CEREBRAL VENOUS THROMBOSIS: AN OVERVIEW OF CLINICAL FEATURES, DIAGNOSIS, AND TREATMENT
Abstract
This narrative review synthesizes current evidence from 2016-2025 articles on cerebral venous thrombosis (CVT), a rare cerebrovascular condition accounting for 0.5-1% of all strokes that predominantly affects young adults, particularly women (3:1 ratio) due to hormonal risk factors. The COVID-19 pandemic introduced novel dimensions including SARS-CoV-2-associated CVT (0.08% incidence) and vaccine-induced immune thrombotic thrombocytopenia (VITT) requiring specific management protocols. Clinical presentation remains heterogeneous, with headache occurring in 60-95% of cases, though 6-25% present with isolated headache without focal signs, necessitating high clinical suspicion and advanced neuroimaging (MRI/MRV as gold standard) for diagnosis. Anticoagulation represents the treatment cornerstone, with accumulating evidence from randomized trials (RE-SPECT CVT, ACTION-CVT, EINSTEIN-Jr CVT) demonstrating that direct oral anticoagulants offer safe and effective alternatives to warfarin, though optimal duration remains debated. Contemporary management has dramatically improved prognosis, reducing mortality from historical 30-50% to current 5-10%, with approximately 80% of patients achieving functional independence, with recurrence risk of ~4% annually and substantial minorities suffer persistent headache, cognitive difficulties, or seizures. Future research priorities include defining optimal anticoagulation duration, standardizing endovascular intervention protocols, and identifying biomarkers for early diagnosis and prognostic stratification.
References
Aguiar de Sousa D. (2021). Cerebral Venous Thrombosis: What's New?. Hamostaseologie, 41(1), 25–30. https://doi.org/10.1055/a-1332-3042
Aguiar de Sousa, D., Lucas Neto, L., Canhão, P., & Ferro, J. M. (2018). Recanalization in Cerebral Venous Thrombosis. Stroke, 49(8), 1828–1835. https://doi.org/10.1161/STROKEAHA.118.022129
Almegren M. O. (2025). Cerebral venous thrombosis: A comprehensive narrative review. Brain circulation, 11(3), 178–186. https://doi.org/10.4103/bc.bc_158_24
Alimohammadi, A., Kim, D. J., & Field, T. S. (2022). Updates in Cerebral Venous Thrombosis. Current cardiology reports, 24(1), 43–50. https://doi.org/10.1007/s11886-021-01622-z
Baldini, T., Asioli, G. M., Romoli, M., Carvalho Dias, M., Schulte, E. C., Hauer, L., Aguiar De Sousa, D., Sellner, J., & Zini, A. (2021). Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. European journal of neurology, 28(10), 3478–3490. https://doi.org/10.1111/ene.14727
Bellanger, G., Kerleroux, B., Hak, J. F., Escalard, S., Dumas, V., Janot, K., Marnat, G., Zhu, F., Forestier, G., Bourcier, R., & Burel, J. (2025). Current practices in cerebral venous thrombectomy: A national survey among French interventional neuroradiology centers. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, 15910199251380371. Advance online publication. https://doi.org/10.1177/15910199251380371
Bose, G., Graveline, J., Yogendrakumar, V., et al. (2021). Direct oral anticoagulants in treatment of cerebral venous thrombosis: A systematic review. BMJ Open, 11(3), e040212.
Bose, G., Graveline, J., Yogendrakumar, V., Shorr, R., Fergusson, D. A., Le Gal, G., Coutinho, J., Mendonça, M., Viana-Baptista, M., Nagel, S., & Dowlatshahi, D. (2021). Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review. BMJ open, 11(2), e040212. https://doi.org/10.1136/bmjopen-2020-040212
Connor, P., Sánchez van Kammen, M., Lensing, A. W. A., Chalmers, E., Kállay, K., Hege, K., Simioni, P., Biss, T., Bajolle, F., Bonnet, D., Grunt, S., Kumar, R., Lvova, O., Bhat, R., Van Damme, A., Palumbo, J., Santamaria, A., Saracco, P., Payne, J., Baird, S., … Coutinho, J. M. (2020). Safety and efficacy of rivaroxaban in pediatric cerebral venous thrombosis (EINSTEIN-Jr CVT). Blood advances, 4(24), 6250–6258. https://doi.org/10.1182/bloodadvances.2020003244
Coutinho, J. M., Zuurbier, S. M., Bousser, M. G., Ji, X., Canhão, P., Roos, Y. B., Crassard, I., Nunes, A. P., Uyttenboogaart, M., Chen, J., Emmer, B. J., Roosendaal, S. D., Houdart, E., Reekers, J. A., van den Berg, R., de Haan, R. J., Majoie, C. B., Ferro, J. M., Stam, J., & TO-ACT investigators (2020). Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial. JAMA neurology, 77(8), 966–973. https://doi.org/10.1001/jamaneurol.2020.1022
Dmytriw, A. A., Song, J. S. A., Yu, E., & Poon, C. S. (2018). Cerebral venous thrombosis: state of the art diagnosis and management. Neuroradiology, 60(7), 669–685. https://doi.org/10.1007/s00234-018-2032-2
Duman, T., Uluduz, D., Midi, I., Bektas, H., Kablan, Y., Goksel, B. K., Milanlioglu, A., Necioglu Orken, D., Aluclu, U., & VENOST Study Group (2017). A Multicenter Study of 1144 Patients with Cerebral Venous Thrombosis: The VENOST Study. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 26(8), 1848–1857. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.04.020
Ferro, J. M., Bousser, M. G., Canhão, P., Coutinho, J. M., Crassard, I., Dentali, F., di Minno, M., Maino, A., Martinelli, I., Masuhr, F., Aguiar de Sousa, D., Stam, J., & European Stroke Organization (2017). European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology. European journal of neurology, 24(10), 1203–1213. https://doi.org/10.1111/ene.13381
Ferro, J. M., & Aguiar de Sousa, D. (2019). Cerebral Venous Thrombosis: an Update. Current neurology and neuroscience reports, 19(10), 74. https://doi.org/10.1007/s11910-019-0988-x
Ferro, J. M., Coutinho, J. M., Dentali, F., Kobayashi, A., Alasheev, A., Canhão, P., Karpov, D., Nagel, S., Posthuma, L., Roriz, J. M., Caria, J., Frässdorf, M., Huisman, H., Reilly, P., Diener, H. C., & RE-SPECT CVT Study Group (2019). Safety and Efficacy of Dabigatran Etexilate vs Dose-Adjusted Warfarin in Patients With Cerebral Venous Thrombosis: A Randomized Clinical Trial. JAMA neurology, 76(12), 1457–1465. https://doi.org/10.1001/jamaneurol.2019.2764
Field, T. S., Dizonno, V., Almekhlafi, M. A., Bala, F., Alhabli, I., Wong, H., Norena, M., Villaluna, M. K., King-Azote, P., Ratnaweera, N., Mancini, S., Van Gaal, S. C., Wilson, L. K., Graham, B. R., Sposato, L. A., Blacquiere, D., Dewar, B. M., Boulos, M. I., Buck, B. H., Odier, C., … SECRET Investigators (2023). Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis. Stroke, 54(11), 2724–2736. https://doi.org/10.1161/STROKEAHA.123.044113
Gurram, S., Thambi, M., Naik, A., & Gorthi, S. P. (2024). Critical Prognostic Factors in Cerebral Venous Sinus Thrombosis: An Observational Study. Annals of Indian Academy of Neurology, 27(1), 67–71. https://doi.org/10.4103/aian.aian_820_23
Hou, S., Zhang, Y., Xia, Y., Liu, Y., Deng, X., Wang, W., Wang, Y., Wang, C., & Wang, G. (2024). Global, regional, and national epidemiology of ischemic stroke from 1990 to 2021. European journal of neurology, 31(12), e16481. https://doi.org/10.1111/ene.16481
Idiculla, P. S., Gurala, D., Palanisamy, M., Vijayakumar, R., Dhandapani, S., & Nagarajan, E. (2020). Cerebral Venous Thrombosis: A Comprehensive Review. European neurology, 83(4), 369–379. https://doi.org/10.1159/000509802
Jianu, D. C., Jianu, S. N., Dan, T. F., Munteanu, G., Copil, A., Birdac, C. D., Motoc, A. G. M., Docu Axelerad, A., Petrica, L., Arnautu, S. F., Sadik, R., Iacob, N., & Gogu, A. E. (2022). An Integrated Approach on the Diagnosis of Cerebral Veins and Dural Sinuses Thrombosis (a Narrative Review). Life (Basel, Switzerland), 12(5), 717. https://doi.org/10.3390/life12050717
Khan, M. W. A., Zeeshan, H. M., & Iqbal, S. (2020). Clinical Profile and Prognosis of Cerebral Venous Sinus Thrombosis. Cureus, 12(12), e12221. https://doi.org/10.7759/cureus.12221
Mehta, A., Danesh, J., & Kuruvilla, D. (2019). Cerebral Venous Thrombosis Headache. Current pain and headache reports, 23(7), 47. https://doi.org/10.1007/s11916-019-0786-9
Miranda, B., Aaron, S., Arauz, A., Barinagarrementeria, F., Borhani-Haghighi, A., Carvalho, M., Conforto, A. B., Coutinho, J. M., Stam, J., Canhão, P., & Ferro, J. M. (2018). The benefit of EXtending oral antiCOAgulation treatment (EXCOA) after acute cerebral vein thrombosis (CVT): EXCOA-CVT cluster randomized trial protocol. International journal of stroke : official journal of the International Stroke Society, 13(7), 771–774. https://doi.org/10.1177/1747493018778137
Moraes Junior, A. A. A., & Conforto, A. B. (2022). Cerebral venous thrombosis. Arquivos de neuro-psiquiatria, 80(5 Suppl 1), 53–59. https://doi.org/10.1590/0004-282X-ANP-2022-S108
Ranjan, R., Ken-Dror, G., & Sharma, P. (2023). Pathophysiology, diagnosis and management of cerebral venous thrombosis: A comprehensive review. Medicine, 102(48), e36366. https://doi.org/10.1097/MD.0000000000036366
Rosa, S., Fragata, I., & Aguiar de Sousa, D. (2025). Update on management of cerebral venous thrombosis. Current opinion in neurology, 38(1), 18–28. https://doi.org/10.1097/WCO.0000000000001329
Saposnik, G., Bushnell, C., Coutinho, J. M., Field, T. S., Furie, K. L., Galadanci, N., Kam, W., Kirkham, F. C., McNair, N. D., Singhal, A. B., Thijs, V., Yang, V. X. D., & American Heart Association Stroke Council; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Hypertension (2024). Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association. Stroke, 55(3), e77–e90. https://doi.org/10.1161/STR.0000000000000456
Silvis, S. M., de Sousa, D. A., Ferro, J. M., & Coutinho, J. M. (2017). Cerebral venous thrombosis. Nature reviews. Neurology, 13(9), 555–565. https://doi.org/10.1038/nrneurol.2017.104
Spadaro, A., Scott, K. R., Koyfman, A., & Long, B. (2021). Cerebral venous thrombosis: Diagnosis and management in the emergency department setting. The American journal of emergency medicine, 47, 24–29. https://doi.org/10.1016/j.ajem.2021.03.040
Ulivi, L., Squitieri, M., Cohen, H., Cowley, P., & Werring, D. J. (2020). Cerebral venous thrombosis: a practical guide. Practical neurology, 20(5), 356–367. https://doi.org/10.1136/practneurol-2019-002415
Yaghi, S., Shu, L., Bakradze, E., Salehi Omran, S., Giles, J. A., Amar, J. Y., Henninger, N., Elnazeir, M., Liberman, A. L., Moncrieffe, K., Lu, J., Sharma, R., Cheng, Y., Zubair, A. S., Simpkins, A. N., Li, G. T., Kung, J. C., Perez, D., Heldner, M., Scutelnic, A., … Furie, K. (2022). Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke, 53(3), 728–738. https://doi.org/10.1161/STROKEAHA.121.037541
Zhang, B., Lang, Y., Zhang, W., Cui, L., & Deng, F. (2021). Characteristics and Management of Autoimmune Disease-Associated Cerebral Venous Sinus Thrombosis. Frontiers in immunology, 12, 671101. https://doi.org/10.3389/fimmu.2021.671101
Zuurbier, S. M., & Coutinho, J. M. (2017). Cerebral Venous Thrombosis. Advances in experimental medicine and biology, 906, 183–193. https://doi.org/10.1007/5584_2016_115
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