Presentation: 37 yo F with progressive headache, R hand tingling, and incidentally found on this ER visit to be pregnant.
Top 5 Teaching Points Cerebral Vein Thrombosis (1):
1) It’s rare: about 1:100,000 in a year (but about 11:100,000 in pregnant women)
2) Pt’s present with a progressively worsening localizing headache over days (as venous pressure builds, capillaries leak and CSF reabsorption is impaired)
3) As the disease progresses, global features (SZ, depressed consciousness) present, however, focal deficits occur as well.
4) Non contrast CT and CT venogram, when combined, are sensitive and specific for the diagnosis and equivalent to MRV.
5) Fractionated heparin (Lovenox) performs better than unfractionated heparin, and anticoagulation is not contraindicated in patients with intracerebral hemorrhage related to cerebral venous thrombosis (2).
1) Ferraro JM, Canhao P. Etiology, clinical features, and diagnosis of cerebral venous thrombosis In: UpToDate, Kassner SE. (Ed), UpToDate, Waltham, MA. (Accessed on August 18, 2014.)
2) Einhäupl K, Stam J, Bousser MG, De Bruijn SF, Ferro JM, Martinelli I, Masuhr F, EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. European Federation of Neurological Societies Eur J Neurol. 2010;17(10):1229.
Had a great followup question:
Should we start with standard CT or go straight to CTV?
About 70% of cerebral venous thrombosis are caught by standard CT. There are certain signs on standard CT like an “empty sinus” or “sinus cord” or “triangle sign” or just general signs of edema from the increased venous pressure.
We should always start with standard non contrast CT. If negative or no other explanation of patients symptoms and your suspicion is high, I’d get the CTV.