Cerebral Venous And Sinus Thrombosis Research Articles

The metabolic syndrome and the risk of cerebral venous and sinus thrombosis: A case–control study

Background & Objective: There is no data about the significance of the metabolic syndrome (MeS) for the development of cerebral venous and sinus thrombosis (CVST). We investigated the association of metabolic syndrome in a consecutive series of patients with CVST. Methods: This is a case–control study, where consecutive patients of CVST and control subjects were assessed for MeS according to the National Cholesterol Education Program criteria. The prevalence of the MeS was compared between patients with CVST and controls. Results: We enrolled 58 patients with a first episode of CVST and 129 controls. In univariate analysis, MeS was significantly more common in CVST patients than in controls [Patients 28 (48.3%), control 28 (21.7%); odds ratio (OR) 3.36; 95% confidence interval (CI) 1.77, 6.53, p<0.001]. After adjustment for age and sex, we found OCP usage (OR 22.7; 95% CI 7.75, 66.66, p<0.001) and the MeS (OR 3.26; 95% CI 1.15, 9.25, p=0.02) to be independently associated with CVST. When coexistence of OCP usage and MeS was considered as a variant in univariate analysis comparing CVST patients and controls, we found association with CVST to be even higher (OR 47.6; 95% CI 5.91, 333.3, P< 0.001). Conclusion: CVST is a disease with multiple risk factors and coexistence of MeS and OCP usage can potentiate the risk of CVST occurrence.

Artery and venous sinus occlusion image score (AVOIS): A novel method to evaluate occlusive cerebral arteries and venous diseases.

AimTo establish an artery and venous sinus occlusion image score (AVOIS) which is compatible in both cerebral arteries and venous system diseases.MethodsA total of 188 consecutive patients with the final diagnosis of anterior circulation infarct (ACI) and 56 consecutive patients with cerebral venous and sinus thrombosis (CVST) were retrospectively studied. The AVOIS was developed based on the severity of occlusive changes of main intracranial arteries and venous sinuses (present = 0, partial occlusion = 1, absent = 2), and divided into four groups (CVST group: 0, 1‐5, 6‐10, >10. ACI group: 0, 1‐5, 6‐10, >10) arbitrarily. A receiver operating characteristic (ROC) curve was applied to discover the sensitivity and specificity of AVOIS. The National Institutes of Health Stroke Scale (NIHSS), Clot Burden Score (CBS) were set as the reference. Logistic regression models were developed to adjust for baseline clinical variables and AVOIS. Length of hospital stay (LOS) was also evaluated using the Kaplan‐Meier estimator.ResultsFor the CVST group, a positive correlation between AVOIS and NIHSS was discovered (Spearman's ρ = 0.54, p < 0.001). For the ACI group, ROC showed relatively high sensitivity (84.8%) and specificity (81.8%). Besides, the probability of time to discharge was significantly different among the AVOIS subgroups as well (p < 0.001).ConclusionThe AVOIS can be used to evaluate the treatment of patients with acute stroke caused by cerebral venous sinus thrombosis and anterior circulation large vessel occlusion. It is a reliable and convenient method that may help prompt prognosis and guide the treatment of individual patients.

Diagnosis and therapy of cerebral venous and sinus thrombosis

Although cerebral venous and sinus thrombosis (CVST) is a rare cerebrovascular disease, it is being diagnosed with increasing frequency due to increased clinical awareness, better imaging capabilities, and higher survival rates in patients with predisposing conditions. This article shows how the diagnosis can be made effectively and what therapeutic options exist in the acute phase and secondary prophylaxis.

Assessment of Patients with Intracerebral Hemorrhage or Hemorrhagic Transformation in the VENOST Study

Introduction: Cerebral venous and sinus thrombosis (CVST) may lead to cerebral edema and increased intracranial pressure; besides, ischemic or hemorrhagic lesions may develop. Intracerebral hemorrhages occur in approximately one-third of CVST patients. We assessed and compared the findings of the cerebral hemorrhage (CH) group and the CVST group. Materials and Methods: In the VENOST study, medical records of 1,193 patients with CVST, aged over 18 years, were obtained from 35 national stroke centers. Demographic characteristics, clinical symptoms, signs at the admission, radiological findings, etiologic factors, acute and maintenance treatment, and outcome results were reported. The number of involved sinuses or veins, localizations of thrombus, and lesions on CT and MRI scans were recorded. Results: CH was detected in the brain imaging of 241 (21.1%) patients, as hemorrhagic infarction in 198 patients and intracerebral hemorrhage in 43 patients. Gynecologic causes comprised the largest percentage (41.7%) of etiology and risk factors in the CVST group. In the CH group, headache associated with other neurological symptoms was more frequent. These neurological symptoms were epileptic seizures (46.9%), nausea and/or vomiting (36.5%), altered consciousness (36.5%), and focal neurological deficits (33.6%). mRS was ≥3 in 23.1% of the patients in the CH group. Discussion and Conclusion: CVST, an important cause of stroke in the young, should be monitored closely if the patients have additional symptoms of headache, multiple sinus involvement, and CH. Older age and parenchymal lesion, either hemorrhagic infarction or intracerebral hemorrhage, imply poor outcome.

Cerebral venous and sinus thrombosis diagnosis: preliminary study of clinical picture and D-dimer concentration correlation

We investigated whether D-dimer (DD) concentration is elevated in cerebral venous and sinus thrombosis (CVST), as has been reported in the literature. CVST is a disease with variable clinical presentations and a challenging diagnosis. We looked into whether D-dimer concentration might be an indicator of CVST, and the need for neuroimaging tests correlated with clinical factors. We included all consecutive patients (mean age 41.6 years) with CVST treated in our neurology department from 2014 to 2018 whose DD levels had been measured. DD concentrations were categorised as normal (≤ 0.5 μg/ml) or elevated ( > 0.5 μg/ml). Appropriate imaging confirmed the diagnosis of CVST. The results were compared to those of a control group consisting of 22 age- and sex-matched patients (mean age 40 years) with a diagnosis of primary headache (tension type or migraine) hospitalised to exclude secondary causes. In 20 patients in the CVST study group, median level of DD was 1.0 + 0.57 μg/ml (range 0.19-2.45 μg/ml), compared to the control group's mean DD level of 0.50 + 0.45 μg/ml (range 0.15-1.73 μg/ml), with p < 0.005. Higher DD levels were associated with complications of the disease and fatal course (p < 0.005). One female and one male patient died because of CVST with DD levels of (respectively) 2.45 and 1.80 μg/ml - the two highest concentrations in our study group. DD concentration, especially in headache patients, may be a factor to predict CVST and an indicator for further diagnostic procedures with venography. But in clinical practice, low levels of DD cannot be taken to exclude CVST.

Evaluation of Diagnostic Values in NCCT and MRI of the Patients With Cerebral Venous or Sinus Thrombosis in Loghman Hakim Hospital in Tehran 2014-2018

Background: Cerebral venous and sinus thrombosis (CVT) is the rare type of stroke, which can be fatal or causes significant morbidity. CVT could cause by multiple etiologies and risk factors and could present with many signs and symptoms such as a headache, seizure or altered mental status. The gold standard for diagnosing CVT is magnetic resonance venography (MRV) or computed tomographic venography (CTV), as these modalities are not available in many health centers and the early diagnosis of this disease improves significantly the outcome of treatment, we evaluated the diagnostic values of CT and magnetic resonance imaging (MRI) in CVT patients. Methods: We compiled and investigated the radiological and clinical records of 92 patients with the final diagnosis of CVT; we observed the sign of thrombosis in 74 patients who had either the non-contrast CT or MRI plus MRV. We statistically analyzed the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, the positive and negative likelihood ratio of these modalities. Results: Our results demonstrated that the sensitivity of CT scan is 60.5%, and its specificity is 66.7%. The positive predictive value of CT is 85%, and its negative predictive value is 34%. Our study demonstrated that the accuracy of CT in diagnosing CVT patients is 62%. Besides our results showed that the sensitivity of MRI in diagnosing CVT is 87%, and the specificity of MRI is 76.9%. Hence the positive predictive value of MRI is 94%, and the negative predictive value is 58%, and the accuracy of this modality is 85% Conclusion: In the absence of gold standard modalities, MRI and CT scan have relatively good diagnostic values, besides MRI is more beneficial between the two, moreover we found that CVT is more prevalent among women and in warm seasons.

Cerebral vein thrombosis due to meningococcal meningitis

Bacterial meningitis is a life-threatening condition and Neisseria meningitidis is a major cause. Cerebrovascular complications can occur. Cerebral venous and sinus thrombosis (CVST) is an uncommon type of these complications, especially in meningococcal meningitis. The initiation of anticoagulant in septic thrombosis is controversial. A 35-year-old man was admitted to a hospital with fever and confusion. The diagnosis of N. meningitidis meningitis was established. Antimicrobial regimen (ceftriaxone) was continued. On the 3rd day, the patient's consciousness was improved; however, according to the patient's headache on day 7, brain imaging was performed which revealed a cerebral thrombosis in transverse and sigmoid sinuses. Although initiation of anticoagulant is controversial in septic thrombosis, the anticoagulant treatment also was started. Control brain magnetic resonance venogram done revealed complete resolution of cerebral CVST after 2 weeks. CVST as a complication of meningococcal meningitis should be considered. Anticoagulant treatment may be considered in the management of septic cerebral thrombosis if there are no contraindications. The use of anticoagulant needs further studies.

Seizure in cerebral venous and sinus thrombosis.

SummaryMany conflicting issues exist about seizure in the setting of cerebral venous and sinus thrombosis (CVST). In this article we aimed to address the existing data regarding incidence, characteristics, predictors, treatment, and prognosis of acute and late seizures in patients with CVST and to prepare more practical information for clinicians. PubMed, Embase, Web of science and Cochrane databases were searched within 1966–2016 using relevant keywords. A total of 63 papers met the inclusion criteria. Seizures are classified as acute symptomatic seizures (ASS; first 14 days) and post‐CVST epilepsy (PCE; after 14 days). The incidence had been reported in a wide range of 6.9–76% for ASS and 4–16% for PCE. Focal and generalized seizures were observed with different predominance. ASS commonly occurred in patients with loss of consciousness, focal neurological deficits, supratentorial lesions and thrombosis in superior sagittal sinus, straight sinus, and cortical veins. PCE had been predisposed by occurrence of ASS, motor deficit, and supratentorial lesions, particularly hemorrhage. Most experts believe that primary prophylaxis with antiepileptic drugs in the acute phase is not indicated. However, the initiation of prophylaxis after the first seizure in patients with supratentorial lesions or focal neurological deficit should be recommended. The quality of current evidence is low and most conclusions are based on expert opinions. More accurate reports of seizure semiology, detailed antiepileptic treatment plans, and outcomes are necessary to answer the existing questions.

Low-dose gonadotropin-releasing hormone agonist therapy (draw-back therapy) for successful long-term management of adenomyosis associated with cerebral venous and sinus thrombosis from low-dose oral contraceptive use

The patient was a 38-year-old nulligravida with a history of smoking. She presented to this hospital with dysmenorrhea and postmenstrual lower abdominal pain. Adenomyosis was diagnosed using ultrasound and magnetic resonance imaging. She was instructed to stop smoking and was administered low-dose OCs. CVST occurred 18 months later. OC therapy was halted, and only antiplatelet therapy was administered. After six months, her chief complaint symptoms intensified, therefore GnRHa draw-back therapy was administered after obtaining informed consent. No uterine enlargement was observed, and the abdominal pain resolved. During 2.5 years of therapy, her bone density levels remained within normal limits. CVST did not recur and no other thromboses were observed.

Abstract TP54: Magnetic Resonance Black-blood Thrombus Imaging Could be a Promising New Tool in the Diagnosis of Cerebral Venous and Sinus Thrombosis

Introduction: BTI is a novel 3D black-blood imaging technique with isotropic, submillimeter spatial resolution. As opposed to conventional methods that indirectly diagnose CVT by imaging the lumen, BTI directly visualizes the thrombus with suppressed blood signals. We aimed to prospectively evaluate the diagnostic performance of BTItechnique in patients with suspected cerebral venous and sinus thrombosis (CVT) as compared to MR venography. Materials and Methods: MR venography and BTI were performed using 3.0 T in consecutive patients suspected of CVT between August 2014 and October 2015. Signal to noise ratio (SNR) and contrast to noise ratio (CNR) were calculated for the detected thrombus on BTI. Diagnostic performance of BTI were analyzed on both per-segment and per-patient basis. Results: A total of 58 met study criteria Thrombus SNR was 206 ± 95 in acute thrombus and 94 ± 41 in chronic thrombus (P &lt; 0.0001). Thrombus to lumen CNR was 201 ± 94 and 86 ± 40 for acute and chronic thrombus, respectively (P &lt; 0.0001). The sensitivity and specificity rates of BTI in the detection of CVT were 97.3% (36/37, 95% confidence interval [CI] 85.8% to 99.9%) and 95.2% (20/21, 95% CI 76.2% to 99.9%), respectively on per patient level. On per segment level, the sensitivity and specificity were 95.6% (152/159, 95% CI 91.1% to 98.2%) and 98.0% (640/653, 95%CI 96.6% to 98.9%), respectively. The characteristics of the study population are summarized in Table 1. Figure 2 demonstrated thrombus volume quantification in one patient and total volume was 11.8cc. Conclusions: BTI allows for selective visualization of acute and chronic thrombus with high sensitivity, specificity and accuracy. Our findings suggest that BTI may emerge as a promising first line diagnostic imaging tool in the diagnosis of CVT. Figure 1. BTI images of a 13-year-old female with suspected acute CVT. Sagittal, coronal, and axial images of BTI depict the hyperintense signal of acute thrombi (A, B, and C) in ISS, Galen, SS, RSS, and RTS. Thrombus volume measurement was segmented and total thrombus volume was 11.8cc(D, E, and F). Table 1. Clinical Characteristics of 58 patients who underwent BTI

The interpretation of "Chinese expert consensus on diagnosis and treatment of cerebral venous and sinus thrombosis"

Cerebral venous and sinus thrombosis (CVST) is an infrequent cerebral venous system disease caused by a lot of reasons, which usually affects young and middle-aged adults. Due to variable clinical presentations, such as headache, vomiting, epilepsy and local neurological impairment, CVST is easy to be misdiagnosed or missed in diagnosis, with a high morbidity and mortality. To improve the standard diagnosis and treatment of CVST and guide the clinical practice of neurologists and neurosurgeons, Multicenter Expert Consensus Group on Diagnosis and Treatment of Cerebral Venous and Sinus Thrombosis in China wrote the "Chinese expert consensus on diagnosis and treatment of cerebral venous and sinus thrombosis" in the year 2013. This paper aims to interpret the main contents of this consensus. DOI: 10.3969/j.issn.1672-6731.2016.12.003

Imaging of Cerebral Venous and Sinus Thrombosis

Early  and correct diagnosis of cerebral venous and sinus thrombosis (CVST) is necessary for prompt management of this disorder. Neuro-imaging is a crucial part of diagnosis of CVST. I reviewed the findings of non-enhanced computerized tomography (CT), Contrast enhanced CT, CT venography (CTV), different techniques of magnetic resonance imaging (MRI), MR venography, and digital subtraction angiography. I also reviewed the potential pitfalls in image interpretation.

Imaging of Cerebral Venous and Sinus Thrombosis

Early and correct diagnosis of cerebral venous and sinus thrombosis (CVST) is necessary for prompt management of this disorder. Neuro-imaging is a crucial part of diagnosis of CVST. I reviewed the findings of non-enhanced computerized tomography (CT), Contrast enhanced CT, CT venography (CTV), different techniques of magnetic resonance imaging (MRI), MR venography, and digital subtraction angiography. I also reviewed the potential pitfalls in image interpretation.

New Clinical-Imagistic Features in Cerebral Venous and Sinus Thrombosis

ObjectiveThe cerebral venous and sinus thrombosis (CVST), severe neurological emergencies is an important pathology of the venous brain system. This paper is an on-going study about CVST, the first report was done in 2008. Material and methodsWe received 32 patients hospitalized on emergency between February 2006 – February 2013 (only self - casuistry). Demographic (sex, age), clinical, imagistic (cerebral MRI – venous angiography, cerebral CT), paraclinic (CSF, factor V Leiden mutation) data, as well as risk factors, treatment, evolution and neurologic recovery were all considered. ResultsWe studied 20 females and 12 males (62% versus 38%). Etiology: oral contraceptives (8 cases), otomastoiditis (7cases), dental abscess of the upper jaw (3 cases), maxilar sinusitis (2 cases), penetrating skull trauma (3 cases), ethmoidal puncture for frontal sinusitis (1 case), provoked abortion (2cases), pregnancy (1 case), puerperium (1 case), hereditary thrombophilia- factor V Leiden mutation (heterozigot fenotype - 3 cases), encephalitis with HSV (1case). The symptomatology varied according to the disease etiology and the location of CVST. Initial clinical symptoms include: coma (3 cases), headache (26 cases), seizures (20 cases), motor and mental disturbances (18 cases), cranial nerves palsy (18 cases), intracranial hypertension (8 cases), papilledema (4 cases), nausea and vomiting (20 cases). Cerebral MRI- venous angiography is the optimum diagnosis method we applied to all patients. ConclusionsCVST even with a reduced occurrence, represents a severe neurovascular emergency. CVST is more common in women, frequently associated with oral contraceptives, abortion, pregnancy or puerperium (37%). Young patients with CVST should be screened for thrombophilia. If diagnosed at an early stage, especially by cerebral MRI-venous angiography and correctly treated, the patients have a favorable evolution, the lethal cases decreasing until 3%. Patients with septic CVST and coma from the beginning have bad prognosis. The efficacy of heparin with APTT controlled has been shown.

Low levels of tissue factor pathway inhibitor increase the risk of cerebral venous thrombosis.

Background:Decreased concentration of tissue factor pathway inhibitor (TFPI) is a risk factor for development of deep venous thrombosis and coronary heart disease, but there is no evidence for the relationship between TFPI and cerebral venous and sinus thrombosis (CVST). The aim of this study was to determine the level of TFPI in healthy population and in patients with CVST.Materials and Methods:We determined the plasma level of TFPI in 20 patients with CVST (cases) and 31 healthy volunteer subjects (as control group) by enzyme linked immunoassay method. We also examined the association between TFPI and the risk of CVST. Continuous variables were compared between groups using Student's t test, and odds ratio was calculated by multiple logistic regression analysis.Results:The mean TFPI was significantly lower in the CVST group compared with the control group (8.60 ± 4.05 ng/mL; 14.6 ± 8.6 ng/mL; P = 0. 005), respectively. The odds ratio for CVST associated with low (<25th percentile) levels of TFPI was 5.429 (95% CI, 1.487-19.82, P = 0.012).Conclusion:Our investigation demonstrates that reduced TFPI may be one of the risk factors of CVST and associated with increasing the risk of developing CVST.

Factor V Leiden, factor V Cambridge, factor II GA20210, and methylenetetrahydrofolate reductase in cerebral venous and sinus thrombosis: A case-control study.

Background:Factor V G1691A (FV Leiden), FII GA20210, and methylenetetrahydrofolate reductase (MTHFR) C677T mutations are the most common genetic risk factors for thromboembolism in the Western countries. However, there is rare data in Iran about cerebral venous and sinus thrombosis (CVST) patients. The aim of this study was to evaluate the frequency of common genetic thrombophilic factors in CVST patients.Materials and Methods:Forty consequently CVST patients from two University Hospital in Isfahan University of Medical Sciences aged more than 15 years from January 2009 to January 2011 were recruited. In parallel, 51 healthy subjects with the same age and race from similar population selected as controls. FV Leiden, FII GA20210, MTHFR C677T, and FV Cambridge gene mutations by polymerase chain reaction technique were evaluated in case and control groups.Results:FV Leiden, FII GA20210, and FV Cambridge gene mutations had very low prevalence in both case (5%, 2%, 0%) and control (2.5%, 0%, 0%) and were not found any significant difference between groups. MTHFR C677T mutations was in 22 (55%) of patients in case group and 18 (35.5%) of control group (P = 0.09).Conclusion:This study showed that the prevalence of FV Leiden, FII GA20210, and FV Cambridge were low. Laboratory investigations of these mutations as a routine test for all patients with CVST may not be cost benefit.

Therapiemöglichkeiten bei schweren, intensivpflichtigen Sinus- und Venenthrombosen

Cerebral venous and sinus thrombosis (CVST) constitutes less than 0.5-1 % of all strokes and occurs predominantly in young female adults. In general the clinical outcome is favorable but 3-15 % of patients die in the acute phase and in the majority of cases due to cerebral herniation. Intensive care treatment analogous to that of severe ischemic infarct leads to an aggressive interdisciplinary therapy concept that can achieve good clinical outcome. Based on five cases of severe CVST treatment options will be presented. All five patients were affected by impending or incipient cerebral herniation and severe focal neurological deficits which resulted in the decision to implement thrombectomy, thrombolysis or hemicraniectomy. Despite the severe course and many intensive care complications which suggested a poor prognosis, all five patients could be transferred to rehabilitation after having survived the acute phase and achieved an amazingly good overall clinical outcome. Considering the life-threatening course of severe CVST, aggressive interdisciplinary management by endovascular thrombectomy and hemicraniectomy can lead to a scarcely expected clinical outcome without disability or severe dependency. This treatment should be performed early and in an escalatory manner in patients with severe CVST who have an increased risk of an unfavorable outcome due to edema, infarction and hemorrhage.

Soluble Thrombomodulin and Endothelial Cell Protein C Receptor Levels in Patients with Cerebral Venous and Sinus Thrombosis

Introduction: Cerebral venous and sinus thrombosis (CVST) is a potentially serious disorder. In search for underlying coagulopathy in CVST patients, we measured plasma levels of soluble thrombomodulin (sTM) and soluble endothelial protein C receptor (sEPCR) in patients with CVST as candidate biomarkers of thrombosis. Materials and Methods: The concentrations of sTM and sEPCR in 19 CVST patients without protein C and protein S deficiency were measured by ELISA and compared with 53 healthy controls. We also examined the association between those plasma markers and the risk of CVST. Results: Significant difference was identified in plasma sTM level between CVST patients and controls (0.95 ± 0.09 vs. 1.26 ± 0.12 ng/ml, respectively; p = 0.038). The plasma level of sEPCR was not different between groups, and no significant quantitative association was identified between the risk of CVST and the levels of sEPCR. The adjusted odds ratio for CVST associated with low (<10th percentile) levels of sTM was 2.3 (95% CI: 1.29-20.08; p = 0.012) after adjustment for confounding factors. Conclusion: Decreased plasma sTM concentration may be associated with an increased risk of CVST.

Headache and Status Epilepticus in the Postpartum Period; Posterior Reversible Encephalopathy Syndrome or Cerebral Venous Thrombosis?

We report a case of a young woman, with a history of a miscarriage and a molar pregnancy, who developed headache and status epilepticus in postpartum day three. Posterior reversible encephalopathy syndrome (PRES) and cerebral venous and sinus thrombosis (CVST) can present with identical clinical picture; however, the imaging findings can help the clinician to make the correct diagnosis and initiate the appropriate treatment. Both PRES and CVST are medical emergencies and fully reversible entities especially when treatment initiation is immediate.

EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients

Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed as a result of the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous LMWH or with dose-adjusted intravenous heparin (level B recommendation). Concomitant intracranial haemorrhage (ICH) related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulant therapy after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with "mild" thrombophilia, such as heterozygous factor V Leiden or prothrombin G20210A mutation and high plasma levels of factor VIII. Indefinite AC should be considered in patients with recurrent episodes of CVST and in those with one episode of CVST and 'severe' thrombophilia, such as antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without large ICH and threatening herniation (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. However, in severe cases with impending herniation craniectomy can be used as a life-saving intervention (good practice point).