Central venous sinus thrombosis (CVT) and venous cerebral infarction are important differentials for the causes of headache or seizure in the young person, particularly in the young woman who is/has recently been pregnant. It is probably the most rare form of stroke, but - when it happens - the patient usually will end up in ICU, and the critical care trainee will probably see more of this than any other specialty.
This has come up in Question 26 from the second paper of 2015. Dural sinus thrombosis in that question was associated with pregnancy (as typically they are) and the question could easily be shoved into the O&G section, but the specific information requested from the candidates ("outline the management priorities", etc) was more neurological/neurosurgical in nature.
If one needed to limit one's reading to a single article, that sole article should probably be the AHA/ASA CVT management algorithm (2011).
Central venous sinus thrombosis (CVT) and venous cerebral infarction are important differentials for the causes of headache or seizure in the young person, particularly in the young woman who is/has recently been pregnant. It is probably the most rare form of stroke, but - when it happens - the patient usually will end up in ICU, and the critical care trainee will probably see more of this than any other specialty.
This has come up in Question 26 from the second paper of 2015. Dural sinus thrombosis in that question was associated with pregnancy (as typically they are) and the question could easily be shoved into the O&G section, but the specific information requested from the candidates ("outline the management priorities", etc) was more neurological/neurosurgical in nature.
If one needed to limit one's reading to a single article, that sole article should probably be the AHA/ASA CVT management algorithm (2011).
The following lisk of risk factors was compiled using UpToDate and Ferro et al (2004). The latter was a multinational multicentre observational study which identified 624 patients with confirmed CVT. Of this group, the following risk factors were observed:
If all the possible risk factors were piled into one big table, it would look like this:
Local inflammation or injury:
Drugs and diet:
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Acquired procoagulant states:
Autoimmune disease:
Congenital procoagulant states:
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Ferro et al (2004) found the following common presentation features:
So, highly nonspecific. That young person with seizures and headache could just as easily have had an SAH, be full of cocaine, have a brain tumour, abscess, or any damn thing. Specific features are sadly lacking.
Imaging may include:
A contrast CT venogram may reveal a characteristic feature known as "dense triangle sign" or "empty delta sign" A picture tells a thousand words:
The arrow points at "a triangular area of enhancement or high attenuation with a relatively low-attenuating center on multiple contiguous transverse CT images obtained in the region of the superior sagittal sinus" (the picture is shamelessly stolen from the same article by Lee, 2002). Another variant of this is the "Cord sign", essentially the same "empty" appearance in a deeper cortical vein. You really need to do a venogram to see these, as they are apparently only spotted on 25% of non-contrast CTs of known CVT. This often-quoted statistic is probably wrong, because it comes from a 1987 study (Virapongse et al)- back in the day when one slice of CT data took three weeks to reconstruct on the Commodore Amiga.
Other CT features (on a non-contrast CT) may include the following:
Unenhanced MRI is more sensitive in picking up CVT, and is recommended as the modality of choice by the AHA/ASA CVT management algorithm (2011).
The major approaches to fixing this problem are anticoagulation, thrombolysis, endovascular thrombectomy and open clot retrieval.
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