Sudden Headache and Vomiting in a 33-Year-Old Woman

Roshen Mathew, MBBS; Mathew Abraham, MD, DM

Disclosures

September 12, 2016

The physical examination is normal in 15%-30% of patients, although careful examination may reveal loss of normal spontaneous retinal venous pulsations. It has been reported that headache (89%), paresis (37%), generalized (30%) or focal (20%) seizures, papilledema (28%), and mental status changes (22%) are the most frequent presenting symptoms and signs associated with CVT.[1,2,3,4]

The differential diagnosis of CVT includes subarachnoid hemorrhage, intracranial hemorrhage, ischemic stroke, and bacterial meningitis. In patients presenting with the more typical subacute onset, pseudotumor cerebri, cavernous sinus syndromes, intracranial abscess, subdural empyema, and brain tumor should be considered.[2,3]

CVT is definitively diagnosed by demonstration of a thrombus on neuroimaging. Non–contrast-enhanced CT of the head is normal in 25% of patients with a normal examination and 10% of patients with focal neurologic findings (including papilledema). The delta sign is a dense triangle in the superior sagittal sinus caused by the thrombus, and it may be seen on CT.

MRV is considered the radiographic investigation of choice and will demonstrate areas of lack of signal where the thrombus involves the venous sinuses. Cerebral angiography may be required if MRV is nondiagnostic and suspicion remains high. CT venography is increasingly being used to diagnose CVT, and it has been shown to be very sensitive and specific. The empty delta sign is a triangular filling defect in the superior sagittal sinus that complements the delta sign on non–contrast-enhanced CT.

Lumbar punctures are sometimes performed in patients with no evidence of mass effect on CT. About 50% of patients have abnormal cerebrospinal fluid (CSF) findings, including mild lymphocytic pleocytosis; elevated protein levels; the presence of red blood cells; and, more commonly, an elevated CSF opening pressure (which must be measured with the patient as relaxed as possible in the lateral decubitus position).[1,3,5,6]

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