History

Patients with cerebral venous thrombosis (CVT) may present with headache.^[14]Although thunderclap headache usually indicates subarachnoid hemorrhage (SAH), it may also be seen in sinus thrombosis.

SAH has been described as the presenting event with CVT. CVT should be considered in the workup of SAH, especially when the basilar cisterns are not involved.^[15]

Patients with lateral sinus thrombosis may present with a pseudotumor cerebri–like syndrome. Using a technique called auto-triggered elliptic-centric-ordered 3-dimensional gadolinium-enhanced magnetic resonance venography (MRV), Farb et al found that 27 of 29 patients with idiopathic intracranial hypertension had bilateral sinovenous stenosis; this was seen in only 4 of 59 control subjects.^[16]

Nausea and vomiting may also be associated with CVT. In some cases, seizures, which can be recurrent, occur. Some patients may experience a decreased level of consciousness that progresses to coma.

Focal neurologic deficit may develop, depending on the area involved. Hemiparesis may occur, and in some cases of sagittal sinus thrombosis, weakness may develop in the lower extremity. This also may occur as bilateral lower extremity involvement. Aphasia, ataxia, dizziness, chorea, and hemianopia all have been described.

Cranial nerve syndromes are seen with venous sinus thrombosis. These include the following:

Vestibular neuronopathy
Pulsatile tinnitus
Unilateral deafness
Double vision
Facial weakness
Obscuration of vision

Site of headache versus location of sinus involvement

Wasay et al found little association between headache location and the site of sinus involvement in patients with CVT. In their study, the authors described the pattern and location of headache in 200 consecutive patients with a proven diagnosis of CVT to identify an association between the site of the headache and location of sinus involvement. The quality of headache was reported as throbbing (9%), bandlike (20%), thunderclap (5%), and other (pounding, exploding, stabbing, etc) (20%).

The authors found no association between headache location and the site of sinus thrombosis except in cases of sigmoid sinus thrombosis, in which 17 of 28 patients (61%) with involvement of the sigmoid sinus alone or in combination with the transverse sinus had pain in the occipital and neck region. There was no association between lateralization of pain and the site of thrombosis.^[17]

Physical Examination

The effect of cerebral venous thrombosis (CVT) on mental status is quite variable, with some patients showing no change in alertness, others developing mild confusion, and still others progressing to coma.

Cranial nerve findings may include papilledema, hemianopia, oculomotor and abducens palsies, facial weakness, and deafness. If the thrombosis extends to the jugular vein, the patient may develop involvement of cranial nerves IX, X, XI, and XII with the jugular foramen syndrome.

Thrombosis of the superior sagittal (longitudinal) sinus may present with unilateral paralysis that then extends to the other side secondary to extension of the clot into the cerebral veins. Because of the location, this may present as a unilateral lower extremity weakness or paraplegia.

Cavernous sinus thrombosis with obstruction of the ophthalmic veins may be associated with proptosis and ipsilateral periorbital edema. Retinal hemorrhages and papilledema may be present. Paralysis of extraocular movements, ptosis, and decreased sensation in the first division of the trigeminal nerve often are observed.

Although unusual, cortical vein thrombosis may be seen in the absence of dural sinus involvement. These cases are associated with varied focal deficits, including aphasia, hemiparesis, hemisensory loss, and hemianopia.

Differential Diagnoses

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Media Gallery

Left lateral sinus thrombosis demonstrated on magnetic resonance venography (MRV). This 42-year-old woman presented with sudden onset of headache. Physical examination revealed no neurologic abnormalities.
Same patient as in the previous image. One week after treatment with heparin, the magnetic resonance (MR) venogram displayed increased flow in the left lateral sinus consistent with early recanalization of the sinus; headache had resolved at this point.
Magnetic resonance venogram (MRV) - axial view; A = lateral (transverse) sinus; B = sigmoid sinus; C = confluence of sinuses; and D = superior sagittal sinus.
Magnetic resonance venogram (MRV) - sagittal view; A = lateral (transverse) sinus; C = confluence of sinuses; D = superior sagittal sinus; and E = straight sinus.
Computed tomography (CT) scan demonstrates a left posterior temporal hematoma in a 38-year-old woman on oral contraceptives (the only identified risk factor).
Contrast-enhanced magnetic resonance imaging (MRI) scan showing lack of filling of left transverse sinus.
Axial view of magnetic resonance (MR) venogram demonstrating lack of flow in transverse sinus.
Coronal view of magnetic resonance (MR) venogram demonstrating lack of flow in the left transverse and sigmoid sinuses.

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Author

W Alvin McElveen, MD Director, Stroke Unit, Lakewood Ranch Medical Center; Neurologist, Manatee Memorial Hospital

W Alvin McElveen, MD is a member of the following medical societies: American Academy of Neurology, Southern Clinical Neurological Society, American Stroke Association, American Medical Association, American Society of Neuroimaging

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew P Keegan, MD Private Practice, Bradenton Neurology, Inc; Consulting Staff, Department of Neurology, Manatee Memorial Hospital, Lakewood Ranch Medical Center, Blake Medical Center

Andrew P Keegan, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Acknowledgements

Ralph F Gonzalez, MD Private Practice, Bradenton Neurology, Inc; Consulting Staff, Department of Neurology, Blake Hospital, Lakewood Ranch Medical Center, Manatee Memorial Hospital

Ralph F Gonzalez, MD is a member of the following medical societies: American Academy of Neurology and Florida Medical Association

Disclosure: Nothing to disclose.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Norman C Reynolds Jr, MD Neurologist, Veterans Affairs Medical Center of Milwaukee; Clinical Professor, Medical College of Wisconsin

Norman C Reynolds Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, Movement Disorders Society, Sigma Xi, and Society for Neuroscience

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment