Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Cerebral venous thrombosis: Etiology, clinical features, and diagnosis

José M Ferro, MD, PhD
Patrícia Canhão, MD, PhD
Section Editor
Scott E Kasner, MD
Deputy Editor
John F Dashe, MD, PhD


Cerebral vein and dural sinus thrombosis (CVT) is less common than most other types of stroke but can be more challenging to diagnose. Due to the widespread use of MRI and rising clinical awareness, CVT is recognized with increasing frequency. In addition, it is now known to have a more varied clinical spectrum than previously realized. Because of its myriad causes and presentations, CVT is a disease that may be encountered not only by neurologists and neurosurgeons, but also by emergency clinicians, internists, oncologists, hematologists, obstetricians, pediatricians, and family practitioners.

This topic will review the epidemiology, pathogenesis, clinical features, and diagnosis of CVT. Prognosis and treatment are discussed separately. (See "Treatment and prognosis of cerebral venous thrombosis".)

CVT in newborns is also reviewed elsewhere. (See "Stroke in the newborn: Classification, manifestations, and diagnosis", section on 'Cerebral sinovenous thrombosis'.)


The available data suggest that CVT is uncommon [1]. The annual incidence ranges from 0.22 to 1.57 per 100,000 [2-4], and is more common in women than men, with a female to male ratio of 3:1 [5,6]. The imbalance may be due to the increased risk of CVT associated with pregnancy and puerperium and with oral contraceptives [7]. (See 'Acquired thrombophilia' below.)

In adults, CVT affects patients who are younger on average than those with arterial types of stroke. In the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT), the mean age of patients with CVT was 39 years [5], and only 8 percent of the patients were older than 65 [8].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Saposnik G, Barinagarrementeria F, Brown RD Jr, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:1158.
  2. Ferro JM, Correia M, Pontes C, et al. Cerebral vein and dural sinus thrombosis in Portugal: 1980-1998. Cerebrovasc Dis 2001; 11:177.
  3. Coutinho JM, Zuurbier SM, Aramideh M, Stam J. The incidence of cerebral venous thrombosis: a cross-sectional study. Stroke 2012; 43:3375.
  4. Devasagayam S, Wyatt B, Leyden J, Kleinig T. Cerebral Venous Sinus Thrombosis Incidence Is Higher Than Previously Thought: A Retrospective Population-Based Study. Stroke 2016; 47:2180.
  5. Ferro JM, Canhão P, Stam J, et al. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004; 35:664.
  6. Coutinho JM, Ferro JM, Canhão P, et al. Cerebral venous and sinus thrombosis in women. Stroke 2009; 40:2356.
  7. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005; 352:1791.
  8. Ferro JM, Canhão P, Bousser MG, et al. Cerebral vein and dural sinus thrombosis in elderly patients. Stroke 2005; 36:1927.
  9. Coutinho JM. Cerebral venous thrombosis. J Thromb Haemost 2015; 13 Suppl 1:S238.
  10. Gotoh M, Ohmoto T, Kuyama H. Experimental study of venous circulatory disturbance by dural sinus occlusion. Acta Neurochir (Wien) 1993; 124:120.
  11. Corvol JC, Oppenheim C, Manaï R, et al. Diffusion-weighted magnetic resonance imaging in a case of cerebral venous thrombosis. Stroke 1998; 29:2649.
  12. Lövblad KO, Bassetti C, Schneider J, et al. Diffusion-weighted mr in cerebral venous thrombosis. Cerebrovasc Dis 2001; 11:169.
  13. Yoshikawa T, Abe O, Tsuchiya K, et al. Diffusion-weighted magnetic resonance imaging of dural sinus thrombosis. Neuroradiology 2002; 44:481.
  14. Röther J, Waggie K, van Bruggen N, et al. Experimental cerebral venous thrombosis: evaluation using magnetic resonance imaging. J Cereb Blood Flow Metab 1996; 16:1353.
  15. Chu K, Kang DW, Yoon BW, Roh JK. Diffusion-weighted magnetic resonance in cerebral venous thrombosis. Arch Neurol 2001; 58:1569.
  16. deVeber G, Andrew M, Adams C, et al. Cerebral sinovenous thrombosis in children. N Engl J Med 2001; 345:417.
  17. Duman T, Uluduz D, Midi I, et al. A Multicenter Study of 1144 Patients with Cerebral Venous Thrombosis: The VENOST Study. J Stroke Cerebrovasc Dis 2017; 26:1848.
  18. Ferro JM, Canhão P. Cerebral venous sinus thrombosis: update on diagnosis and management. Curr Cardiol Rep 2014; 16:523.
  19. Martinelli I, Sacchi E, Landi G, et al. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med 1998; 338:1793.
  20. de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in [correction of who are] carriers of hereditary prothrombotic conditions. The Cerebral Venous Sinus Thrombosis Study Group. BMJ 1998; 316:589.
  21. Zuurbier SM, Arnold M, Middeldorp S, et al. Risk of Cerebral Venous Thrombosis in Obese Women. JAMA Neurol 2016; 73:579.
  22. Marjot T, Yadav S, Hasan N, et al. Genes associated with adult cerebral venous thrombosis. Stroke 2011; 42:913.
  23. Lee MK, Ng SC. Cerebral venous thrombosis associated with antithrombin III deficiency. Aust N Z J Med 1991; 21:772.
  24. Kanaya Y, Takamatsu K, Shimoe Y, et al. Cerebral venous sinus thrombosis in the patient with multiple sclerosis associated with congenital antithrombin deficiency. Rinsho Shinkeigaku 2016; 56:248.
  25. Enevoldson TP, Russell RW. Cerebral venous thrombosis: new causes for an old syndrome? Q J Med 1990; 77:1255.
  26. Deschiens MA, Conard J, Horellou MH, et al. Coagulation studies, factor V Leiden, and anticardiolipin antibodies in 40 cases of cerebral venous thrombosis. Stroke 1996; 27:1724.
  27. Lüdemann P, Nabavi DG, Junker R, et al. Factor V Leiden mutation is a risk factor for cerebral venous thrombosis: a case-control study of 55 patients. Stroke 1998; 29:2507.
  28. Weih M, Junge-Hülsing J, Mehraein S, et al. [Hereditary thrombophilia with ischemiC stroke and sinus thrombosis. Diagnosis, therapy and meta-analysis]. Nervenarzt 2000; 71:936.
  29. Biousse V, Conard J, Brouzes C, et al. Frequency of the 20210 G-->A mutation in the 3'-untranslated region of the prothrombin gene in 35 cases of cerebral venous thrombosis. Stroke 1998; 29:1398.
  30. Reuner KH, Ruf A, Grau A, et al. Prothrombin gene G20210-->A transition is a risk factor for cerebral venous thrombosis. Stroke 1998; 29:1765.
  31. Lauw MN, Barco S, Coutinho JM, Middeldorp S. Cerebral venous thrombosis and thrombophilia: a systematic review and meta-analysis. Semin Thromb Hemost 2013; 39:913.
  32. Laugesaar R, Kahre T, Kolk A, et al. Factor V Leiden and prothrombin 20210G>A [corrected] mutation and paediatric ischaemic stroke: a case-control study and two meta-analyses. Acta Paediatr 2010; 99:1168.
  33. Hillier CE, Collins PW, Bowen DJ, et al. Inherited prothrombotic risk factors and cerebral venous thrombosis. QJM 1998; 91:677.
  34. Cantu C, Alonso E, Jara A, et al. Hyperhomocysteinemia, low folate and vitamin B12 concentrations, and methylene tetrahydrofolate reductase mutation in cerebral venous thrombosis. Stroke 2004; 35:1790.
  35. Gouveia LO, Canhão P. MTHFR and the risk for cerebral venous thrombosis--a meta-analysis. Thromb Res 2010; 125:e153.
  36. Dobbs TD, Barber ZE, Squier WL, Green AL. Cerebral venous sinus thrombosis complicating traumatic head injury. J Clin Neurosci 2012; 19:1058.
  37. Ferrera PC, Pauze DR, Chan L. Sagittal sinus thrombosis after closed head injury. Am J Emerg Med 1998; 16:382.
  38. Grangeon L, Gilard V, Ozkul-Wermester O, et al. Management and outcome of cerebral venous thrombosis after head trauma: A case series. Rev Neurol (Paris) 2017; 173:411.
  39. Bousser MG, Russell RR. Cerebral venous thrombosis. In: Major Problems in Neurology, Warlow CP, Van Gijn J (Eds), WB Saunders, London 1997. p.27, 104.
  40. Bousser MG, Chiras J, Bories J, Castaigne P. Cerebral venous thrombosis--a review of 38 cases. Stroke 1985; 16:199.
  41. Biousse V, Ameri A, Bousser MG. Isolated intracranial hypertension as the only sign of cerebral venous thrombosis. Neurology 1999; 53:1537.
  42. Ferro JM, Falcao F, Melo TP, Campos JG. Dural sinus thrombosis mimicking "capsular warning syndrome". J Neurol 2000; 247:802.
  43. Lancon JA, Killough KR, Tibbs RE, et al. Spontaneous dural sinus thrombosis in children. Pediatr Neurosurg 1999; 30:23.
  44. Coutinho JM, Stam J, Canhão P, et al. Cerebral venous thrombosis in the absence of headache. Stroke 2015; 46:245.
  45. Cumurciuc R, Crassard I, Sarov M, et al. Headache as the only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry 2005; 76:1084.
  46. Agostoni E. Headache in cerebral venous thrombosis. Neurol Sci 2004; 25 Suppl 3:S206.
  47. Ameri A, Bousser MG. Headache in cerebral venous thrombosis: A study of 110 cases. Cephalalgia 1993; 13 (Suppl 13):110.
  48. Lopes MG, Ferro J, Pontes C, et al for the Venoport Investigators. Headache and cerebral venous thrombosis. Cephalalgia 2000; 20:292.
  49. de Bruijn SF, Stam J, Kappelle LJ. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group. Lancet 1996; 348:1623.
  50. Heckmann JG, Schüttler M, Tomandl B. Achard-Lévi syndrome: pupil-sparing oculomotor nerve palsy due to midbrain stroke. Cerebrovasc Dis 2003; 16:109.
  51. Newman DS, Levine SR, Curtis VL, Welch KM. Migraine-like visual phenomena associated with cerebral venous thrombosis. Headache 1989; 29:82.
  52. Martins IP, Sá J, Pereira RC, et al. Cerebral venous thrombosis – May mimic migraine with aura. Headache Q 2001; 12:121.
  53. Slooter AJ, Ramos LM, Kappelle LJ. Migraine-like headache as the presenting symptom of cerebral venous sinus thrombosis. J Neurol 2002; 249:775.
  54. Ferro JM, Canhão P, Bousser MG, et al. Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics. Stroke 2008; 39:1152.
  55. Wasay M, Dai AI, Ansari M, et al. Cerebral venous sinus thrombosis in children: a multicenter cohort from the United States. J Child Neurol 2008; 23:26.
  56. Ferro JM, Canhão P, Stam J, et al. Delay in the diagnosis of cerebral vein and dural sinus thrombosis: influence on outcome. Stroke 2009; 40:3133.
  57. Sakaida H, Kobayashi M, Ito A, Takeuchi K. Cavernous sinus thrombosis: linking a swollen red eye and headache. Lancet 2014; 384:928.
  58. Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med 2001; 161:2671.
  59. Press CA, Lindsay A, Stence NV, et al. Cavernous Sinus Thrombosis in Children: Imaging Characteristics and Clinical Outcomes. Stroke 2015; 46:2657.
  60. Smith DM, Vossough A, Vorona GA, et al. Pediatric cavernous sinus thrombosis: A case series and review of the literature. Neurology 2015; 85:763.
  61. Jacobs K, Moulin T, Bogousslavsky J, et al. The stroke syndrome of cortical vein thrombosis. Neurology 1996; 47:376.
  62. Ahn TB, Roh JK. A case of cortical vein thrombosis with the cord sign. Arch Neurol 2003; 60:1314.
  63. Cakmak S, Hermier M, Montavont A, et al. T2*-weighted MRI in cortical venous thrombosis. Neurology 2004; 63:1698.
  64. Damak M, Crassard I, Wolff V, Bousser MG. Isolated lateral sinus thrombosis: a series of 62 patients. Stroke 2009; 40:476.
  65. Utz N, Mull M, Kosinski C, Thron A. Pulsatile tinnitus of venous origin as a symptom of dural sinus thrombosis. Cerebrovasc Dis 1997; 7:150.
  66. Waldvogel D, Mattle HP, Sturzenegger M, Schroth G. Pulsatile tinnitus--a review of 84 patients. J Neurol 1998; 245:137.
  67. Kuehnen J, Schwartz A, Neff W, Hennerici M. Cranial nerve syndrome in thrombosis of the transverse/sigmoid sinuses. Brain 1998; 121 ( Pt 2):381.
  68. Crawford SC, Digre KB, Palmer CA, et al. Thrombosis of the deep venous drainage of the brain in adults. Analysis of seven cases with review of the literature. Arch Neurol 1995; 52:1101.
  69. Lafitte F, Boukobza M, Guichard JP, et al. Deep cerebral venous thrombosis: imaging in eight cases. Neuroradiology 1999; 41:410.
  70. Lacour JC, Ducrocq X, Anxionnat R, et al. [Thrombosis of deep cerebral veins in form adults: clinical features and diagnostic approach]. Rev Neurol (Paris) 2000; 156:851.
  71. van den Bergh WM, van der Schaaf I, van Gijn J. The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis. Neurology 2005; 65:192.
  72. Wasay M, Bakshi R, Bobustuc G, et al. Cerebral venous thrombosis: analysis of a multicenter cohort from the United States. J Stroke Cerebrovasc Dis 2008; 17:49.
  73. Girot M, Ferro JM, Canhão P, et al. Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke 2007; 38:337.
  74. Coutinho JM, van den Berg R, Zuurbier SM, et al. Small juxtacortical hemorrhages in cerebral venous thrombosis. Ann Neurol 2014; 75:908.
  75. Ferro JM, Morgado C, Sousa R, Canhão P. Interobserver agreement in the magnetic resonance location of cerebral vein and dural sinus thrombosis. Eur J Neurol 2007; 14:353.
  76. Selim M, Fink J, Linfante I, et al. Diagnosis of cerebral venous thrombosis with echo-planar T2*-weighted magnetic resonance imaging. Arch Neurol 2002; 59:1021.
  77. Fellner FA, Fellner C, Aichner FT, Mölzer G. Importance of T2*-weighted gradient-echo MRI for diagnosis of cortical vein thrombosis. Eur J Radiol 2005; 56:235.
  78. Casey SO, Alberico RA, Patel M, et al. Cerebral CT venography. Radiology 1996; 198:163.
  79. Majoie CB, van Straten M, Venema HW, den Heeten GJ. Multisection CT venography of the dural sinuses and cerebral veins by using matched mask bone elimination. AJNR Am J Neuroradiol 2004; 25:787.
  80. Wetzel SG, Kirsch E, Stock KW, et al. Cerebral veins: comparative study of CT venography with intraarterial digital subtraction angiography. AJNR Am J Neuroradiol 1999; 20:249.
  81. Linn J, Ertl-Wagner B, Seelos KC, et al. Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses. AJNR Am J Neuroradiol 2007; 28:946.
  82. Leach JL, Fortuna RB, Jones BV, Gaskill-Shipley MF. Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 2006; 26 Suppl 1:S19.
  83. Meckel S, Reisinger C, Bremerich J, et al. Cerebral venous thrombosis: diagnostic accuracy of combined, dynamic and static, contrast-enhanced 4D MR venography. AJNR Am J Neuroradiol 2010; 31:527.
  84. Rizzo L, Crasto SG, Rudà R, et al. Cerebral venous thrombosis: role of CT, MRI and MRA in the emergency setting. Radiol Med 2010; 115:313.
  85. Boukobza M, Crassard I, Bousser MG, Chabriat H. MR imaging features of isolated cortical vein thrombosis: diagnosis and follow-up. AJNR Am J Neuroradiol 2009; 30:344.
  86. Dormont D, Anxionnat R, Evrard S, et al. MRI in cerebral venous thrombosis. J Neuroradiol 1994; 21:81.
  87. Isensee C, Reul J, Thron A. Magnetic resonance imaging of thrombosed dural sinuses. Stroke 1994; 25:29.
  88. Favrole P, Guichard JP, Crassard I, et al. Diffusion-weighted imaging of intravascular clots in cerebral venous thrombosis. Stroke 2004; 35:99.
  89. Virapongse C, Cazenave C, Quisling R, et al. The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis. Radiology 1987; 162:779.
  90. Lee EJ. The empty delta sign. Radiology 2002; 224:788.
  91. Boukobza M, Crassard I, Bousser MG. When the "dense triangle" in dural sinus thrombosis is round. Neurology 2007; 69:808.
  92. Sztajzel R, Coeytaux A, Dehdashti AR, et al. Subarachnoid hemorrhage: a rare presentation of cerebral venous thrombosis. Headache 2001; 41:889.
  93. Oppenheim C, Domigo V, Gauvrit JY, et al. Subarachnoid hemorrhage as the initial presentation of dural sinus thrombosis. AJNR Am J Neuroradiol 2005; 26:614.
  94. Spitzer C, Mull M, Rohde V, Kosinski CM. Non-traumatic cortical subarachnoid haemorrhage: diagnostic work-up and aetiological background. Neuroradiology 2005; 47:525.
  95. Ozsvath RR, Casey SO, Lustrin ES, et al. Cerebral venography: comparison of CT and MR projection venography. AJR Am J Roentgenol 1997; 169:1699.
  96. Khandelwal N, Agarwal A, Kochhar R, et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol 2006; 187:1637.
  97. Rodallec MH, Krainik A, Feydy A, et al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics 2006; 26 Suppl 1:S5.
  98. Ayanzen RH, Bird CR, Keller PJ, et al. Cerebral MR venography: normal anatomy and potential diagnostic pitfalls. AJNR Am J Neuroradiol 2000; 21:74.
  99. Zouaoui A, Hidden G. Cerebral venous sinuses: anatomical variants or thrombosis? Acta Anat (Basel) 1988; 133:318.
  100. de Bruijn SF, Majoie CB, Koster PA, et al. Interobserver agreement for MR-imaging and conventional angiography in the diagnosis of cerebral venous thrombosis. In: erebral venous sinus thrombosis. Clinical and epidemiological studies, de Bruijn SF (Ed), Thesis, Amsterdam 1998. p.23.
  101. Dentali F, Squizzato A, Marchesi C, et al. D-dimer testing in the diagnosis of cerebral vein thrombosis: a systematic review and a meta-analysis of the literature. J Thromb Haemost 2012; 10:582.
  102. Meng R, Wang X, Hussain M, et al. Evaluation of plasma D-dimer plus fibrinogen in predicting acute CVST. Int J Stroke 2014; 9:166.
  103. Canhão P, Abreu LF, Ferro JM, et al. Safety of lumbar puncture in patients with cerebral venous thrombosis. Eur J Neurol 2013; 20:1075.
  104. Ferro JM, Bousser MG, Canhão P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology. Eur J Neurol 2017; 24:1203.