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The Clot Thickens: Navigating Cerebral Venous Thrombosis

  • The Review Course in Family Medicine
  • 4 hours ago
  • 2 min read


With Vital FM Update in Toronto wrapping up last weekend, our spring events have officially come to a close.


It was an incredible experience travelling across Canada and connecting with so many of you.


We’re already looking forward to seeing everyone again at Vital FM Update this summer!


-Simon and Paul


My brain has a plumbing problem, and it’s not the pipes you think.


As the 2026 CMAJ article highlights, we need to rethink our approach to the "atypical" headache to consider cerebral venous thrombosis (CVT).


  • Rare: 0.5%-3% of strokes.

  • Demographic: Reproductive-aged females (estrogen-linked).

  • Risk: 80% have identifiable risks.


Stop & Think: A 28-year-old on an OCP pill presents with a progressive, severe headache and blurred vision. Her non-contrast CT is normal. What is your next move?


Cerebral Venous Thrombosis (CVT) is the ultimate diagnostic chameleon. Unlike arterial strokes that hit like a thunderclap, CVT often smoulders. The headache is usually diffuse and worsened by the Valsalva manoeuvre. Look for signs of raised intracranial pressure or focal deficits that don't fit a single arterial territory.


Workup:

  • Venous imaging is required for diagnosis

  • CT Venography or Magnetic Resonance Imaging Venography are the gold standards.

  • Non-contrast CT misses most cases.

  • D-dimer is unreliable and cannot rule out CVT.


Management:

  • Start anticoagulation immediately (Low-Molecular-Weight Heparin or Unfractionated Heparin).

  • Counter-intuitive pearl: Anticoagulate even if intracranial hemorrhage is present.

  • Consult Neurology and Hematology early to guide anticoagulation and follow-up planning.

  • Admission: Patients should be admitted to a Stroke Unit or Intensive Care Unit.


The follow-up: Ongoing care involves managing "The Big Three" post-CVT complications: seizures, chronic headaches, and neurocognitive symptoms. Specialists will determine the duration of anticoagulation and screen for underlying thrombophilias.


EXAM TIP: On a SAMP, don't let a "normal" non-contrast CT brain distract you. If the clinical suspicion for CVT is high (e.g., pregnancy, oral contraceptives, progressive headache), the correct "Next Step" is venous imaging (CT/MR Venography), not discharge or lumbar puncture.



 
 
 

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