A 20-year-old woman, gravida 1 para 0, comes to the emergency department due to severe headache and right-sided weakness. She has had a constant, dull headache for the past week. The pain is greatest when she awakens in the morning. Coughing or straining worsens the pain and causes transient blurry vision. When the patient awoke this morning she was unable to stand due to right leg weakness, and she had difficulty calling for help because she could not pick up the phone with her right hand. She has no prior medical issues. The patient is at 24 weeks gestation and had nausea and vomiting during the first trimester, but she has had no other pregnancy-related complications. Her only medication is a daily prenatal multivitamin. She stopped smoking cigarettes and drinking alcohol once she learned she was pregnant, and she has no history of illicit drug use. Her sister has a history of pulmonary embolism. Temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is 80/min and regular, and respirations are 16/min. Bilateral pupils are equal, round, and reactive. Funduscopy shows bilateral papilledema. Neurologic examination is notable for right-sided motor weakness with pronator drift and Babinski sign on the right. Sensation is intact, and she has normal mentation. Meningeal signs are absent. Neuroimaging reveals intraluminal thrombus in the sagittal sinus and a small area of intraparenchymal hemorrhage. Which of the following is the best next step in management of this patient?

Question

A 20-year-old woman, gravida 1 para 0, comes to the emergency department due to severe headache and right-sided weakness.  She has had a constant, dull headache for the past week.  The pain is greatest when she awakens in the morning.  Coughing or straining worsens the pain and causes transient blurry vision.  When the patient awoke this morning she was unable to stand due to right leg weakness, and she had difficulty calling for help because she could not pick up the phone with her right hand.  She has no prior medical issues.  The patient is at 24 weeks gestation and had nausea and vomiting during the first trimester, but she has had no other pregnancy-related complications.  Her only medication is a daily prenatal multivitamin.  She stopped smoking cigarettes and drinking alcohol once she learned she was pregnant, and she has no history of illicit drug use.  Her sister has a history of pulmonary embolism.  Temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is 80/min and regular, and respirations are 16/min.  Bilateral pupils are equal, round, and reactive.  Funduscopy shows bilateral papilledema.  Neurologic examination is notable for right-sided motor weakness with pronator drift and Babinski sign on the right.  Sensation is intact, and she has normal mentation.  Meningeal signs are absent.  Neuroimaging reveals intraluminal thrombus in the sagittal sinus and a small area of intraparenchymal hemorrhage.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Cerebral venous sinus thrombosis (CVST) is a rare, potentially life-threatening condition characterized by the formation of a blood clot within the dural sinuses. Most cases are associated with pregnancy, combination estrogen-progestin contraception, malignancy, infection, or head trauma. As the dural sinuses drain cerebrospinal fluid and venous blood from the brain, obstruction usually causes: Increased intracranial pressure, leading to a gradually worsening headache that is maximal on awakening and with Valsalva-like maneuvers (eg, coughing, sneezing) Venous congestion of the brain, leading to focal deficits (eg, hemiparesis), seizures, and/or confusion MRI of the brain with magnetic resonance venography is usually diagnostic. Patients are typically treated with low-molecular-weight heparin to recanalize the obstructed sinus and prevent thrombus propagation. Although hemorrhagic foci or infarctions may be present on imaging, anticoagulation does not seem to increase the risk of clinically consequential brain hemorrhage. (Choice A) As CVST is primarily mediated by the activation of the coagulation cascade, antiplatelet therapy is not typically used for treatment. (Choice B) Straining during labor can raise intracranial pressure and increase the risk of intracranial hemorrhage in patients with CVST; labor induction would be contraindicated. In addition, labor induction would not treat a preexisting CVST. (Choice D) Systemic thrombolysis is not considered a first-line therapy for CVST and is generally contraindicated during pregnancy. (Choice E) Vitamin K antagonists such as warfarin require several days to become efficacious and may transiently increase coagulability; warfarin should not be used without first initiating a heparin product. In addition, warfarin is generally contraindicated during pregnancy. Educational objective: Patients with central venous sinus thrombosis usually develop a gradually worsening headache due to elevated intracranial pressure, and may have focal neurologic deficits or seizure due to cerebral venous congestion. Although focal cerebral hemorrhage may be present on imaging, treatment with heparin or low-molecular-weight heparin is considered safe and the standard of care. References: Treatment of cerebral venous and sinus thrombosis. (http://www.ncbi.nlm.nih.gov/pubmed/18004059)

A 20-Year-Old Woman, Gravida 1 Para 0, Comes to the Emergency