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Cerebral venous sinus thrombosis with secondary haemorrhagic infarction — MRCEM SBA MCQ

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HardNeurological emergenciesCerebral venous sinus thrombosis with secondary haemorrhagic infarctionMRCEM SBA

A 32-year-old woman taking a combined oral contraceptive presents after five days of worsening headache and a generalised tonic–clonic seizure. The seizure has stopped. She is now alert but has new left leg weakness. Non-contrast CT shows a small right parasagittal haemorrhagic infarct without significant mass effect. CT venography confirms superior sagittal sinus thrombosis. Her platelet count, coagulation results and renal function are normal; she is not taking an anticoagulant. Which immediate treatment and disposition plan is most appropriate?

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Correct answer: C — Start full-dose heparin and arrange specialist acute stroke-unit admission.

CT venography establishes **cerebral venous sinus thrombosis (CVST)**, and the parasagittal haemorrhagic infarct is a complication of that thrombosis—not a reason, by itself, to withhold treatment. NICE recommends **full-dose anticoagulation, initially with heparin, even when CVST has caused secondary cerebral haemorrhage**, unless a comorbidity precludes it. She has no stated contraindication and needs urgent specialist acute stroke-unit care. A is tempting because haemorrhage commonly prompts caution with anticoagulation, but waiting for an interval CT leaves confirmed CVST untreated; deferral could be appropriate if a separate contraindication to anticoagulation emerged. B offers too little anticoagulation to treat the sinus thrombus; prophylactic dosing addresses venous thromboembolism prevention rather than treatment of established CVST. D borrows the aspirin strategy for acute arterial ischaemic stroke after haemorrhage has been excluded; neither that diagnosis nor that imaging condition applies here. E may attract candidates because the weakness is new, but systemic thrombolysis is not the indicated initial treatment for confirmed CVST with intracerebral haemorrhage. The crucial distinction is **venous thrombosis with secondary bleeding versus arterial ischaemic or primary haemorrhagic stroke**.

Reference: NICE NG128: Stroke and transient ischaemic attack in over 16s — recommendations 1.3.1, 1.4.9 and 1.4.13 (Published 2019; last updated April 2022; minor update March 2025) — https://www.nice.org.uk/guidance/NG128/chapter/recommendations NICE QS2: Prompt admission to specialist acute stroke units (Published 2010; last updated April 2016) — https://www.nice.org.uk/guidance/QS2/chapter/Quality-statement-1-Prompt-admission-to-specialist-acute-stroke-units