Synopsis
Recognise cerebral venous sinus thrombosis across headache, seizure and focal-deficit presentations, confirm it with venous imaging, and start anticoagulation and raised-pressure management safely in specialist care.
- Cerebral venous thrombosis is an uncommon but treatable cause of headache, intracranial hypertension, seizure, focal deficit, encephalopathy or haemorrhagic venous infarction.
- Risk is increased by pregnancy and the puerperium, oestrogen-containing contraception, malignancy, inflammatory disease, infection, dehydration, inherited thrombophilia and previous venous thromboembolism.
- Headache may be progressive, thunderclap or the only symptom; papilloedema, diplopia from sixth-nerve palsy, focal seizure or a deficit crossing conventional arterial territories should raise suspicion.
Key red flags
Declining consciousness, new pupillary abnormality or extensor posturing indicates mass effect or herniation and needs immediate neurocritical and neurosurgical action.
Investigation priorities
Demonstrate absent filling or thrombus in dural sinuses and cortical veins rapidly alongside emergency CT.
Management branches
Headache is new or progressive with papilloedema, seizure, focal signs or a prothrombotic context.
- Assess consciousness, pupils, focal neurology, fundi, pregnancy or postpartum status, infection and VTE risk while treating seizures or instability.
- Obtain urgent CT brain plus CT venography, or MRI with MRV when clinically and logistically appropriate; do not stop at a normal unenhanced CT.
Key medicines
EnoxaparinUse a therapeutic weight-based subcutaneous regimen, commonly 1 mg/kg every 12 hours, adjusted for renal function, body weight, pregnancy and the local anticoagulation protocol.
Unfractionated heparinGive an intravenous loading and infusion regimen titrated by the hospital heparin protocol when rapid reversibility, severe renal impairment or an urgent procedure makes it preferable.