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Venous thrombosis involving either a cortical vein or dural venous sinus
is an important cause of convexal SAH.
Causes of Thunderclap Headache
Present clinically with headache, seizures, altered mental status,
and sequelae of IICP, such as papilledema.
Similarly, the patient’s clinical appearance can be quite benign, especially early in the course of the illness,
More severe cases : IICP, seizures (40%), stroke, coma (14%).
Focal cerebral edema, Venous cerebral infarctions, Intracranial hypertension
With mean age of 39 years, women, peripartum period
(young adult, women of childbearing age, children)
Hypercoagulable states : oral contraceptives,
hematologic disorders, factor V Leiden homozygous mutation,
protein S or protein C deficiency, and anti–thrombin III deficiency.
Superior sagittal sinus (65%), transverse sinus, sigmoid sinus
Normal CT up to 30% of CVT
Cord sign (hyperdense cortical vein on unenhanced CT)
Empty delta sign (nonfilling of the superior sagittal sinus on enhanced CT)
Commonly described parenchymal findings result from venous hypertension and include
cerebral edema, parenchymal hemorrhages, and ischemic and hemorrhagic infarcts.
SAH is a relatively uncommon complication,
likely resulting from rupture of thin-walled cortical veins under elevated pressure.
In this setting, SAH is usually found within the cerebral convexities or sylvian fissures,
sparing the basal cisterns.
An elevated LP opening pressure should raise suspicion of cerebral venous thrombosis
Presentation is variable.
Range from asymptomatic to coma and death.
Typically patients complain of headache, nausea, vomiting.
Neurological deficits are variable.
Anticoagulant therapy
- UFH 80U/kg bolus then 18U/kg/h or LMWH 100U/kg SC BID
- LMWH better functional prognosis than UFH
- Bridge to vitamin K antagonists 3-12 months (INR 2-3)
Intravascular thrombolysis
- Chemical thrombolysis (urokinase), mechanical thrombectomy, both
Control increased ICP
AED prophylaxis only for patients with both seizures at presentation and supratentorial lesions
Carotid-cavernous sinus fistula (CCF)
Subjective bruit (80 %), bruits may also be auscultated over the globe
Blurred vision (25 to 59 %)
Headache (53 to 75 %)
Diplopia (50 to 85 %)
Ocular and/or orbital pain (35 %)
Proptosis (72 to 87 %)
Chemosis and conjunctival injection (55 to 89 %)
Cavernous sinus thrombosis (CST)
感染, 發炎, 血管病變, 外傷, 腫瘤
The cause is usually from a spreading infection in the nose, sinuses, ears, or teeth.
(Staphylococcus aureus and Streptococcus)
Signs : Periorbital cellulitis, proptosis, chemosis (眼瞼水腫)
Headache, Isolated CN 3 palsy is thought to be an early manifestation.
眼球疼痛, 結膜或眼瞼水腫, 眼球突出 (proptosis), 眼肌麻痺 (ophthalmoplegia)
Horner syndrome, trigeminal sensory loss
眼壓增高, 視神經水腫, 視網膜出血, 視力喪失, 視野缺損
Non-contrast CT : high-density thrombus in affected cavernous sinus (seen in only 25%)
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