1. Cerebral Venous Sinus Thrombosis
Brandon Friedman, MD, Madison Watts, MD,
Faith Meyers, MD, Steven Perry, MD
Carolinas Medical Center & Levine Children’s Hospital
Department of Emergency Medicine
Michael Gibbs, MD, Imaging Mastery Project Lead Editor
Neuroimaging Mastery Project
Presentation #2

2. Disclosures
 This ongoing imaging interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of imaging interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Meet Our Neuroimaging Editorial Team
Andrew Asimos, MD, FACEP
Medical Director, Atrium Health Stroke Network
Neurosciences Institute
Clinical Professor, Department of Emergency Medicine
Jonathan Clemente, MD, FACR
Chief, Department of Radiology, Carolinas Medical Center
Charlotte Radiology, Neuroradiology Section
Adjunct Clinical Associate Professor, Department of Radiology
Andrew Perron, MD, FACEP
Associate Dean of Graduate Medical Education and DIO
Professor of Emergency Medicine
Department of Graduate Medical Education
Dartmouth Hitchcock Medical Center

4. Meet Our Neuroimaging Editorial Team
Christa Swisher, MD, FNCS, FACNS
Neurocritical Care/Pulmonary Critical Care Consultants
Department of Medicine, Atrium Health
Clinical Assistant Professor, Department of Neurology
Scott Wait, MD, FAANS
Chief, Pediatric Neurosurgery, Levine Children’s Hospital
Carolina Neurosurgery & Spine Associates
Adjunct Clinical Associate Professor, Department of Neurosurgery

5. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

6. Cerebral Venous Sinus Thrombosis
Cases From Carolinas Medical Center

7. Case #1
A 31-year-old female undergoing invitro fertiliation with hormone
supplementation presented to the ED with 12 hours of headache, visual loss,
and difficulty speaking.
Her Neurological Exam Demonstrated:
• Clear mental status and a normal level of alertness
• Intact upper/lower extremity motor and sensory function
• No facial weakness or numbness
• A right visual field cut (homonymous hemianopsia)
• Expressive and receptive aphasia
• Normal gait without ataxia or unsteadiness
Given these findings a CODE Stroke evaluation was initiated

8. Non-Contrast CT: hemorrhagic infarct of the left temporal lobe.
31-Year-Old Presents with Headache, Impaired Vision, and Aphasia.

9. 31-Year-Old Presents with Headache, Impaired Vision, and Aphasia.
The infarct is anatomically adjacent to two temporal lobe venous sinuses.

10. 31-Year-Old Presents with Headache, Impaired Vision, and Aphasia.
The infarct overlaps two arterial vascular territories: the MCA and the PCA.

11. Reviewing The Data That We Have So Far:
1. The patient is young
2. She is currently undergoing exogenous hormone therapy
3. Her head CT demonstrates an acute hemorrhage that:
- Is anatomically adjacent to two large venous sinuses
- Crosses over two arterial vascular territories (MCA + PCA)
This prompted the team to order a CT venogram
31-Year-Old Presents with Headache, Impaired Vision, and Aphasia.

12. 31-Year-Old Presents with Headache, Impaired Vision, and Aphasia.
CT Venogram: filling defect (→) of the left transverse & sigmoid sinuses.
This explains the acute venous infarct of the left temporal lobe.

13. 31-Year-Old Presents with Headache, Impaired Vision, and Aphasia.
These finding are diagnostic of a Cerebral Venous Sinus Thrombosis (CVST).

14. Case #2
A 32-year-old female with a recent Cesarian section complicated by chorioamnionitis,
now on medroxyprogesterone acetate injections presented to the ED with 1 week of
intermittent headaches, right upper extremity numbness, and syncope.
Further History Noted:
• 1 week of intermittent diffuse headaches; with a maximum intensity of 9/10
• No prior personal or family history of headaches or migraines
• Intermittent numbness of the right arm for one week; without weakness
• Two syncopal episodes; once yesterday and once right before ED presentation
Neurological Exam:
• Fully alert, no cranial nerve deficits, normal and equal strength bilaterally, intact
sensation in all dermatomes, normal cerebellar testing, normal gait
A CODE Stroke was not activated; but she underwent a rapid non-contrast head CT

15. Non-Contrast CT: hyperdense appearance (→) of the superior sagittal sinus and cortical veins.
32-Year-Old Presents with Headache, Right Arm Numbness, and
Syncope.

16. 32-Year-Old Presents with Headache, Right Arm Numbness, and
Syncope.
The area of hyperdensity corresponds to the location of the superior sagittal sinus.

17. 32-Year-Old Presents with Headache, Right Arm Numbness, and
Syncope.
The hyperdensity overlaps two arterial vascular territories: the ACA and the PCA.

18. 32-Year-Old Presents with Headache, Right Arm Numbness, and
Syncope.
Reviewing The Data That We Have So Far:
1. The patient is young
2. She is receiving medroxyprogesterone injections
after her recent delivery by C-section
3. Her head CT demonstrates a midline hyperdensity
that:
- Overlies the location of the superior sagittal sinus
- Crosses 2 arterial vascular territories (ACA + PCA)
This prompted the team to order a CT venogram

19. CT Venogram: filling defect (→) of the superior sagittal sinus, right transverse
sinus, right sigmoid sinus, and right internal jugular vein.
32-Year-Old Presents with Headache, Right Arm Numbness, and
Syncope.

20. These finding are diagnostic of a Cerebral Venous Sinus Thrombosis (CVST).
32-Year-Old Presents with Headache, Right Arm Numbness, and
Syncope.

21. Case #3
A 19-year-old female with recent admission for aseptic meningitis presented to the ED after a
transient right sided hemiparesis and a seizure-like episode, now reporting a headache.
Further History Noted:
• The patient was admitted one month prior for aseptic meningitis from which she recovered
• Sudden-onset right arm weakness when reaching for an object in the grocery store
• Subsequently experienced right leg weakness, making it difficult to ambulate
• The patient had a seizure-like episode enroute to the hospital; witnessed by friend
• Weakness resolved on arrival to the ED; now complaining of a headache
Neurological Exam:
• Alert, no cranial nerve deficits, normal and equal strength bilaterally, intact sensation in all
dermatomes, normal cerebellar testing, normal gait
A CODE Stroke was not activated; but she underwent a rapid non-contrast head CT

22. 19-Year-Old Presents with Headache, Right Hemiparesis, and Seizure.
Cortical veins branch off of the major cerebral venous sinuses.

23. 19-Year-Old Presents with Headache, Right Hemiparesis, and Seizure.
Non-Contrast CT: hyperdense cortical vein (→) over the left frontal convexity.

24. 19-Year-Old Presents with Headache, Right Hemiparesis, and Seizure.
Reviewing The Data That We Have So Far:
1. The patient is young
2. She has a recent admission for aseptic meningitis
3. She presented after a transient right-sided
hemiparesis and a seizure-like episode
4. Her head CT demonstrates a hyperdensity overlying
the distribution of a cortical vein, adjacent to the
superior sagittal sinus
This prompted the team to order an MRI/MRV

25. Brain MRI demonstrates: “Subtle loss of the flow void
involving the high superior sagittal sinus, which may
reflect a small amount of thrombosis extending into
the superior sagittal sinus.”
Brain MRV demonstrates: “A thrombosed cortical vein
overlying the left frontal and parietal lobes and
extending along the left lateral parietal convexity. No
flow related signal is identified in this vessel.”
Patent Right-
Sided Flow
Absent Left-
Sided Flow
19-Year-Old Presents with Headache, Right Hemiparesis, and Seizure.

26. These finding suggest
Cerebral Venous Sinus Thrombosis.
19-Year-Old Presents with Headache, Right Hemiparesis, and Seizure.

27. Case #4
A 51-year-old female started on oral contraceptives for heavy vaginal bleeding
presented to the ED for headaches, dizziness, and reported confusion by family.
Her Neurological Exam Demonstrated:
• Clear mental status and a normal level of alertness; normal speech
• No facial weakness or numbness; normal sensation in all dermatomes
• Diminished strength with right grip and right leg raise
• Right-sided pronator drift; no left-sided drift
• Right toe upgoing with Babinski reflex; reflexes otherwise normal
• Left-sided hemianopia on visual field testing
• Right arm ataxia with finger-to-nose testing; normal coordination otherwise
Patient received a rapid head CT without contrast at an outside ED

28. 51-Year-Old Presents with Headache, Dizziness, and Confusion.
Non-Contrast CT: Focal intraparenchymal hemorrhages (→) in the right parietal
and temporal lobes, with associated small-volume subarachnoid hemorrhage (→).

29. 51-Year-Old Presents with Headache, Dizziness, and Confusion.
The area of hemorrhage may correspond to the path of a cortical vein.

30. 51-Year-Old Presents with Headache, Dizziness, and Confusion.
The hemorrhage also appears to span multiple arterial territories.

31. 51-Year-Old Presents with Headache, Dizziness, and Confusion.
Reviewing The Data That We Have So Far:
1. The patient’s symptoms started shortly after she was started
on exogenous hormone therapy
2. Her head CT demonstrates an acute hemorrhage that:
- May correspond to the path of a cortical vein
- Crosses over multiple arterial vascular territories
This prompted the team to order a CT venogram, due to the
presence of an intraparenchymal hemorrhage of unknown origin

32. CT Venogram: filling defect (→) of the superior sagittal sinus – the “Empty Delta Sign.”
51-Year-Old Presents with Headache, Dizziness, and Confusion.

33. 51-Year-Old Presents with Headache, Dizziness, and Confusion.
MRV: confirmed the presence of superior sagittal sinus thrombosis.

34. These finding are diagnostic of a Cerebral Venous Sinus Thrombosis (CVST).
51-Year-Old Presents with Headache, Dizziness, and Confusion.

35. Case #5
A 23-year-old female with ulcerative colitis on Humira and prednisone presented to the ED for
headache, transient inability to move her right arm, and diminished sensation in the right hand.
Further History Noted:
• Intermittent headache week; suddenly worsening three hours prior to presentation
• Inability to move right arm with onset of headache; weakness resolved on presentation
• Ongoing difficulty with fine motor movements of the right hand
• Numbness over her 4th and 5th digits of her right hand
• She is using a hormonal birth control patch
Neurological Exam:
• Diminished sensation to the 4th & 5th right fingers; otherwise normal in all other dermatomes
• 4/5 strength in entire right upper extremity; strength testing otherwise normal
• Alert, no cranial nerve deficits, normal cerebellar testing, normal gait
A CODE Stroke was not activated; but she underwent a non-contrasted head CT

36. 23-Year-Old Presents with Headache and Right Arm Weakness & Numbness.
Non-Contrast CT: Increased density (→) in the anterior aspect of the
superior sagittal sinus and small frontal white-matter hemorrhage (→).

37. The area of hyperdensity corresponds to the location of the superior sagittal sinus
23-Year-Old Presents with Headache and Right Arm Weakness & Numbness.

38. Reviewing The Data That We Have For This Case So Far:
1. The patient is young
2. She is currently on a hormonal birth control patch
3. Head CT demonstrates a midline hyperdensity that
corresponds to the location of the superior sagittal
sinus
This prompted the team to order a CT venogram
23-Year-Old Presents with Headache and Right Arm Weakness & Numbness.

39. CT Venogram: filling defect (→) of the superior sagittal sinus, that was noted to extend bilaterally
into the transverse sinuses and veins of Trollard. The “Empty Delta Sign” is seen (→).
23-Year-Old Presents with Headache and Right Arm Weakness & Numbness.

40. These finding are diagnostic of a Cerebral Venous Sinus Thrombosis (CVST).
23-Year-Old Presents with Headache and Right Arm Weakness & Numbness.

41. New England Journal of Medicine 2021;385:59-64.

42. Practical Neurology 2020; 20:356–367.

43. European Neurology 2020; 83:369-379.

45. Stroke 2004; 35:664-670.
Objectives
The International Study of Cerebral Vein and Dural Sinus Thrombosis (ISCVT) was designed to
characterize the presenting the clinical characteristics, imaging findings, and outcomes of a
large population with this cerebral vein thrombosis (CVT).
Methods
Multinational (21) countries, multicenter (89 centers), prospective observational study of
patients with CVT. All patients who were entered into the ISCVT Registry were followed for 6
months and yearly thereafter.
Results
From May 1998 to May 2001, 624 adult patients with CVT were registered, representing the
largest prospectively collected dataset published to date.

46. Stroke 2004; 35:664-670.
Age (Mean)
Age (Median)
39 years (16-86)
37 years
Female 75%
Ethnicity
White
Hispanic
Black
Asian
Other
79%
9%
5%
4%
3%
Patient Demographics

47. Stroke 2004; 35:664-670.
Risk Factors In Rank Order
Oral Contraceptives 54%
Thrombophilia
• Genetic
• Acquired
34%
22%
16%
Puerperium1 14%
Hematologic Condition 12%
Infection (ENT, CNS, Head) 12%
Malignancy 7%
Pregnancy 6%
None Identified 12%
1The time immediately following childbirth (+/- 6 weeks)
during which the uterus returns to normal size.

48. Cerebral venous thrombosis: Diagnosis and management in the
emergency department setting.
American Journal of Emergency Medicine 2021; 47:24-29.

49. Continuum 2023;29(2):519-539.

50. Stroke 2004; 35:664-670.
Presenting Signs And Symptoms
General Findings
Headache 89%
Any Seizure 39%
Any Paresis 37%
Any AMS 36%
Any Visual 27%
Aphasia 19%
Sensory 5%
Seizures
Generalized 30%
Focal 20%
Paresis
Right Paresis 20%
Left Paresis 20%
Bilateral 5%
Visual
Visual Loss 13%
Diplopia 13%
Papilledema 28%
Altered Mental Status
Stupor/Coma 14%
Non-Coma AMS 22%

51. Cerebral venous thrombosis: Diagnosis and management in the
emergency department setting.
American Journal of Emergency Medicine 2021; 47:24-29.

52. Occluded Cerebral Vein/Sinus
NEJM 2005; 352:1791–1798.

53. Cerebral venous thrombosis: Diagnosis and management in the
emergency department setting.
American Journal of Emergency Medicine 2021; 47:24-29.

54. Practical Neurology 2020; 20:356–367.

55. Stroke 2004; 35:664-670.
CT/MRI Imaging Findings
Infarct Pattern
Any Infarct 46%
Left Hemisphere 31%
Right Hemisphere 28%
Posterior Fossa 3%
Hemorrhage Pattern
Any Hemorrhage 40%
Left Hemisphere 25%
Right Hemisphere 18%
Posterior Fossa 2%

56. European Neurology 2020; 83:369-379.

57. Practical Neurology 2020; 20:356–367.

60. New England Journal of Medicine 2005; 352:1791-8.

61. Lancet Neurology 2007;6:162-170.

62. Stroke 2004; 35:664-670.
Patient Outcomes At Last Follow-Up
Modified Rankin Scale
0 (No Residual Symptoms) 57%
1 (No Disability) 22%
2 (Mild Disability) 7%
3 (Moderate Disability) 3%
4 (Mod/Severe Disability) 2%
5 (Severe Disability) 0.6%
Complete Recovery 79%
Death Or Dependency 13%
Death 8%

63. Stroke 2011; 42:1158-1192.

64. Stroke 2011; 42:1158-1192.
The Decision To Obtain Cerebral Venous Imaging
Recommendations:
• A ”negative” non-contrasted head CT does not rule out CVST.
• In patients with lobar ICH of otherwise unclear origin with cerebral infarction that crosses
typical arterial boundaries, imaging of the cerebral venous system should be performed.
• Imaging of the cerebral venous systems is also reasonable for patient clinical evidence of
idiopathic intracranial hypertension.

65. Stroke 2011; 42:1158-1192.
Clinical Diagnosis Of CVST
Several Clinical Features Distinguish CVST From Other Neurologic Syndromes:
• Focal or generalized seizures occur in 40% of patients
• Patients with CVST often progress with slowly progressive symptoms
• Based on venous anatomy, bilateral neurological findings are not infrequent:
Bilateral Involvement And Neurologic Findings
Bilateral Thalamic Structures
(Deep Venous Sinuses )
Altered level of consciousness without
focal neurologic findings.
Bi-Hemispheric Structures
(Superior Sagittal Sinus)
Paraparesis

66. Acute Management
Recommendations:
• Anticoagulation with unfractionated or low-molecular-weight heparin should be initiated.
Concomitant ICH related to CVST is not a contraindication to heparin therapy.
• Anti-epileptics should be initiated in patients who experience a seizure.
• Management of intracranial hypertension should be based on clinical symptoms.
• Steroid therapy is not recommended in patients with CVST.
• Antibiotics should be initiated promptly when and infectious cause of CVST is suspected.
Stroke 2011; 42:1158-1192.

67. Annals Of Emergency Medicine 2022; 80:329-331.
Meta-analysis comparing outcomes in CVST patient treated either with warfarin or a direct oral anticoagulant.
Riva N. British Journal of Haematology. Published online March 2022. doi.org/10.1111/bjh.18177

68. Embedded References:
Cerebral Venous Thrombosis. N Engl J Med 2021;385:59-74.
Cerebral venous thrombosis: a practical guide. Practical Neurology 2020;20:356-367.
EFNS CVTS treatment guidelines. European Journal of Neurology 2010;17:1229-1235.
Thrombosis of the Cerebral Veins and Sinuses. N Engl J Med 2005;352:1791-8.
International Study of Cerebral Venous Thrombosis. Stroke 2004;35:664-670.
CVTS: Diagnosis and management in the ED setting. Am J Emerg Med 2021;47:24-29.
Diagnosis and Management of Cerebral Venous Thrombosis. Stroke 2011;42:1158-1192.
Direct Oral Anticoagulants vs. Vitamin K Antagonists in Patient with CVT? Ann Emerg Med
2022;80:329-30.

69. See You Next Month!