Did you do the last question of the week?
An MRV should be obtained to evaluate for Cerebral Venous Thrombosis.
CVT is a difficult diagnosis to suspect in the ED: Headache is the most common presenting symptom, and focal neurological signs will prompt evaluation for stroke. Since a negative head CT does not rule out CVT, when does the EP consider ordering an MRV - a test rarely ordered in the ED - which is the diagnostic study of choice?
- Several features distinguish CVT from other mechanisms of cerebrovascular disease. Given the anatomy of cerebral venous drainage, bilateral brain involvement is not infrequent. Bilateral motor signs, including paraparesis, may be present due to sagittal sinus thrombosis and bihemispheric injury. Patients with CVT often present with slowly progressive symptoms.
- An ischemic lesion on CT that crosses usual arterial boundaries (particularly with a hemorrhagic component) or in close proximity to a venous sinus is suggestive of CVT.
- CVT is an important diagnostic consideration in patients with headache and papilledema or diplopia (caused by 6th nerve palsy) even without other signs suggestive of idiopathic intracranial hypertension.
- 30% - 40% of patients with CVT present with ICH. Features suggestive of CVT as a cause of ICH include prodromal headache (which is highly unusual with other causes of ICH), bilateral parenchymal abnormalities, and clinical evidence of a hypercoagulable state. In patients with lobar ICH of otherwise unclear origin or with cerebral infarction that crosses typical arterial boundaries, imaging of the cerebral venous system should be performed.