Cerebral Venous Thrombosis Clinical Presentation

Updated: Oct 09, 2018
  • Author: W Alvin McElveen, MD; Chief Editor: Helmi L Lutsep, MD  more...
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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.