sagittal sinus thrombosis

This was a new one to me...

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.

What's in a Criteria?

To scan or not to scan, that is the question....
One of my attending physicians made a good point, everything that we do is about risk stratification and playing the odds. There are no definitive answers.






New Orleans (applies ONLY if GCS 15). If positive for just ONE of these, CT!
1) Headache
2) Vomiting
3) >60 y/o
4) Drug or alcohol consumption
5) persistent anterograde amnesia
6) visible trauma above clavicle
7) seizure

Subdural

Canadian (applies to GCS 13-15 after LOC, amnesia to event, or witnessed disorientation from trauma). If positive for just ONE of these, CT!
1) GCS less than 15 at 2 hours post injury
2) suspected open or depressed skull fracture
3) any sign of basilar skull fracture (racoon eyes, battle sign, hemotympanum)
4) >2 episodes of vomiting
5) > 65 y/o
6) retrograde amnesia of 30 minutes or more
7) "dangerous mechanism" (i.e. auto vs. pedestrian, fall > 3 feet or five stairs)

Subarachnoid

PECARN
Pediatrics is the tough one, as the risk for radiation induced malignancy increases as age decreases (roughly 1:1000/5000).  This applies for suspected head trauma less than 24h old:

Check out Dr Michelle Lin's blog for some great info, or
Click below to get calculations of exposure:

References:
Ebell, MH. Computed Tomography after Head Injury. Am Fam Physician 2006 June 15; 73(12): 2205-7. PubMed PMID: 16836038

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14. PubMed PMID: 19758692.