So let's say you have a patient present to the ED, she had a new onset H/A 2 days ago that was "the worst ever" and went to another ED. No history of migraines. Not responsive to migraine cocktail. Ancillary workup unremarkable, CT and LP unremarkable. Patient was D/C home with pain control.
She presents to you now in obvious distress. Physical exam reveals no focal deficits. What's your differential?
Differential Diagnosis:
Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)
Spinal Headache
Sagittal Sinus Thrombosis (What?!?!)
Quick and dirty:
A. rare, and presentations are variable
B. most common among female, 30ish year olds
C. venous structures in the brain get obstructed, this can lead to increased pressure of capillary beds and end up with cerebral edema.
D. Risk Factors:
1. prothrombic conditions (MOST COMMON)
2. head injury
3. all those things that put you at risk for hypercoagulable states
a. OCP
b. pregnancy
c. malignancy
d. infection
E. MRI-venous
1. CT is normal in 30% of cases
F. D-Dimer is not specific (if elevated it can support, but negative does not rule-out)
References:
Ferro, JM, & Canhão , P. Etiology, clinical features, and diagnosis of cerebral venous thrombosis. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.
Pathak, V, Rendon, ISH, Freddo, L, Dangal, MM. Sagittal Sinus Thrombosis in a Young Migraineur. New York Medical Journal, Fall 2009.
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