After Ribes'1 initial description in 1825 of a patient with cerebral venous thrombosis (CVT), this disorder was universally considered to be fatal, the diagnosis being made at postmortem. In the past 3 decades, as a result of the development and increasing availability of non-invasive neuroimaging techniques, CVT is increasingly recognised, not just in the neurology or neurosurgery wards but now in acute medical receiving and stroke units. It is difficult to estimate the incidence of CVT in the absence of epidemiological studies. Early postmortem studies showed a low incidence, 21.7 persons/year in England and Wales between 1952 and 1961, whereas recent clinical series suggest that the incidence is possibly 10 times higher.2 3

It is evident that clinical presentation, imaging appearances, causation, and outcome of this disorder (or group of disorders) are variable, emphasising its heterogeneity. With such clinical diversity and absence of large adequately powered designed clinical trials, the optimum treatment remains uncertain, in particular the appropriate place of supportive treatment alone, anticoagulants, or endovascular thrombolysis. Bousser4 in an excellent editorial, accompanying two recent articles on treatment,5 6 drew attention to the dilemma of “nothing, heparin or local thrombolysis”. This overview stressed the extreme diversity of CVT and concluded that “heparin remains the first-line treatment for CVT because of its efficacy, safety and feasibility”. Despite the lack of definitive supporting evidence, placebo controlled or comparative studies of heparin with thrombolysis were not regarded as priorities. This editorial importantly stressed the need to stratify risk within the patient population but its conclusions on management did not seem to clarify matters for the stroke physician or neurologist, increasingly confronted with how to best manage this disorder. An earlier survey of 13 teaching hospitals in The Netherlands disclosed eight centres opposed to the use of anticoagulants in CVT …