EMCrit Podcast 304 - CVT with Casey Albin

Overview of Cerebral Venous Thrombosis

Cerebral venous thrombosis is a condition that presents with atypical headaches and can have various presentations, but most patients do well if the acute illness is managed effectively. It is a blend of neurology and medicine, requiring multidisciplinary management, including neurosurgery. The brain's arterial and venous systems are different, and cerebral venous thrombosis can occur in either the cerebral veins or venous sinuses, causing different pathophysiologies. It can lead to edema, infarction, and intracranial hemorrhage. The presentation may include new onset headaches, responsive to positioning, and focal neurological deficits.

Diagnostic Approach and Imaging

In emergency medicine, patients who present with new-onset headaches, especially those without a headache history, should be evaluated for cerebral venous thrombosis. Imaging modalities such as non-contrast CT and CT angiography can be used to detect and assess the extent of thrombosis. However, MRI with gadolinium and MR venography provide a more detailed and accurate diagnosis. The empty delta sign in the sagittal sinus is a key finding in venous sinus thrombosis.

Treatment and Management

Treatment for cerebral venous thrombosis involves anticoagulation, even in the presence of intracranial hemorrhage. Prompt initiation of full-dose anticoagulation is crucial, and a direct oral anticoagulant (DOAC) is preferred over warfarin. Seizure prophylaxis is not routinely recommended, but continuous EEG monitoring may be considered for patients with altered mental status. Monitoring intracranial pressure can be challenging, but non-invasive techniques like capnometry and optic nerve sheath diameter measurement are useful. In cases of hydrocephalus, cerebrospinal fluid diversion may be necessary. Neurointerventional procedures are reserved for specific cases, and long-term anticoagulation duration depends on the underlying cause.

Special Considerations: Cavernous Sinus Thrombosis and COVID-19

Cavernous sinus venous thrombosis is a rare but distinct presentation associated with severe head and neck infections. It may require additional antibiotic treatment. COVID-19 infection and certain vaccines have been linked to a higher risk of cerebral venous thrombosis, although the incidence is extremely low. Treatment for vaccine-induced cases resembles heparin-induced thrombocytopenia, while treatment for COVID-induced cases follows standard protocols. In cases of mild idiopathic intracranial hypertension being considered, cerebral venous thrombosis must be excluded.

EMCrit Podcast

EMCrit Podcast 304 - CVT with Casey Albin

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Quick takeaways

Deep dives

Overview of Cerebral Venous Thrombosis

Diagnostic Approach and Imaging

Treatment and Management

Special Considerations: Cavernous Sinus Thrombosis and COVID-19

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