Cerebral venous sinus thrombosis differential diagnosis: Difference between revisions

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! rowspan="2" |Disease
! rowspan="2" |Disease
! rowspan="2" |Symptoms
! rowspan="2" |Symptoms
! colspan="2" |Diagnosis
! colspan="3" |Diagnosis
|-
|-
!Gold Standard
!CT/MRI
!CT/MRI
!Other Investigation Findings
!Other Investigation Findings
|-
|[[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>
|
* 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".
|-
|-
|[[Subarachnoid hemorrhage]]  
|[[Subarachnoid hemorrhage]]  
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* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Rapid progression of symptoms
* Rapid progression of symptoms
|[[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>
* 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>
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* [[Phonophobia]] (inability to tolerate loud noises) 
* [[Phonophobia]] (inability to tolerate loud noises) 
* [[Irritability]], [[altered mental status]] (in small children)
* [[Irritability]], [[altered mental status]] (in small children)
|[[Lumbar puncture]] for [[CSF]]
|
|
* [[CT]] scan of the head may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]].
* [[CT]] scan of the head may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]].
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* [[Seizures]]
* [[Seizures]]
* Focal symptoms of brain damage
* Focal symptoms of brain damage
* Associated co-morbid conditions like [[tuberculosis]], etc
* Associated comorbid conditions like [[tuberculosis]], etc
|[[MRI]]
|
|
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions.  
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions.  
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* Progression of focal neurological deficits over periods of hours
* Progression of focal neurological deficits over periods of hours
|[[CT]] scan without contrast
|
|
* [[CT scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]]
* [[CT scan]] without contrast is the initial test performed to differentiate [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]]
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as hyperattenuating clot.
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as hyperattenuating clot.
* 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 as sensitive as [[CT]] for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.
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|[[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]] 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]].  
|[[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 performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]] CT may show hypo-attenuation and swelling of involved area.
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* [[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 [[angiogram]] 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]] 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]]). 
 
|-
|[[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]]
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* Severe or moderate [[headache]] (which is often one-sided and pulsating) lasts between several hours to three days.
* Severe or moderate [[headache]] (which is often one-sided and pulsating) lasts between 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 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>   
|'''---'''
|
|
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]].
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]].
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* [[Headache|Loss of consciousness]]
* [[Headache|Loss of consciousness]]
* [[lucid interval]]
* [[lucid interval]]
|[[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 performed and identifies [[cerebral hemorrhage]] (appears as hyperattenuating clot) following head injury. [[CT]] scan is also less time consuming.
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|[[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 often seen in late pregnancy or the [[postpartum]] period with the following symptoms:
* Mass lesion effect such as [[headache]] or [[Visual field defect|visual field defects]]
* [[Hypopituitarism]]
* [[Hypopituitarism]]
* Mass lesion effect such as [[headache]] or [[Visual field defect|visual field defects]]
|Pituitary biopsy
|
|
* [[CT]] & [[MRI]] typically reveal features of a pituitary mass.
* [[CT]] & [[MRI]] typically reveal features of a pituitary mass.
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|
|
* [[Headache]]
* [[Headache]]
* Impairment of [[mental function]] is the most prominent feature such as [[Personality change due to another medical condition|personality change]], impairment of memory, [[confusion]], [[learning difficulties]].
* Impairment of [[mental function]] is the most prominent feature such as [[Personality change due to another medical condition|personality change]], impairment of memory, [[confusion]], [[learning difficulties]]
* Focal [[neurological]] abnormalities and evidence of [[raised intracranial pressure]].
* Focal [[neurological]] abnormalities and evidence of [[raised intracranial pressure]]
|Surgical exploration including biopsy (histological confirmation)
|
|
[[CT]] & [[MRI]] will show:
[[CT]] & [[MRI]] will show:

Revision as of 16:07, 31 July 2017

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Differentiating Cerebral venous sinus thrombosis From Other Diseases

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
Subarachnoid hemorrhage Digital subtraction angiography
Meningitis Lumbar puncture for CSF
  • CT scan of the head may be performed before LP to determine the risk of herniation.
  • Diagnosis is based on clinical presentation in combination with CSF analysis.
  • CSF analysis is the investigation of choice.
  • For more information on CSF analysis in meningitis please click here.
Intracranial mass MRI
  • CT or MRI is the initial test to detect intracranial lesions.
  • These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.
  • Biopsy of the lesion is needed to identify the nature of the lesion such as:
  • X- ray of the skull is a non specific test, but useful if any of the lesions are calcified.
Cerebral hemorrhage
  • Progression of focal neurological deficits over periods of hours
 CT scan without contrast
  • CT scan without contrast is the initial test performed to differentiate ischemic stroke and rule out hemorrhagic stroke.
  • CT is very sensitive for identifying acute hemorrhage which appears as hyperattenuating clot.
  • 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.
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 click here. Cerebral angiography
Intracranial venous thrombosis Digital subtraction angiography
  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
  • Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
Migraine ---
  • CT and MRI may be needed to rule out other suspected possible causes of headache.
 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.
Head injury 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.
  • MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT scan.
Lymphocytic hypophysitis Lymphocytic hypophysitis is most often seen in late pregnancy or the postpartum period with the following symptoms: Pituitary biopsy
  • CT & MRI typically reveal features of a pituitary mass.
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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