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neuro.cerebral-venous-thrombosis.v1PRODUCTION
neuro.cerebral-venous-thrombosis.v1

Cerebral Venous Sinus Thrombosis (CVST)

neurologyacutesubacuteadultpregnancy
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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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)

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CVST suspected on syndromic grounds

Patient inputs (15)

Reproductive-age woman 20-50 predominant (ISCVT median age 37; AHA 2024 PMID 38284265)

Female sex ≈75% of CVST; pregnancy / postpartum / OCP / HRT highest substrate (ISCVT gender Coutinho Stroke 2009 PMID 19478226)

Pregnancy / postpartum status determines LMWH-only regimen + 6 wk postpartum + future-pregnancy counselling (AHA 2024 PMID 38284265)

OCP / HRT is the single strongest modifiable CVST risk factor in young women — discontinue lifelong post-CVST (AHA 2024 PMID 38284265; ISCVT PMID 14976332)

MRV gradient-echo (sens ≈95%) or CTV is the diagnostic gold standard; plain CT misses ≈30% (AHA 2024 PMID 38284265; ESO 2017 PMID 31008314)

Parenchymal lesion: non-arterial-territory cortico-subcortical edema, hemorrhagic venous infarct (≈40%), bilateral thalamic edema for deep venous (AHA 2024 PMID 38284265)

Baseline + monitoring for HIT / VITT / thrombocytopenia; ESO interim VITT 2021 PMID 34746428 — non-heparin anticoag if VITT-CVT

Baseline before anticoagulation; APTT goal 1.5-2× baseline if UFH (AHA 2024 PMID 38284265)

GCS<13 + coma are independent poor-prognostic factors and ICU triggers (ISCVT PMID 14976332; AHA 2024 PMID 38284265)

BP management (cautious — venous infarct + edema — no aggressive lowering like arterial ICH) and pregnancy-related HTN / preeclampsia mimic (AHA 2024 PMID 38284265)

LMWH dose adjustment (enoxaparin 1 mg/kg q12h SC; CrCl<30 dose-reduce or switch to UFH); DOAC contraindication threshold (AHA 2024 PMID 38284265)

Factor V Leiden / prothrombin G20210A / antiphospholipid / antithrombin / protein C/S deficiency informs indefinite-anticoag decision (AHA 2024 PMID 38284265)

Septic CVST mechanism — adjacent sinusitis / mastoiditis / meningitis (esp. paediatric / S. aureus) requires source control + antibiotics + anticoag (AHA 2024 PMID 38284265)

Malignancy is an independent poor-prognostic factor in ISCVT CVT-risk-score (PMID 14976332) and triggers indefinite anticoag

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)

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Severity triggers (10)

10 need judgement
  • informationallife_threateninggcs_le_8_or_coma
    GCS ≤8 OR coma at presentation or decline (ISCVT PMID 14976332; AHA 2024 PMID 38284265)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdeep_venous_cvst
    Straight sinus / vein of Galen / internal cerebral vein thrombosis on MRV (AHA 2024 PMID 38284265)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningimpending_herniation_venous_infarct
    Large venous infarct + edema + midline shift + GCS decline (AHA 2024 PMID 38284265 Class I for hemicraniectomy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_seizure_or_status_epilepticus
    New clinical or electrographic seizure (≈40% in CVST) or refractory status (ISCVT PMID 14976332)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehemorrhagic_venous_infarct_present
    Hemorrhagic transformation within venous-infarct territory on CT/MRI (AHA 2024 PMID 38284265)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_postpartum_cvst
    CVST occurring during pregnancy or within 12 wk postpartum (ISCVT gender Coutinho Stroke 2009 PMID 19478226)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevitt_associated_cvst
    CVST 4-30 d after SARS-CoV-2 adenoviral vaccine OR after heparin exposure + platelet drop >50% (HIT/VITT) (ESO 2021 PMID 34746428)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_cvst
    Recurrent CVST off anticoag OR breakthrough on therapeutic anticoag (AHA 2024 PMID 38284265)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_apl_thrombophilia
    Antiphospholipid syndrome (triple-positive aPL on 2 occasions 12 wk apart) OR antithrombin / protein C/S deficiency (AHA 2024 PMID 38284265)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateisolated_intracranial_hypertension_phenotype
    Headache + papilledema + visual obscurations + no focal deficit; MRV with sinus thrombosis (AHA 2024 PMID 38284265)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

CVST anticoagulation + endovascular + decompression ladder (AHA 2024 PMID 38284265 + ESO 2017 PMID 31008314 + SECRET PMID 37675613 + RE-SPECT CVT PMID 31479105)
axis: cvst_anticoagulation_bundlestep 1 - Step 1 — Acute anticoagulation at diagnosis (even with hemorrhagic venous infarct) (AHA 2024 PMID 38284265 Class I; ESO 2017 PMID 31008314)
Selected step "Step 1 — Acute anticoagulation at diagnosis (even with hemorrhagic venous infarct) (AHA 2024 PMID 38284265 Class I; ESO 2017 PMID 31008314)" — CVST confirmed on MRV / CTV; no absolute anticoag contraindication
  • enoxaparin
    first line
    LMWH
    1 mg/kg SC q12h (CrCl 30-50: cautious + monitor anti-Xa 0.5-1.0 IU/mL; CrCl<30: switch to UFH or reduce to 1 mg/kg q24h) • SC • q12h
    triggers: CVST_confirmed, no_active_bleed_other_than_venous_infarct, CrCl_>=30
    LMWH preferred first-line in CVST per AHA 2024 (PMID 38284265) and ESO 2017 (PMID 31008314); superior to UFH for outpatient transition
    rxcui 67108
  • heparin
    first line
    UFH
    80 U/kg IV bolus then 18 U/kg/h infusion, titrate APTT 1.5-2× control • IV • continuous infusion
    triggers: CrCl_<30, imminent_surgery_or_LP, bleeding_risk_high
    UFH preferred when reversibility / renal-failure / imminent-procedure favour shorter half-life (AHA 2024 PMID 38284265)
    rxcui 5224

outpatient playbook — drug actions (3)

  1. 1. warfarin OR rivaroxaban OR apixaban
    rxcui 11289
    Warfarin INR 2-3; rivaroxaban 20 mg PO daily; apixaban 5 mg PO BID • PO • daily / BID
    trigger: CVST maintenance × 3-12 mo provoked vs indefinite unprovoked / recurrent / thrombophilia
    Duration per AHA 2024 (PMID 38284265); SECRET PMID 37675613 supports rivaroxaban for non-APS; RE-SPECT CVT PMID 31479105 supports dabigatran
  2. 2. LMWH for future pregnancy
    rxcui 67108
    Enoxaparin 1 mg/kg SC q12h throughout pregnancy + 6 wk postpartum • SC • q12h
    trigger: Future pregnancy in post-CVST patient
    LMWH-only regimen for pregnancy (AHA 2024 PMID 38284265); warfarin teratogenic; DOAC pregnancy contraindicated
  3. 3. sertraline OR escitalopram
    Sertraline 50 mg PO daily; escitalopram 10 mg PO daily • PO • daily
    trigger: PHQ-9 ≥10
    Post-CVST mood disorder; SSRI first-line; caution with concomitant anticoag (AHA 2024 PMID 38284265)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New severe / progressive headache in young woman on OCP or postpartum (ISCVT Ferro Stroke 2004 PMID 14976332); Papilledema + headache pattern (isolated intracranial hypertension CVST phenotype; AHA 2024 PMID 38284265); New seizure + focal deficit — seizure ≈40% in CVST vs <10% arterial stroke (ISCVT PMID 14976332).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cerebral Venous Sinus Thrombosis (CVST)** (neuro.cerebral-venous-thrombosis.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CVST anticoagulation + endovascular + decompression ladder (AHA 2024 PMID 38284265 + ESO 2017 PMID 31008314 + SECRET PMID 37675613 + RE-SPECT CVT PMID 31479105)** — step "Step 1 — Acute anticoagulation at diagnosis (even with hemorrhagic venous infarct) (AHA 2024 PMID 38284265 Class I; ESO 2017 PMID 31008314)".
1. enoxaparin 1 mg/kg SC q12h (CrCl 30-50: cautious + monitor anti-Xa 0.5-1.0 IU/mL; CrCl<30: switch to UFH or reduce to 1 mg/kg q24h) SC q12h (LMWH, first line) — LMWH preferred first-line in CVST per AHA 2024 (PMID 38284265) and ESO 2017 (PMID 31008314); superior to UFH for outpatient transition
2. heparin 80 U/kg IV bolus then 18 U/kg/h infusion, titrate APTT 1.5-2× control IV continuous infusion (UFH, first line) — UFH preferred when reversibility / renal-failure / imminent-procedure favour shorter half-life (AHA 2024 PMID 38284265)

Setting playbook (outpatient) — Stroke-clinic 4-6 wk + 3-6 mo + 12 mo: thrombophilia workup off anticoag, follow-up MRV at 3-6 mo for recanalization, anticoag-duration decision (3-12 mo provoked vs indefinite recurrent / thrombophilia / APS), pregnancy / contraception counselling, mood / cognition screen (AHA 2024 PMID 38284265)
3. warfarin OR rivaroxaban OR apixaban Warfarin INR 2-3; rivaroxaban 20 mg PO daily; apixaban 5 mg PO BID PO daily / BID — CVST maintenance × 3-12 mo provoked vs indefinite unprovoked / recurrent / thrombophilia (Duration per AHA 2024 (PMID 38284265); SECRET PMID 37675613 supports rivaroxaban for non-APS; RE-SPECT CVT PMID 31479105 supports dabigatran)
4. LMWH for future pregnancy Enoxaparin 1 mg/kg SC q12h throughout pregnancy + 6 wk postpartum SC q12h — Future pregnancy in post-CVST patient (LMWH-only regimen for pregnancy (AHA 2024 PMID 38284265); warfarin teratogenic; DOAC pregnancy contraindicated)
5. sertraline OR escitalopram Sertraline 50 mg PO daily; escitalopram 10 mg PO daily PO daily — PHQ-9 ≥10 (Post-CVST mood disorder; SSRI first-line; caution with concomitant anticoag (AHA 2024 PMID 38284265))

Non-pharmacologic actions:
- Recurrent-stroke / CVST counselling — symptom recognition, when to call 911 (AHA 2024 PMID 38284265)
- Smoking + alcohol cessation reinforcement (AHA 2024 PMID 38284265)
- Aerobic exercise prescription 150 min/wk moderate (AHA 2024 PMID 38284265)
- Genetic counselling for hereditary thrombophilia if positive (AHA 2024 PMID 38284265)
- Driving evaluation per jurisdictional regulation (post-seizure abstention)

AVOID / contraindication checks:
- No_routine_systemic_tPA_in_CVST_unless_endovascular_protocol (AHA 2024 PMID 38284265)
- No_estrogen_containing_OCP_or_HRT_lifelong_post_CVST (AHA 2024 PMID 38284265)
- No_DOAC_in_APS_triple_positive (warfarin preferred — TRAPS trial paradigm; AHA 2024 PMID 38284265)
- No_LMWH_if_HIT_or_VITT_history (use argatroban / bivalirudin / fondaparinux; ESO VITT 2021 PMID 34746428)
- No_aggressive_BP_lowering_below_MAP_70_venous_infarct_perfusion_dependent (AHA 2024 PMID 38284265)
- No_routine_AED_prophylaxis_without_documented_seizure (AHA 2024 PMID 38284265)

Monitoring

Regimen monitoring:
- platelet count q3d x 2wk if heparin for HIT 4Ts (AHA 2024 PMID 38284265)
- anti Xa 0.5 1.0 IU mL 4h post dose LMWH in pregnancy obesity renal impairment (AHA 2024 PMID 38284265)
- APTT 1.5 2x control if UFH (AHA 2024 PMID 38284265)
- INR 2 3 if warfarin weekly until stable then q4wk (AHA 2024 PMID 38284265)
- follow up MRV at 3 6mo to confirm recanalization (AHA 2024 PMID 38284265)
- daily neuro checks during acute admission (AHA 2024 PMID 38284265)

Setting (outpatient) monitoring:
- Clinic visit at 7-14 d post-discharge for medication reconciliation (AHA 2024 PMID 38284265)
- Stroke clinic at 4-6 wk (thrombophilia workup), 3-6 mo (follow-up MRV + anticoag-duration decision), 12 mo (long-term outcome) (AHA 2024 PMID 38284265)
- INR weekly until stable then q4 wk if warfarin (AHA 2024 PMID 38284265)
- Renal function q6 mo if on DOAC; q3 mo if CrCl 30-50 (AHA 2024 PMID 38284265)
- PHQ-9 + MoCA at 3-6 mo + 12 mo (AHA 2024 PMID 38284265)

Follow-up plan: 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)
- Close-out criterion: Long-term anticoag duration + contraception + thrombophilia plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Stroke-clinic 4-6 wk + 3-6 mo + 12 mo: thrombophilia workup off anticoag, follow-up MRV at 3-6 mo for recanalization, anticoag-duration decision (3-12 mo provoked vs indefinite recurrent / thrombophilia / APS), pregnancy / contraception counselling, mood / cognition screen (AHA 2024 PMID 38284265)

Disposition criteria:
- Continue indefinite anticoag if recurrent / persistent thrombophilia / APS (AHA 2024 PMID 38284265)
- Stop anticoag at 3-6 mo if provoked (transient OCP / postpartum / infection) + recanalization confirmed (AHA 2024 PMID 38284265)
- Lifelong avoidance of estrogen-containing OCP / HRT (AHA 2024 PMID 38284265)

Escalation triggers (move to higher acuity):
- Any new TIA-spectrum / focal deficit / new severe headache → ED (AHA 2024 PMID 38284265)
- New seizure off AED → ED + AED reinstitution (AHA 2024 PMID 38284265)
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral (AHA 2024 PMID 38284265)
- Recurrent CVST → re-image, escalate anticoag duration to indefinite, vascular neurology referral (AHA 2024 PMID 38284265)

Patient Action Plan

**CVST anticoagulation + recurrence action plan**
Personalised values: anticoag_agent, INR_target_if_warfarin, next_MRV_date, thrombophilia_status, pregnancy_postpartum_status.

**Doing well — stable on anticoag** (green):
Triggers:
- no_new_headache
- no_focal_deficit
- no_new_seizure
- INR_in_range_if_warfarin
- no_unusual_bruising
Actions:
- Continue maintenance anticoag as prescribed
- Keep stroke-clinic + MRV appointments
- Avoid estrogen-containing OCP/HRT lifelong
- Use only LMWH if becoming pregnant + 6 wk postpartum (call stroke clinic FIRST when pregnancy planned/confirmed)

**Caution — call stroke clinic same day** (yellow):
Triggers:
- new_persistent_headache_x_>24h
- minor_nose_or_gum_bleed
- INR_>4_or_<2_if_warfarin
- missed_anticoag_dose
- planned_surgery_or_dental_work
Actions:
- Call the stroke clinic / anticoag clinic same day
- Do NOT stop anticoag without instruction
- Bring medication list to clinic call

**Emergency — call 911 / go to ED** (red):
Triggers:
- thunderclap_or_worst_ever_headache
- new_focal_weakness_or_speech_difficulty
- new_seizure
- loss_of_consciousness
- major_bleed_GI_or_intracranial
- severe_abdominal_or_back_pain
Actions:
- Call 911 / go to nearest ED
- Bring medication list and anticoag card
- Tell ED you have a history of CVST and are on anticoagulation
Contact provider when:
- Any red-zone trigger
- After any ED visit so stroke team is updated

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] GCS ≤8 OR coma at presentation or decline (ISCVT PMID 14976332; AHA 2024 PMID 38284265)
- [LIFE_THREATENING] Straight sinus / vein of Galen / internal cerebral vein thrombosis on MRV (AHA 2024 PMID 38284265)
- [LIFE_THREATENING] Large venous infarct + edema + midline shift + GCS decline (AHA 2024 PMID 38284265 Class I for hemicraniectomy)

Citations

- 2024 AHA Scientific Statement on Diagnosis and Management of Cerebral Venous Thrombosis (Saposnik et al, Stroke 2024) + 2017 ESO guideline (Ferro Eur Stroke J) [PMID:38284265](https://pubmed.ncbi.nlm.nih.gov/38284265/)
- Cited evidence (PMID 31008314) [PMID:31008314](https://pubmed.ncbi.nlm.nih.gov/31008314/)
- Cited evidence (PMID 14976332) [PMID:14976332](https://pubmed.ncbi.nlm.nih.gov/14976332/)
- Cited evidence (PMID 32421159) [PMID:32421159](https://pubmed.ncbi.nlm.nih.gov/32421159/)
- Cited evidence (PMID 37675613) [PMID:37675613](https://pubmed.ncbi.nlm.nih.gov/37675613/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2024 AHA Scientific Statement on Diagnosis and Management of Cerebral Venous Thrombosis (Saposnik et al, Stroke 2024) + 2017 ESO guideline (Ferro Eur Stroke J) — PMID:38284265
  • Cited evidence (PMID 31008314) — PMID:31008314
  • Cited evidence (PMID 14976332) — PMID:14976332
  • Cited evidence (PMID 32421159) — PMID:32421159
  • Cited evidence (PMID 37675613) — PMID:37675613