Cerebral venous sinus thrombosis is one of the serious causes of headache.
Over 90% will report headache prior to diagnosis.
It can usually cause two main types of headache:
Pregnancy is a risk factor for thrombosis.
Usually there are other clinical signs to indicate that this may be one of the more dangerous headaches.
New onset seizures, or a stroke in a young person or woman on the oral contraceptive pill or who is pregnant should also raise this condition as a potential diagnosis.
This is a new onset headache in someone with no previous headache history
There may past medical history to suggest the person is at increased risk of their blood clotting too readily - a pro-thrombotic disorder.
Vomiting, and worsening of headache with straining, lying or coughing.
Papilloedema or visual obscurations.
Isolated CSF protein elevation (usually modest e.g. 0.6g/l).
Unexplained high CSF pressure at Lumbar Puncture.
The venous sinuses are the final drainage channels for blood from the head.
In the brain, capillaries merge to form cortical veins. These veins then merge and flow into venous channels made by folds of dura mater.
The main venous channel that runs along the middle, for the entire length of the brain is the superior saggital sinus. There is also an inferior saggital sinus. The other sinus that is commonly thrombosed is the transverse or lateral sinus. (Images courtesy of Bartleby.com: Creative Commons License).
Superior saggital sinus thrombosis is more likely to be associated with stroke, but transverse or lateral sinus thrombosis is more likely to cause raised intracranial pressure.
In summary, to make a diagnosis you need
Like all acute headaches, some level of diagnostic suspicion is needed.
If you are not considering CVST you are quite likely to not find it.
A plain CT brain will only show changes in 20% of cases.
Specific imaging - like CT Venography or MR Venography is necessary. The choice between CT and MR Venography will mostly be determined by local availability and local expertise.
In our hospital we have better resolution on CT Venography, so it is the modality of choice for me. Most publications will recommend MR Venography - but you need to discuss the modalities with your radiologist.
Properly performed CT venography and MR Venography will stand a high chance of correctly identifying cerebral venous sinus thrombosis. Thrombosis of a cortical vein (cortical vein thrombosis) may require formal catheter angiography for diagnosis.
In any acute headache, if CT Brain is normal, then Lumbar Puncture should be performed, especially if thunderclap headache occurred.
Suspected raised intracranial pressure also means that Lumbar Puncture is necessary (as long as CT Brain scan does not demonstrate an abnormality that contraindicates Lumbar Puncture - e.g. mass effect with lateral brain shift).
The Cerebrospinal fluid in venous sinus thrombosis is often at high pressure (>20cm pressure) and has a slightly elevated protein concentration.
Subarachnoid haemorrhage can be caused by venous sinus thrombosis, and most neurologists will have seen a case of CVST present with subarachnoid haemorrhage. Therefore bilirubin may be detected on cerebrospinal fluid analysis for xanthochromia (using spectrophotometry).
It is accepted that anti-coagulation with intravenous unfractionated heparin or high dose subcutaneous low molecular weight heparin is necessary.
This should be followed by at least 3 months of anti-coagulation, although I note that in one series the mean duration of warfarin (Coumadin) use was 9 months. I have recommended 6 months in my own cases.
The recent reports of isolated venous sinus
thrombosis causing headache without stroke or seizures had a good
I suspect many people have presented for assessment of new onset headaches which resolved over several weeks. These people probably did have dural sinus thrombosis, such as the transverse sinus, but fortunately their problem resolved itself.
However, a small number have a catastrophic outcome, and once seen is never forgotten. I also know cases where there have been persistent headaches that are very difficult to treat satisfactorily.
Overall the risk of recurrence is about 12% in one series of 154 people (20 had a recurrent thrombotic event).
If you found this page helpful, why not share on Facebook or Twitter:
Keep up to date by subscribing to the monthly newsletter.
If there are no references listed, please notify me, as this box should contain a list of information sources, or a link to a 'Systematic Review' of the topic discussed on this page.
Preter M, et al. Long-term prognosis in CVST: follow-up of 77 patients. Stroke. 1996;27:243-246.
Cantu & Barinagarrementeria. CVST associated with pregnancy and puerperium: review of 67 cases. Stroke. 1993;24:1880-1884.
Kimber J. Cerebral Sinus Thrombosis QJM; 2002; 95: 137 - 142.
Cumurciuc R et al JNNP 2005;76:1084-7. 17 cases presenting as isolated headache.
Gosk-Bierska I et al. CVST: Incidence of venous thrombosis recurrence and survival. Neurology. 2006;67:814-9.
Allroggen and Abbott Cerebral venous sinus thrombosis Postgrad Med J.2000; 76: 12-15
de Bruijn et al. Clinical features and prognostic factors of cerebral
venous sinus thrombosis in a prospective series of 59 patients. J Neurol
Neurosurg Psychiatry. 2001;70:105-8.
Georgiadis et al. Cerebral sinus thrombosis presenting with cluster-like
headache. Cephalalgia 2006;27:79-82.
Stam J. Thrombosis of the Cerebral Veins and Sinuses NEJM 2005;352:1791-8.