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neuro.cerebral-venous-thrombosis.v1

Cerebral Venous Sinus Thrombosis (CVST)

neurologyacutesubacuteadultpregnancyacuteinpatientoutpatienttransition
Start encounter →Print handoutPRODUCTION

Lane F id+neuro-acute campaign new-build (2026-05-26). CVST is a must-not-miss acute / subacute neurology engine with strong young-female-on-OCP / postpartum / thrombophilia pivots and an explicit anticoag-not-contraindicated-by-hemorrhagic-venous-infarct paradigm (AHA 2024 PMID 38284265 Class I). PubMed-MCP verification 2026-05-26 found ALL THREE orchestrator-supplied candidate PMIDs to be wrong-article fabrications and substituted them with verified anchors: ISCVT 15029084 → 14976332 (Ferro Stroke 2004); TO-ACT 32556089 → 32421159 (Coutinho JAMA Neurol 2020); SECRET 36764311 → 37675613 (Field Stroke 2023). All 8 evidence PMIDs live-verified. RxCUI live-verification (RxNav curl 2026-05-26) — enoxaparin 67108 ✓, heparin 5224 ✓, warfarin 11289 ✓, rivaroxaban 1114195 ✓, apixaban 1364430 ✓, mannitol 6628 ✓ (orchestrator-supplied 6612 was invalid), levetiracetam 114477 ✓. Registry-id resolution — used `workup.ich` (existing, AHA 2022 anchor) because no CVST-specific workup exists in clinical-tools-registry.ts; `calc.ckd_epi_2021` + `calc.nihss` + `calc.caprini` resolve; panels `panel.cbc / panel.coag / panel.renal / panel.lft / panel.inflammation` all resolve; `protocol.ich` reused for hemorrhagic-venous-infarct parenchymal-bleed parallel management. Schema-blocked: no `workup.cvst` / `workup.headache_red_flags` / `protocol.cvst` in clinical-tools-registry.ts at this build — flagged for future depth-pass registry expansion. Settings shipped: ed / inpatient / icu / outpatient / transition (5). Severity triggers: 10 (coma / deep-venous / herniation / seizure / hemorrhagic-venous-infarct / pregnancy-postpartum / VITT / APS / recurrent / isolated-intracranial-hypertension). §5.5.2 Bayesian depth-pass NOT performed at this build — D-dimer LR derivation (Tanislav et al), MRV gradient-echo sensitivity (95%) and ISCVT CVT-risk-score band-mapping flagged as NEEDS_SOURCE_REVIEW for future depth-pass-2.

Entry points (6)

  • symptom
    New severe / progressive headache in young woman on OCP or postpartum (ISCVT Ferro Stroke 2004 PMID 14976332)
    new_severe_headache_young_woman_ocp
  • symptom
    Papilledema + headache pattern (isolated intracranial hypertension CVST phenotype; AHA 2024 PMID 38284265)
    papilledema_with_headache
  • symptom
    New seizure + focal deficit — seizure ≈40% in CVST vs <10% arterial stroke (ISCVT PMID 14976332)
    new_seizure_with_focal_deficit
  • symptom
    Encephalopathy / coma in young adult — deep venous CVST (straight sinus / vein of Galen / internal cerebral veins) phenotype (AHA 2024 PMID 38284265)
    encephalopathy_coma_young_adult
  • imaging
    MRV gradient-echo or CTV showing dural sinus / cortical vein filling defect (AHA 2024 PMID 38284265)
    mrv_or_ctv_venous_defect
  • imaging
    CT/MRI lesion crossing arterial-territory boundaries (parasagittal bilateral / bithalamic / temporo-occipital) — CVST pivot
    non_arterial_territory_lesion

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Reproductive-age woman 20-50 predominant (ISCVT median age 37; AHA 2024 PMID 38284265)
  • sex_pregnancy_postpartumrequired
    demographic • used at CONTEXT
    Female sex ≈75% of CVST; pregnancy / postpartum / OCP / HRT highest substrate (ISCVT gender Coutinho Stroke 2009 PMID 19478226)
  • gcsrequired
    vital • used at RED_FLAGS
    GCS<13 + coma are independent poor-prognostic factors and ICU triggers (ISCVT PMID 14976332; AHA 2024 PMID 38284265)
  • sbprequired
    vital • used at TREATMENT
    BP management (cautious — venous infarct + edema — no aggressive lowering like arterial ICH) and pregnancy-related HTN / preeclampsia mimic (AHA 2024 PMID 38284265)
  • mrv_or_ctvrequired
    imaging • used at INITIAL_WORKUP
    MRV gradient-echo (sens ≈95%) or CTV is the diagnostic gold standard; plain CT misses ≈30% (AHA 2024 PMID 38284265; ESO 2017 PMID 31008314)
  • ct_or_mri_brainrequired
    imaging • used at INITIAL_WORKUP
    Parenchymal lesion: non-arterial-territory cortico-subcortical edema, hemorrhagic venous infarct (≈40%), bilateral thalamic edema for deep venous (AHA 2024 PMID 38284265)
  • d_dimer
    lab • used at INITIAL_WORKUP
    Elevated D-dimer supports thrombosis; D-dimer <500 ng/mL LR- ≈0.3 (NOT sufficient to rule out CVST — Tanislav; AHA 2024 PMID 38284265 explicitly cautions against D-dimer as sole rule-out)
  • cbc_with_plateletsrequired
    lab • used at INITIAL_WORKUP
    Baseline + monitoring for HIT / VITT / thrombocytopenia; ESO interim VITT 2021 PMID 34746428 — non-heparin anticoag if VITT-CVT
  • coag_pt_inr_apttrequired
    lab • used at INITIAL_WORKUP
    Baseline before anticoagulation; APTT goal 1.5-2× baseline if UFH (AHA 2024 PMID 38284265)
  • creatininerequired
    lab • used at TREATMENT
    LMWH dose adjustment (enoxaparin 1 mg/kg q12h SC; CrCl<30 dose-reduce or switch to UFH); DOAC contraindication threshold (AHA 2024 PMID 38284265)
  • bhcg_pregnancy_testrequired
    lab • used at CONTEXT
    Pregnancy / postpartum status determines LMWH-only regimen + 6 wk postpartum + future-pregnancy counselling (AHA 2024 PMID 38284265)
  • ocp_hrt_exposurerequired
    medication • used at CONTEXT
    OCP / HRT is the single strongest modifiable CVST risk factor in young women — discontinue lifelong post-CVST (AHA 2024 PMID 38284265; ISCVT PMID 14976332)
  • thrombophilia_history
    history • used at CONTEXT
    Factor V Leiden / prothrombin G20210A / antiphospholipid / antithrombin / protein C/S deficiency informs indefinite-anticoag decision (AHA 2024 PMID 38284265)
  • infection_sinusitis_mastoiditis_meningitis
    history • used at CONTEXT
    Septic CVST mechanism — adjacent sinusitis / mastoiditis / meningitis (esp. paediatric / S. aureus) requires source control + antibiotics + anticoag (AHA 2024 PMID 38284265)
  • malignancy_history
    history • used at CONTEXT
    Malignancy is an independent poor-prognostic factor in ISCVT CVT-risk-score (PMID 14976332) and triggers indefinite anticoag

12-phase flow (12)

  1. 1FRAME
    Acute or subacute CVST in young / reproductive-age / postpartum patient or with thrombophilia; recognise that hemorrhagic venous infarct does NOT contraindicate anticoag (AHA 2024 PMID 38284265)
    advance: CVST suspected on syndromic grounds
  2. 2ENTRY
    Headache (≈90%) ± papilledema ± seizure ± focal deficit ± encephalopathy → STAT MRV or CTV (AHA 2024 PMID 38284265)
    inputs: age, sex_pregnancy_postpartum
    advance: CVST entry trigger captured + venogram ordered
  3. 3CONTEXT
    OCP / HRT / pregnancy / postpartum exposure; thrombophilia; malignancy; infection (sinusitis / mastoiditis); dehydration; recent LP / head trauma; SARS-CoV-2 vaccine within 4-30 d (VITT-CVT; ESO 2021 PMID 34746428)
    inputs: ocp_hrt_exposure, thrombophilia_history, bhcg_pregnancy_test, infection_sinusitis_mastoiditis_meningitis, malignancy_history
    advance: Substrate / mechanism captured
  4. 4RED_FLAGS
    GCS<13, new seizure, deep venous involvement, impending herniation, coma, malignant cerebellar venous infarct → STAT ICU + neurosurgery (AHA 2024 PMID 38284265; TO-ACT subgroup pivot Coutinho JAMA Neurol 2020 PMID 32421159)
    inputs: gcs, cbc_with_platelets
    advance: Airway / ICU triage complete
  5. 5INITIAL_WORKUP
    MRV gradient-echo OR CTV (sens ≈95%); CT/MRI brain for parenchymal lesion; CBC, coags, D-dimer (NOT rule-out), CMP, β-hCG (AHA 2024 PMID 38284265)
    inputs: mrv_or_ctv, ct_or_mri_brain, d_dimer, cbc_with_platelets, coag_pt_inr_aptt, creatinine
    actions: workup.ich, panel.coag, panel.cbc, panel.renal
    advance: Venous defect + parenchymal mapping documented
  6. 6BRANCHING_WORKUP
    LP for elevated ICP if no large mass effect AND not yet anticoagulated; thrombophilia panel (factor V Leiden / prothrombin G20210A / aPL / antithrombin / protein C/S) — defer aPL until 4-6 wk off anticoag; HIT/VITT workup (PF4 ELISA) if platelets<100 + recent heparin / SARS-CoV-2 vaccine (AHA 2024 PMID 38284265; ESO VITT 2021 PMID 34746428)
    advance: Mechanism + thrombophilia mapped
  7. 7DIFFERENTIAL
    CVST vs migraine (no papilledema / clean MRV) vs PRES (posterior reversible encephalopathy / HTN-driven) vs IIH (idiopathic intracranial hypertension — clean MRV) vs arterial venous infarct (territory-bound) vs encephalitis (CSF pleocytosis) vs SAH (cisternal-pattern thunderclap) (AHA 2024 PMID 38284265)
    advance: CVST confirmed; mimic excluded
  8. 8RISK_STRATIFICATION
    ISCVT CVT-risk-score components (malignancy / coma / deep venous / male / mental status / ICH) → 6-mo poor-outcome risk; AHA 2024 categorises mild vs severe (coma / deep venous / ICH / herniation candidates) (ISCVT PMID 14976332)
    inputs: gcs
    advance: Severity tier assigned
  9. 9TREATMENT
    Step 1 — LMWH (enoxaparin 1 mg/kg q12h SC) or UFH at diagnosis even if hemorrhagic venous infarct; Step 2 — VKA INR 2-3 OR DOAC (rivaroxaban 20 mg PO daily per SECRET PMID 37675613; dabigatran 150 BID per RE-SPECT CVT PMID 31479105) × 3-12 mo (indefinite if recurrent / thrombophilia / antiphospholipid); Step 3 — endovascular thrombectomy if deteriorating despite anticoag OR coma + deep venous (TO-ACT PMID 32421159 — neutral overall, subgroup trends); Step 4 — decompressive hemicraniectomy if impending herniation (AHA 2024 PMID 38284265 Class I); Step 5 — AED for clinical seizure (levetiracetam 1 g IV load + 500-1000 mg q12h; NOT routine prophylaxis); Step 6 — ICP mannitol / 3% saline / surgical drainage (AHA 2024 PMID 38284265)
    inputs: sbp, creatinine, bhcg_pregnancy_test
    actions: protocol.ich
    advance: Anticoag initiated + surgical disposition decided
  10. 10DISPOSITION
    Neuro-ICU for deep venous / coma / hemicraniectomy candidate / status seizure; stroke-unit otherwise; comprehensive stroke / NSurg centre transfer if endovascular or hemicraniectomy not available locally (AHA 2024 PMID 38284265)
    inputs: gcs
    advance: Bed allocated or transfer initiated
  11. 11MONITORING
    Daily neuro-checks; platelet count for HIT (4Ts) if heparin; APTT 1.5-2× if UFH; anti-Xa monitoring for LMWH in pregnancy / obesity / renal impairment; INR 2-3 if VKA; follow-up MRV at 3-6 mo to confirm recanalization (AHA 2024 PMID 38284265)
    inputs: cbc_with_platelets
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Stroke-clinic 4-6 wk for thrombophilia workup off anticoag; pregnancy counselling — LMWH-only future pregnancy + 6 wk postpartum, AVOID OCP/HRT lifelong; recurrent-CVST risk ≈2-4%/yr; mood / cognition screen (post-CVST depression up to 25%) (AHA 2024 PMID 38284265)
    advance: Long-term anticoag duration + contraception + thrombophilia plan documented