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A clinical picture
Surat Tanprawate, MD, MSc(Lond.), FRCP(T) the Northern Neuroscience Center in collaboration with Division of Neurology, Department of Medicine Chiang Mai University
Case scenario-1
A 52 years old man presented with motor seizure on the right side with subsequently mild hemiparesis and headache on the right side
Cerebral cortical vein, sagittal sinus, right lateral and sigmoid sinus thrombosis with brain edema
CVST is a stroke of (venous site) but the clinical symptoms are not typical as stroke syndrome Arterial stroke:
sudden onset, reach a peak at the onset, typically no seizure, typically no headache
subacute onset (2 days to 1 month;50-80%) can be chronic (more than 2 months) in patient presenting with isolated intracranial hypertension
Bousser MG. Stroke 1985;16:199213.
Neurological decit
can be unilateral or bilateral negative symptoms(weakness) +/- positive symptoms (seizure) Bilateral cerebral infarct +/- haemorrhage is common
Hemorrhage infarct
Venous infarct
Seizure
Seizure: partial or generalize Associated location: supratentorial lesion (OR=4.05), cortical vein thrombosis (OR=2.31), sagittal sinus thrombosis (OR=2.18), puerperal CVST (OR=2.06)
First or worst Abrupt onset Subacute headache with increasing frequency or severity Headache bought by exertion or Valsalva manoeuvre Systemic symptoms/signs such fever, vomiting Headache associated with neurological symptoms/signs
Case scenario-1
A middle age man with progressive headache
123 patients with CVST/ 17 patients had only headache Headache character:
Thunderclapsudden onset of an excruciating headache (VAS more than 8/10), reaching maximum intensity in less than one minute, and lasting more than 1 hour The differential diagnosis of Thunderclap headache
: SAH, carotid/vertebral artery dissection, CVST, pituitary apoplexy, 3rd ventricular colloid cyst, Call-Fleming syndrome(reversible vasoconstriction syndrome), post-coital headache, primary
Subarachnoid hemorrhage
CT brain in 10 patients with CVST presenting with thunderclap headache - 5 normal - 3 SAH - 2 multiple intracerebral haemorrhage
Bruijin et al. The Lancet 1996, 348: 1623 - 1625
Topographic diagnosis
From: http://www.radnet.ucla.edu
From: http://wfffun.info/
Unusual presentation
Subarachnoid hemorrhage Isolated psychiatric symptoms Reversible parkinsonism Trigeminal neuralgia Acute visual loss Migraine like phenomena Hearing loss ocular utter