Emergency Department Diagnosis and Management of Cerebral Venous Sinus Thrombosis - Stroke EXTRA Supplement (Stroke CME)

Table of Contents

 

About This Issue

Cerebral venous sinus thrombosis is an uncommon cause of stroke, seen primarily in young individuals and women, particularly those who use oral contraceptive pills or are in pregnancy or puerperium. Because CVST can have a subacute or lingering course and the signs and symptoms can mimic many other conditions, diagnosis can be delayed. Prompt recognition and initiation of anticoagulant therapy will prevent life-threating stroke. In this issue, you will learn:

The wide range of predisposing conditions for CVST

How the clinical features of headache and focal neurologic deficit can be differentiated from the presentation of CVST

How the varied clinical presentations may help predict the location of the occluded sinus or vein

CT/MRI and CT and MR venography: when each one is most useful

When invasive procedures for imaging are appropriate and when they are not

The evidence supporting anticoagulation, even in the presence of intracerebral hemorrhage

Which anticoagulants are indicated for pregnant and nonpregnant patients: heparin, warfarin, or DOACs?

When endovascular therapies are indicated

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Incidence
   2. Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Testing
       1. Complete Blood Cell Count
       2. Chemistry Panel
       3. D-dimer
11. Imaging
    1. Noninvasive Diagnostic Modalities
       1. Noncontrast Computed Tomography Brain
       2. Direct Signs of Cerebral Venous Sinus Thrombosis
          1. Indirect Signs of Cerebral Venous Sinus Thrombosis
       3. Contrast Computed Tomography Brain
          1. Computed Tomographic Venography
       4. Magnetic Resonance Imaging of the Brain
    2. Magnetic Resonance Venography of the Brain
    3. Invasive Diagnostic Angiographic Procedures
       1. Potential Pitfalls of Invasive Procedures
12. Treatment
    1. Anticoagulation
       1. Length of Treatment
    2. Endovascular Therapies
    3. Cerebral Edema and Intracranial Hypertension
    4. Hydrocephalus
    5. Seizures
    6. Clinical Course and Outcomes
    7. Recurrence
13. Special Populations
    1. Pregnant and Postpartum Patients
       1. Recurrence of CVST and Future Pregnancies
    2. Pediatric Patients
    3. Malignancy
    4. Antiphospholipid Antibody Syndrome
    5. Head Trauma
    6. Postoperative Complications
    7. Dural Arteriovenous Fistulae
14. Controversies and Cutting Edge
    1. Corticosteroids
15. Summary
16. Time- and Cost-Effective Strategies
17. 5 Things That Will Change Your Practice
18. Risk Management Pitfalls for Emergency Department Patients With Cerebral Venous Sinus Thrombosis
19. Case Conclusions
20. Clinical Pathway for the Diagnosis and Management of ED Patients With Cerebral Venous Sinus Thrombosis
21. Tables and Figures
22. References

Abstract

Cerebral venous sinus thrombosis is a rare cause of stroke with an overall good prognosis. It predominantly affects women of reproductive age and patients with prothrombotic conditions. It has a diverse presentation that includes headache, seizures, focal neurological deficits, and encephalopathy. A strong index of suspicion is required to make a prompt diagnosis and initiate early management. Despite aggressive care, death or functional dependence occurs in 10% to 15% of patients. This review provides an overview of the literature and recent guidelines on the emergency department approach and the therapeutic challenges in the management of patients with cerebral venous sinus thrombosis.

Case Presentations

A 25-year-old woman with a history of migraine headaches for the past 5 years presents to the ED with an “excruciating“ headache that she has had for 2 days...

Her typical migraines have been in the left and right temporal regions, but she reports that this one is different, with a global, aching sensation that is worse when lying down. She denies photophobia. Her temperature is 37°C; heart rate, 64 beats/min; blood pressure, 116/80 mm Hg; and respiratory rate, 20 breaths/min. She is taking oral contraceptive pills. What is your next diagnostic step for this patient?

A 35-year-old woman with sickle cell trait who is 10 weeks pregnant, presents to the ED with headache for 5 days and right-sided weakness for 1 day…

Two days ago, she was evaluated at another ED for this headache, for which she received diphenhydramine. She had relief of her symptoms for a few hours, but then her symptoms recurred. Given her medical conditions, what next steps should you take?

A 73-year-old woman with a history of ovarian cancer and hypertension presents to the ED with headache and slurred speech for 4 days...

Her temperature is 37°C; heart rate, 56 beats/min; blood pressure, 190/98 mm Hg; and respiratory rate, 24 breaths/min. She is obtunded, not following commands, has a left-gaze preference, and withdraws to pain in all extremities. You suspect the patient has an acute stroke. What are your management priorities for this patient?

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Clinical Pathway for Managing Patients Presenting with Acute Diarrhea in Urgent Care

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke. 2024;55(3):e77-e90. (Guide-lines) DOI: 10.1161/STR.0000000000000456

3. * Saposnik G, Barinagarrementeria F, Brown RD Jr, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158-1192. (Guidelines) DOI: 10.1161/STR.0b013e31820a8364

6. * Stam J, De Bruijn SF, DeVeber G. Anticoagulation for cerebral sinus thrombosis. Cochrane Database Syst Rev. 2002(4):CD002005. (Cochrane review) DOI: 10.1002/14651858.CD002005

7. * Coutinho J, de Bruijn SF, Deveber G, et al. Anticoagulation for cerebral venous sinus thrombosis. Cochrane Database Syst Rev. 2011;2011(8):CD002005. (Cochrane review) DOI: 10.1002/14651858.CD002005.pub2

8. * Ciccone A, Canhao P, Falcao F, et al. Thrombolysis for cerebral vein and dural sinus thrombosis. Cochrane Database Syst Rev. 2004;2004(1):CD003693. (Cochrane review) DOI: 10.1002/14651858.CD003693.pub2

16. * Ferro JM, Canhao P, Stam J, et al. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35(3):664-670. (Prospective multicenter; 624 patients) DOI: 10.1161/01.STR.0000117571.76197.26

62. * Field TS, Dizonno V, Almekhlafi MA, et al. Study of rivaroxaban for cerebral venous thrombosis: a randomized controlled feasibility trial comparing anticoagulation with rivaroxaban to standard-of-care in symptomatic cerebral venous thrombosis. Stroke. 2023;54(11):2724-2736. (Prospective randomized trial; 55 patients) DOI: 10.1161/STROKEAHA.123.044113

63. * Ferro JM, Coutinho JM, Dentali F, et al. Safety and efficacy of dabigatran etexilate vs dose-adjusted warfarin in patients with cerebral venous thrombosis: a randomized clinical trial. JAMA Neurol. 2019;76(12):1457-1465. (Prospective randomized trial; 120 patients) DOI: 10.1001/jamaneurol.2019.2764

64. * Coutinho JM, Zuurbier SM, Bousser MG, et al. Effect of endovascular treatment with medical management vs standard care on severe cerebral venous thrombosis: the TO-ACT randomized clinical trial. JAMA Neurol. 2020;77(8):966-973. (Prospective randomized trial; 67 patients) DOI: 10.1001/jamaneurol.2020.1022

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Keywords: thrombosis; headache; venous; contraceptive; CT venography; MR venography; anticoagulation; heparin; endovascular; pregnancy