Written by Anand Shah, D.O. and edited by Van Wall, D.O.
CC: Headache, nausea/vomiting
HPI: 20 yo male presents with persistent headache over the past two weeks. The HA has been constant and gradually worsened over the past two weeks. It is not positional, but worse in the morning and improves slightly throughout the day. Initially it was bi-temporal, but now hurts over the occipital region and today was associated with multiple episodes of non-bloody, non-bilious emesis and photophobia. He denies neck stiffness, fever, vision changes, weakness, or other associated symptoms and has no history of similar headaches in the past. He tried Maxalt, Motrin or Tylenol with little relief.
Of note, the patient was admitted a week earlier with syncope and questionable seizure activity as well as rhabdomyolysis presumed to be secondary to a heat related illness (core temp of 105.6 in the field but 100.6 at presentation to ED). During admission ECGs demonstrated a transient conduction delay and RBBB with questionable ST elevations; echocardiogram revealed a PFO and normal wall motion. He was discharged in stable condition but continued to have a persistent HA. After discharge from the hospital he followed up with his primary care doctor who ordered a CT Head w/o contrast which was normal. An MRI/MRV was then ordered however the patient does not know the results.
Relevant vitals/PMH/meds/allergies, etc:
Medications: Maxalt (has been taking for past week with no relief)
VS : 137/68 HR 76 RR 18 O2 sat 100% Temp 99.3
PE: Slightly pale/diaphoretic but otherwise normal exam.
Normal neurological exam including strength/sensation/cerebellar testing
Work up: ECG, labs, imaging
ECG: NSR, normal intervals, normal axis.
Labs: CBC: 14/14/44/214, CMP: 136/4.4/96/23/13/0.7/149
Mg, PO4, TSH, FT4: WNL
LP: WBC 2, RBC 2, Glucose 83, Protein 23. Clear, colorless, Opening pressure 37 cm H20
Prothrombotic panel: Sent
CT Head w/o contrast: No acute intracranial abnormality
MRI/MRV: Dural venous sinus thrombosis which involves superior sagittal sinus and left transverse sinus
Ddx: Things to consider
Idiopathic intracranial hypertension
Dural venous sinus thrombosis (DVST)
Cavernous sinus thrombosis
Intracranial hemorrhage (chronic subdural, epidural, SAH)
Spontaneous CSF leak
Carbon Monoxide exposure
Dural venous sinus thrombosis
What we learned from the case:
In addition to the common HA red flags I would add 2 to the list based on this case: HA not improving with typical HA cocktail and no history of HA/migraines in the past. Despite a totally normal neuro exam and really no complaints other than HA this patient had an extensive thrombosis of his sagittal and transverse sinuses. Therefore, although a normal neuro exam is reassuring it is not as reliable as we may think. If you continue to have concerns and the patient continues to complain of pain, keep searching.
We typically only perform LP’s to evaluate for infection or SAH in the ED, however it can also help to evaluate for elevated ICP.
A CT venogram is a good alternative to evaluate for DVST if MRI is not readily available. (our patient had one done which showed extensive clot in the sagittal and transverse sinuses (L>R) with extension into bilateral IJ’s and almost complete occlusion of the left IJ)
In hindsight, neurology believes that the patient may have actually had a seizure as oppose to heat syncope when he initially presented. They think his fever and rhabdomyolysis may have been secondary to his seizure and that his seizure was likely due to his DVST.
Dural venous sinus thrombosis (DVST)
•Also known as Cerebral venous sinus thrombosis
•Not to be confused with Cavernous sinus thrombosis which is usually infectious in etiology and usually due to spread from nasal furuncles, sinus and dental infections
•Incidence < 1.5:100,000
•More common in women (3:1) – likely due to risks factors of pregnancy, OCP’s, hormone replacement therapy
•Risk factors – prothombotic conditions, OCP’s, pregnancy and puerperium, malignancy, infection, head injury
•Most common presenting symptom – Headache (~89%)
•Other symptoms include – any symptoms of stroke (i.e. weakness, sensory disturbance, ataxia), vision changes, seizure, vomiting, altered mental status
•Diagnosis – MRI with MRV is most sensitive
•Head CT can be normal in 30 percent of cases and abnormalities are usually nonspecific
•CT venography is good alternative to MRI – quicker in most centers, more readily available, and can be done on patients who have contraindications to MR
•Additional testing – D-dimer, LP to evaluate for infection elevated ICP (rare cases of septic dural venous sinus thrombosis), evaluation for cause of DVST (prothrombotic workup)
•Overall good prognosis
•Treatment – anticoagulation with LMWH or IV heparin
•For patients with progressive neurologic worsening consider endovascular thrombolysis or mechanical thrombectomy
•Consider seizure prophylaxis
•Treatments for reducing ICP – Head of bed elevation, mannitol, hyperventilation, acetazolamide, repeated LP’s, ICP monitoring
•Stopping OCP’s or hormone replacement therapy if determined to be the cause
•After the acute phase – anticoagulation for 3-12 months with Coumadin for adults, 3-6 months for children. INR target 2.5