Cerebral venous sinus thrombosis differential diagnosis: Difference between revisions

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{{Cerebral venous sinus thrombosis}}
{{Cerebral venous sinus thrombosis}}
{{CMG}} {{AE}} {{ SharmiB}}
==Overview==
[[Cerebral venous sinus thrombosis]] is often get misdiagnosed due to the overlapping of [[symptoms]] with other [[neurological]] [[conditions]]


==Differentiating Cerebral venous sinus thrombosis From Other Diseases==
==Differential Diagnosis==
[[Cerebral venous sinus thrombosis]] should be differentiated from other [[diseases]] causing severe [[headache]] for example: <ref>{{Cite journal
[[Cerebral venous sinus thrombosis]] should be differentiated from other [[diseases]] causing severe [[headache]] for example: <ref>{{Cite journal
  | author = [[Endrit Ziu]] & [[Fassil Mesfin]]
  | author = [[Endrit Ziu]] & [[Fassil Mesfin]]
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!CT/MRI
!CT/MRI
!Other Investigation Findings
!Other Investigation Findings
|-
|[[Intracranial venous thrombosis]]
|
* [[Headache]]: Most common presentation(90% of cases); may start suddenly ([[thunderclap headache]]) or gradually worsening over a few days.
* Unable to move one or multiple limbs.
* Unilateral [[facial]] [[weakness]].
* [[Seizure|Seizures]]: 40% of patients present with [[seizure]].
* [[Coma|Decreased level of consciousness]] or [[cognitive]] impairments are common symptoms in the elderly.<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-4|[4]]]</sup>
|[[Digital subtraction angiography]]
|
* Hyperattenuating signal in the occluded [[sinus]] is the classic finding of [[sinus]] [[thrombosis]] in [[CT scan]].
* [[CT]] and [[MRI]] may identify [[Cerebral edema]] and venous [[infarction]].
|
* CT [[venography]] detects the [[thrombus]], [[computed tomography]] with [[radiocontrast]] in the venous phase (CT venography or CTV) has a higher efficacy than [[MRI]].
* [[Cerebral angiography]] can identify smaller clots and 'corkscrew appearance is typical for occluded [[veins]].
|-
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|[[Subarachnoid hemorrhage]]  
|[[Subarachnoid hemorrhage]]  
|
|
* [[Headache|Severe headache]] (as a worst headache of the life)
* [[Headache|Severe headache]] (patients demonstrate as the worst headache in their life)
* Headache is the main symptom (often starts suddenly and starts after a popping or snapping feeling in the head)
* Most common [[symptom]] is [[headache]]
* [[Double vision]]
* [[Diplopia]]
* [[Nausea]] and [[vomiting]]
* [[Nausea]], [[vomiting]]
* Symptoms of [[meningeal irritation]]
* Symptoms of [[meningeal irritation]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
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|[[Digital subtraction angiography]]
|[[Digital subtraction angiography]]
|
|
* The modality of choice for diagnosis of [[subarachnoid hemorrhage]] is noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* Noncontrast head [[Computed tomography|computed tomography (CT)]] is the modality of choice for [[subarachnoid hemorrhage]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* [[Computed tomography|CT]] shows hyperattenuating material filling the subarachnoid space.
* [[Computed tomography|CT]] shows [[subarachnoid space]] filled with hyperattenuating material.
|
|
* [[Lumbar puncture|Lumbar puncture (LP)]] is necessary when there is a strong suspicion of [[subarachnoid hemorrhage]]. LP will show:
* [[Lumbar puncture|Lumbar puncture (LP)]] is required in case of a strong suspicion of [[subarachnoid hemorrhage]]. LP will show:
** Elevated opening pressure
** Raised opening pressure
** Elevated [[Red blood cell|red blood cell (RBC)]]
** Raised [[Red blood cell|red blood cell (RBC)]]
** [[Xanthochromic|Xanthochromia]]
** [[Xanthochromic|Xanthochromia]]
|-
|-
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* [[Fever]]  
* [[Fever]]  


* [[Photophobia]] (inability to tolerate bright light)
* [[Photophobia]] 
* [[Phonophobia]] (inability to tolerate loud noises) 
* [[Phonophobia]]  
* [[Irritability]], [[altered mental status]] (in small children)
* [[Irritability]], [[altered mental status]] (in small children)
|[[Lumbar puncture]] for [[CSF]]
|[[Lumbar puncture]] for [[CSF]]
|
|
* [[CT]] scan of the head may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]].
* To determine the risk of [[herniation]] [[CT scan]] of the [[head]] should be done before [[Lumbar puncture]].
|
|
* Diagnosis is based on clinical presentation in combination with [[CSF]] analysis.  
* [[Clinical]] presentation in combination with [[CSF]] [[analysis]] are deciding factors for [[diagnosis]].  
* [[CSF]] analysis is the investigation of choice.
* [[CSF]] analysis is the test of choice.
* For more information on [[CSF]] analysis in meningitis please [[Meningitis#Diagnosis|click here.]]
 
|-
|-
|[[Intracranial mass]]
|[[Intracranial mass]]
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|[[MRI]]
|[[MRI]]
|
|
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions.  
* To detect intracranial [[lesions]] [[CT]] or [[MRI]] is the initial test of choice.  
* These imaging tests determine the location of [[intracranial mass]] lesion(s) and help in guiding [[therapy]].
* To determine the location of [[intracranial mass]] lesion(s) and treatment method, imgaing findings are helpful.
|
|
* [[Biopsy]] of the lesion is needed to identify the nature of the lesion such as:
* [[Biopsy]] of the [[lesion]] is needed To identify the natures of the [[lesions]] such as:
** [[Tumor]]  
** [[Tumor]]  
** [[Abscess]]
** [[Abscess]]


* X- ray of the skull is a non specific test, but useful if any of the lesions are [[Calcified lesion|calcified]].
* X- ray of the skull is a non specific test, but useful to identify [[Calcified lesion|calcified]] [[lesions]].
|-
|-
|[[Cerebral hemorrhage]]
|[[Cerebral hemorrhage]]
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* [[Headache]], vomiting, and depressed level of [[consciousness]] from [[increased intracranial pressure]] (ICP)  
* [[Headache]], vomiting, and depressed level of [[consciousness]] from [[increased intracranial pressure]] (ICP)  


* Progression of focal neurological deficits over periods of hours
* Progressive focal neurological deficits  
|[[CT]] scan without contrast
|[[CT]] scan without contrast
|
|
* [[CT scan]] without contrast is the initial test performed to differentiate [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]]
* [[CT scan]] without contrast is the initial test to differentiate [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]]
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as hyperattenuating clot.
* Acute [[hemorrhage]] appears as a hyperattenuating clot in [[CT scan]].
* Gradient echo and T2 susceptibility-weighted [[MRI]] are as sensitive as [[CT]] for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.
* Gradient echo and T2 susceptibility-weighted [[MRI]] are equally sensitive as [[CT]] for detection of acute hemorrhage and are more sensitive to identify prior hemorrhage.
|
|
* [[PT]]/ [[INR]] and [[aPTT]] should be checked to rule out [[coagulopathy]].
* [[Coagulopathy]] should be ruled out by checking [[PT]]/ [[INR]] and [[aPTT]].


|-
|-
|[[Cerebral]] [[Infarction]]
|[[Cerebral]] [[Infarction]]
|The [[symptoms]] of an [[ischemic stroke]] vary widely depending on the site and blood supply of the area involved. For more information on [[symptoms]] of [[ischemic stroke]] based on area involved please [[Ischemic stroke#Diagnosis#History and symptoms|click here]].  
|The [[symptoms]] of an [[ischemic stroke]] depend on the site and [[blood]] supply of the area involved.
|[[Cerebral angiography]]
|[[Cerebral angiography]]
|
|
* [[CT scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]] CT may show hypo-attenuation and swelling of involved area.
* [[CT scan]] without contrast is the initial test to diagnose [[ischemic stroke]] and to exclude [[hemorrhagic stroke|hemorrhagic stroke.]] Hypo-attenuation and swelling of the involved area may be found in the [[CT scan]].
* [[MRI|MR]] diffusion weighted imaging is the most sensitive and specific test for diagnosing [[ischemic stroke]] and may help detect presence of [[infarction]] in few minutes of onset of [[symptoms]].  
* [[MRI|MR]] diffusion-weighted imaging is the most sensitive and specific test to diagnose [[ischemic stroke]] and in few minutes of the onset of [[symptoms]], MRI can detect the [[infarction]].  
|
|
* [[Carotid]] [[doppler]] may be done to check for patency of [[carotid arteries]] and blood supply to the [[brain]].
* [[Carotid]] [[doppler]] may be done to check for patency of [[carotid arteries]] and blood supply to the [[brain]].


* [[Cerebral angiography]] is an [[Invasive (medical)|invasive]] test and detect [[abnormalities]] of the [[blood vessels]], including narrowing, blockage, or [[malformations]] (such as [[Aneurysm|aneurysms]] or [[arterio-venous malformations]]). 
* [[Cerebral angiography]] detect [[blood vessels]] [[abnormalities]] as narrowing, blockage, or [[malformations]] (such as [[Aneurysm|aneurysms]] or [[arterio-venous malformations]]). 
 
|-
|[[Intracranial venous thrombosis]]
|
* [[Headache]]: It is a common presentation (present in 90% of cases); it tends to worsen over a period of several days, but may also develop suddenly ([[thunderclap headache]]).<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-Stam2005-1|[1]]]</sup> The [[headache]] may be the only [[symptom]] of [[cerebral venous sinus thrombosis]].<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-Cumurciuc2005-2|[2]]]</sup>
* Inability to move one or more limbs.
* Weakness on one side of the face.
* [[Seizure|Seizures]]: 40% of all patients have seizure.
* [[Coma|Depressed level of consciousness]] and otherwise unexplained changes in [[mental status]] are common symptoms in the elderly.<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-4|[4]]]</sup>
|[[Digital subtraction angiography]]
|
* The classic finding of sinus thrombosis on unenhanced [[CT]] images is a hyperattenuating thrombus in the occluded sinus.
 
* [[CT]] and [[MRI]] may identify [[Cerebral edema]] and venous [[infarction]] may be apparent.
|
* CT [[venography]] detects the [[thrombus]], [[computed tomography]] with [[radiocontrast]] in the venous phase (CT venography or CTV) has a detection rate that in some regards exceeds that of [[MRI]].
 
* [[Cerebral angiography]] may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
|-
|-
|[[Migraine]]
|[[Migraine]]
|
|
* Severe or moderate [[headache]] (which is often one-sided and pulsating) lasts between several hours to three days.
* Severe or moderate [[headache]] (often unilateral) lasting several hours to three days.
* Other [[symptoms]] include gastrointestinal upsets, such as [[nausea and vomiting]], and a heightened sensitivity to bright lights ([[photophobia]]) and noise ([[phonophobia]]). Approximately one third of people who experience [[migraine]] get a preceding [[Aura (symptom)|aura]].<sup>[[Migraine overview#cite note-4|[4]]]</sup>   
* Other [[symptoms]] include gastrointestinal upsets, such as [[nausea and vomiting]], and an increased sensitivity to bright lights ([[photophobia]]) and sound ([[phonophobia]]). [[Aura (symptom)|aura]] is a preceding symptom in one third patients.<sup>[[Migraine overview#cite note-4|[4]]]</sup>   
|'''---'''
|'''---'''
|
|
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]].
* To exclude other suspected possible [[causes]] of [[headache]] [[CT]] and [[MRI]] might be required.


|[[Migraine]] is a clinical [[diagnosis]] that does not require any laboratory tests. Laboratory tests can be ordered to rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of [[migraine]] therapy.
|[[Migraine]] does not need any diagnostic test; it is a clinical diagnosis. To rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of [[migraine]] [[therapy]] [[laboratory]] tests can be done.
|-
|-
|[[Head injury]]
|[[Head injury]]
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|[[CT]] scan without contrast
|[[CT]] scan without contrast
|
|
* [[CT]] scan is the first test performed and identifies [[cerebral hemorrhage]] (appears as hyperattenuating clot) following head injury. [[CT]] scan is also less time consuming.
* [[CT]] scan is the first test to identify [[cerebral hemorrhage]] (appears as hyperattenuating clot) after head injury.  


* [[MRI]] is more sensitive, takes more time and is done in patients with symptoms unexplained by [[Computed tomography|CT]] scan.  
* [[MRI]] is time-consuming, expensive, and is done in cases with nonspecific findings in [[CT scans]].  
|
|
* The [[Glasgow Coma Scale]] is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury.  
* The [[Glasgow Coma Scale]] is used to determine the severity of the injury.  
* The [[Pediatric Glasgow Coma Scale]] is used in young children.
* The [[Pediatric Glasgow Coma Scale]] is used in young children.
|-
|-
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]] is most often seen in late pregnancy or the [[postpartum]] period with the following symptoms:
|[[Lymphocytic hypophysitis]] is most common in late pregnancy or the [[postpartum]] period with the following symptoms:
* Mass lesion effect such as [[headache]] or [[Visual field defect|visual field defects]]
* Mass lesion effect such as [[headache]] or [[Visual field defect|visual field defects]]
* [[Hypopituitarism]]
* [[Hypopituitarism]]
|Pituitary biopsy
|Pituitary biopsy
|
|
* [[CT]] & [[MRI]] typically reveal features of a pituitary mass.
* [[CT]] & [[MRI]] are helpful to identify a [[pituitary]] [[mass]].
|
|
* The most accurate test is pituitary [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
* [[Lymphocytic]] [[Infiltration (medical)|infiltration]] in pituitary biopsy confirms the diagnosis.
|-
|-
|[[Radiation injury]]
|[[Radiation injury]]
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* Contrast-enhancing mass surrounded by [[edema]] and mass effect
* Contrast-enhancing mass surrounded by [[edema]] and mass effect
|[[PET scan]]
|[[PET scan]]
* [[Radiation]] [[necrosis]] is hypo metabolic and will have decreased uptake of [[fluorodeoxyglucose]].
* [[Radiation]] [[necrosis]] is hypo metabolic and shows reduced uptake of [[fluorodeoxyglucose]].


|}
|}
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== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 01:19, 3 August 2021

Cerebral venous sinus thrombosis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sharmi Biswas, M.B.B.S

Overview

Cerebral venous sinus thrombosis is often get misdiagnosed due to the overlapping of symptoms with other neurological conditions

Differential Diagnosis

Cerebral venous sinus thrombosis should be differentiated from other diseases causing severe headache for example: [1][2][3][4][5][6][7][8][9][10]

Disease Symptoms Diagnosis
Gold Standard CT/MRI Other Investigation Findings
Intracranial venous thrombosis
  • Unable to move one or multiple limbs.
 Digital subtraction angiography
Subarachnoid hemorrhage Digital subtraction angiography
Meningitis Lumbar puncture for CSF
Intracranial mass MRI
  • To detect intracranial lesions CT or MRI is the initial test of choice.
  • To determine the location of intracranial mass lesion(s) and treatment method, imgaing findings are helpful.
  • X- ray of the skull is a non specific test, but useful to identify calcified lesions.
Cerebral hemorrhage
  • Progressive focal neurological deficits
 CT scan without contrast
  • CT scan without contrast is the initial test to differentiate ischemic stroke and rule out hemorrhagic stroke.
  • Acute hemorrhage appears as a hyperattenuating clot in CT scan.
  • Gradient echo and T2 susceptibility-weighted MRI are equally sensitive as CT for detection of acute hemorrhage and are more sensitive to identify prior hemorrhage.
Cerebral Infarction The symptoms of an ischemic stroke depend on the site and blood supply of the area involved. Cerebral angiography
Migraine --- Migraine does not need any diagnostic test; it is a clinical diagnosis. To rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of migraine therapy laboratory tests can be done.
Head injury CT scan without contrast
  • CT scan is the first test to identify cerebral hemorrhage (appears as hyperattenuating clot) after head injury.
  • MRI is time-consuming, expensive, and is done in cases with nonspecific findings in CT scans.
Lymphocytic hypophysitis Lymphocytic hypophysitis is most common in late pregnancy or the postpartum period with the following symptoms: Pituitary biopsy
Radiation injury Surgical exploration including biopsy (histological confirmation)

CT & MRI will show:

PET scan

References

  1. ↑ Endrit Ziu & Fassil Mesfin (2017). "Subarachnoid Hemorrhage". PMID 28722987.
  2. ↑ Benedikt Schwermer, Daniel Eschle & Constantine Bloch-Infanger (2017). "[Fever and Headache after a Vacation in Thailand]". Deutsche medizinische Wochenschrift (1946). 142 (14): 1063–1066. doi:10.1055/s-0043-106282. PMID 28728201.
  3. ↑ Otto Rapalino & Mark E. Mullins (2017). "Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies". Neurosurgery. doi:10.1093/neuros/nyx201. PMID 28575459.
  4. ↑ I. B. Komarova, V. P. Zykov, L. V. Ushakova, E. K. Nazarova, E. B. Novikova, O. V. Shuleshko & M. G. Samigulina (2017). "[Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]". Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 117 (3. Vyp. 2): 11–19. doi:10.17116/jnevro20171173211-19. PMID 28665364.
  5. ↑ Sanjay Konakondla, Clemens M. Schirmer, Fengwu Li, Xiaogun Geng & Yuchuan Ding (2017). "New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments". Aging and disease. 8 (2): 136–148. doi:10.14336/AD.2016.0915. PMID 28400981.
  6. ↑ Priyanka Yadav, Alec L. Bradley & Jonathan H. Smith (2017). "Recognition of Chronic Migraine by Medicine Trainees: A Cross-Sectional Survey". Headache. doi:10.1111/head.13133. PMID 28653369.
  7. ↑ S. Wulffeld, L. S. Rasmussen, B. Hojlund Bech & J. Steinmetz (2017). "The effect of CT scanners in the trauma room - an observational study". Acta anaesthesiologica Scandinavica. 61 (7): 832–840. doi:10.1111/aas.12927. PMID 28635146.
  8. ↑ Johnston PC, Chew LS, Hamrahian AH, Kennedy L (2015). "Lymphocytic infundibulo-neurohypophysitis: a clinical overview". Endocrine. 50 (3): 531–6. doi:10.1007/s12020-015-0707-6. PMID 26219407.
  9. ↑ Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S (2017). "Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours". Nat Rev Neurol. 13 (1): 52–64. doi:10.1038/nrneurol.2016.185. PMID 27982041.
  10. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
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