A 28-year-old woman on combined oral contraceptives presents with a 3-day history of progressive headache, focal left-sided weakness, and a seizure. MRI brain with post-contrast imaging is shown. The structure marked **A** demonstrates a triangular filling defect with peripheral enhancement of the dural walls. Which of the following is the most appropriate next step in management?

Question

Accepted Answer

B. Initiate anticoagulation with low molecular weight heparin, even though venous infarction with haemorrhage is present. ## Why anticoagulation with LMWH is correct

The empty delta sign (triangular filling defect with peripheral dural enhancement) in the superior sagittal sinus is pathognomonic for cerebral venous sinus thrombosis (CVST). According to Harrison's Principles of Internal Medicine and ESO CVST Guidelines 2017, anticoagulation with low molecular weight heparin (enoxaparin 1 mg/kg BD) or unfractionated heparin is the cornerstone of management — **even in the presence of haemorrhagic venous infarction**. This counterintuitive principle is crucial: the haemorrhage is secondary to venous congestion and infarction, and anticoagulation prevents further thrombosis and improves venous drainage. The patient's presentation (young woman on OCP with headache, focal deficits, and seizure) and imaging findings confirm CVST.

## Why each distractor is wrong

- **Emergency decompressive craniectomy**: While raised ICP management (acetazolamide, CSF diversion, or decompressive craniectomy) may be needed, it is reserved for clinically deteriorating patients *despite* anticoagulation. It is not the first-line next step.
- **Aspirin monotherapy**: Antiplatelet therapy is inadequate for CVST. The thrombosis is venous and requires anticoagulation, not antiplatelet therapy. Observation alone risks further thrombosis and clinical deterioration.
- **Thrombolytic therapy and mechanical thrombectomy**: Thrombolysis is not first-line for CVST and carries unacceptable haemorrhage risk. Endovascular thrombectomy is reserved only for clinically deteriorating patients despite anticoagulation, not as initial management.

**High-Yield:** The empty delta sign is pathognomonic for CVST; anticoagulate even with haemorrhagic infarction — venous haemorrhage improves with restored venous drainage, not with withholding anticoagulation.

[cite: Harrison's Principles of Internal Medicine, 21st ed; ESO CVST Guidelines 2017]

Answer

A. Perform emergency decompressive craniectomy to relieve raised intracranial pressure

Answer

C. Administer thrombolytic therapy (alteplase) followed by mechanical thrombectomy

Answer

D. Start aspirin monotherapy and observe for clinical improvement over 1 week

Explanation

Why anticoagulation with LMWH is correct

Why each distractor is wrong

Practice similar questions