Cerebral venous sinus thrombosis (CVST) is a rare, potentially life-threatening condition characterized by the formation of a blood clot within the dural sinuses. Most cases are associated with pregnancy, combination estrogen-progestin contraception, malignancy, infection, or head trauma.
As the dural sinuses drain cerebrospinal fluid and venous blood from the brain, obstruction usually causes:
MRI of the brain with magnetic resonance venography is usually diagnostic. Patients are typically treated with low-molecular-weight heparin to recanalize the obstructed sinus and prevent thrombus propagation. Although hemorrhagic foci or infarctions may be present on imaging, anticoagulation does not seem to increase the risk of clinically consequential brain hemorrhage.
Systemic thrombolysis is not considered a first-line therapy for CVST and is generally contraindicated during pregnancy.
A 20-year-old woman, gravida 1 para 0, comes to the emergency department due to severe headache and right-sided weakness. She has had a constant, dull headache for the past week. The pain is greatest when she awakens in the morning. Coughing or straining worsens the pain and causes transient blurry vision. When the patient awoke this morning she was unable to stand due to right leg weakness, and she had difficulty calling for help because she could not pick up the phone with her right hand. She has no prior medical issues. The patient is at 24 weeks gestation and had nausea and vomiting during the first trimester, but she has had no other pregnancy-related complications. Her only medication is a daily prenatal multivitamin. She stopped smoking cigarettes and drinking alcohol once she learned she was pregnant, and she has no history of illicit drug use. Her sister has a history of pulmonary embolism. Temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is 80/min and regular, and respirations are 16/min. Bilateral pupils are equal, round, and reactive. Funduscopy shows bilateral papilledema. Neurologic examination is notable for right-sided motor weakness with pronator drift and Babinski sign on the right. Sensation is intact, and she has normal mentation. Meningeal signs are absent. Neuroimaging reveals intraluminal thrombus in the sagittal sinus and a small area of intraparenchymal hemorrhage. Which of the following is the best next step in management of this patient?