Severe headache
Venous stroke · anticoagulate
HallmarkSevere headache (~90%) ± seizures
Most common sinusSuperior sagittal (~60–70%)
Confirm withCTV or MRV
Key ruleAnticoagulate even if hemorrhagic
Hemorrhagic venous infarct? You still anticoagulate — withholding heparin is the wrong answer.
Key clinical features
- Anticoagulate with LMWH/UFH even with a hemorrhagic venous infarct (ISCVT, RE-SPECT CVT)
- Empty delta sign — filling defect on contrast CT
- Dense triangle / cord sign on non-contrast CT
- NCCT is normal in up to 30% — never rules it out
- CTV or MRV confirms the diagnosis
- Superior sagittal sinus → bilateral parasagittal leg weakness
- Deep venous system → bilateral thalamic edema (worst prognosis)
- Cavernous sinus → painful ophthalmoplegia + chemosis + proptosis
◆ Signature clue
A hemorrhagic infarct that does NOT respect an arterial territory (bilateral, parasagittal) → think venous, not arterial. Get CTV/MRV and anticoagulate anyway.
Diagnosis
CTV or MRV confirms. NCCT normal in up to 30% — look for empty delta (contrast CT), dense triangle / cord sign (NCCT). Screen for prothrombotic states.
Management
LMWH/UFH acute — even with hemorrhagic infarct; transition to oral anticoagulation. Manage raised ICP; endovascular reserved for deterioration despite AC.