsis)
- Local factors (skull abnormalities, trauma, or local infection
-

# Presentation

- Presentation is variable but common symptoms include headache, confusion/drowsiness, impaired vision, and nausea/vomiting.

- Other signs include seizures, reduced consciousness, focal neurological deficits, cranial nerve palsies, and papilloedema.

# Investigations

- Non-contrast CT reveals a hyperdensity in the affected sinus.

- CT venogram is used to look for a filling defect ('the empty delta sign').

The most common form of dural venous thrombosis affects the superior sagittal sinus.

Cavernous sinus thrombosis is less common. It is typically caused by spreading sinus infection and presents with chemosis, exophthalmos, and peri-orbital swelling.

# Management

The mainstay of treatment is with low molecular weight heparin (LMWH) and addressing any underlying risk factors that may increase risk of clotting e.g. cancer, autoimmune disease.

Following initial therapy with LMWH, this can be further bridged to a vitamin K antagonist such as Warfarin. 

# References

[Click here for more info on intracranial venous thrombosis](https://patient.info/doctor/intracranial-venous-thrombosis)
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Neurology
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Central Venous Sinus Thrombosis
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Quesmed Tutorial: Advanced Neurology
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Central Venous Sinus Thrombosis
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Intracranial Venous Thrombosis
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Cerebral venous sinus thrombosis is managed acutely with low molecular weight heparin to prevent further thrombus formation.
A 45-year-old woman develops a persistent headache of 4 days duration, not resolving with over the counter painkillers. She presented to Accident & Emergency with bilateral eye pain and blurred vision. At triage, she suffers a generalised tonic-clonic seizure which is terminated with one dose of IV lorazepam. Computed tomography (CT) brain was done immediately, which showed a large clot in the cavernous sinus.

Which is the next best step in acute management?
a