CVT occurs in approximately 5 cases per million people per year, accounting for 0.5% to 1% of all stroke cases. One of the largest cohort studies of patients with confirmed CVT showed that 54% of patients were taking oral contraceptives, 34% were in a hereditary or preacquired thrombotic state, and 21% were pregnant or recently delivered. Other triggers included infection (12%), use of a medication (8%), cancer (7%), and other hematologic disorders (12%). (Some patients have more than one cause.) The disease is most common in women, and the age of onset is mostly under 61 years. Patients aged less than 50 years account for 78% of cases. In Western countries, the incidence of CVT during pregnancy and the postpartum period is about 1-4 cases per 10,000 births, with the highest risk in the last 3 months of pregnancy and the first 4 weeks after delivery. However, CVT is not a contraindication to repeat pregnancy. Patients may exhibit slowly progressive symptoms, and delayed diagnosis is common. According to relevant studies, the average interval between symptom onset and admission to hospital is 4 days, and the average interval between symptom onset and diagnosis is 7 days. Headache is the most common symptom, occurring in approximately 90% of cases. Epileptic seizures were also more common. Approximately 30-40% of patients with CVT present with intracranial hemorrhage. In order to select the appropriate treatment, it is important to determine that the cause of the bleeding is CVT and not a ruptured cerebral artery or other factors. Once CVT is suspected, MRI or magnetic resonance venography (MRV) is recommended to confirm the diagnosis by detecting a thrombus blocking a venous sinus or cerebral vein. In the emergency department, if MRI cannot be performed, CT scan or CT venography is an option. Anticoagulation is the usual first-line treatment, and intravenous heparin or subcutaneous low-molecular-weight heparin can be used for patients without contraindications. The optimal anticoagulation regimen and the duration of intravenous anticoagulation therapy are not known. Evidence on other alternative treatments such as endovascular therapy and decompressive lateral craniectomy is limited and the level of evidence is low. These treatments may be considered for patients with progressive worsening of neurological function despite anticoagulation and optimal medical therapy. A randomized trial is currently underway to compare the effectiveness of anticoagulation versus endovascular thrombolytic therapy for patients with CVT. There is a need to develop evaluation and treatment guidelines for this particular disease,” said Joey E. English, MD, PhD, director of the Center for Neurointerventional Therapies at San Francisco General Hospital and San Francisco VA Medical Center. While there is little controversy about the diagnosis of CVT, the problem is that the disease is relatively rare compared to ischemic stroke and can present with a variety of symptoms, including headache, nausea, vomiting (similar to elevated intracranial pressure), epileptic seizures, sudden focal neurological deficits (similar to acute ischemic arterial stroke), and progressive depressed mental status. These symptoms may occur separately or simultaneously.” Dr. English cautions that imaging tests that do not involve specialized angiography, such as CT or MR, may only reveal small changes, which are often easily overlooked. Early recognition of the disease can be very difficult, both from a clinical and imaging perspective. “One of the goals of issuing this guideline statement is to increase clinicians’ awareness of the disease thereby improving early recognition.” The main controversy regarding CVT is what the best treatment options are, particularly the safety and efficacy of anticoagulation with heparin and heparin analogs (especially for patients with CVT-associated intracranial hemorrhage) and the use of endovascular treatment techniques. “The guidelines clearly recommend that the first-line medical treatment for CVT (including patients with CVT-associated intracranial hemorrhage) be intravenous heparin infusion or subcutaneous heparin analogs.” Many physicians, including neurologists, have limited experience in treating this disease and are often hesitant to use heparin in patients with CVT associated with intracranial hemorrhage for fear of increasing the risk of rebleeding. dr. English concluded, “The safety and efficacy of heparin in these patients is actually well documented, and the guideline’s strong recommendation will hopefully allay As a neurocritical care specialist and neurointerventionist, I also strongly agree that endovascular therapy should be considered for patients whose condition worsens despite the use of heparin. There have been many case reports on the use of endovascular therapy in patients with CVT with intracranial hemorrhage, and hopefully this invasive treatment will no longer replace heparin for direct use in such patients after the guidelines are published.”