Cerebral venous sinus thrombosis differential diagnosis

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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:

Disease	Symptoms	Diagnosis
		Gold Standard	CT/MRI	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. Seizures: 40% of patients present with seizure. Decreased level of consciousness or cognitive impairments are common symptoms in the elderly.[4]	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.
Subarachnoid hemorrhage	Severe headache (patients demonstrate as the worst headache in their life) Most common symptom is headache Diplopia Nausea, vomiting Symptoms of meningeal irritation Sudden decreased level of consciousness Rapid progression of symptoms	Digital subtraction angiography	Noncontrast head computed tomography (CT) is the modality of choice for subarachnoid hemorrhage, with or without lumbar puncture.[1] CT shows subarachnoid space filled with hyperattenuating material.	Lumbar puncture (LP) is required in case of a strong suspicion of subarachnoid hemorrhage. LP will show: Raised opening pressure Raised red blood cell (RBC) Xanthochromia
Meningitis	Headache   Neck stiffness Fever Photophobia  Phonophobia   Irritability, altered mental status (in small children)	Lumbar puncture for CSF	To determine the risk of herniation CT scan of the head should be done before Lumbar puncture.	Clinical presentation in combination with CSF analysis are deciding factors for diagnosis. CSF analysis is the test of choice.
Intracranial mass	Headache Nausea Vomiting Change in mental status Seizures Focal symptoms of brain damage Associated comorbid conditions like tuberculosis, etc	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.	Biopsy of the lesion is needed To identify the natures of the lesions such as: Tumor Abscess X- ray of the skull is a non specific test, but useful to identify calcified lesions.
Cerebral hemorrhage	Headache, vomiting, and depressed level of consciousness from increased intracranial pressure (ICP)   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.	Coagulopathy should be ruled out by checking PT/ INR and aPTT.
Cerebral Infarction	The symptoms of an ischemic stroke depend on the site and blood supply of the area involved.	Cerebral angiography	CT scan without contrast is the initial test to diagnose ischemic stroke and to exclude hemorrhagic stroke. Hypo-attenuation and swelling of the involved area may be found in the CT scan. 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. Cerebral angiography detect blood vessels abnormalities as narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations).
Migraine	Severe or moderate headache (often unilateral) lasting several hours to three days. Other symptoms include gastrointestinal upsets, such as nausea and vomiting, and an increased sensitivity to bright lights (photophobia) and sound (phonophobia). aura is a preceding symptom in one third patients.[4]	---	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.
Head injury	Headache Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness 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. MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT scan.	The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
Lymphocytic hypophysitis	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 defects Hypopituitarism	Pituitary biopsy	CT & MRI typically reveal features of a pituitary mass.	The most accurate test is pituitary biopsy which will show lymphocytic infiltration.
Radiation injury	Headache Impairment of mental function is the most prominent feature such as personality change, impairment of memory, confusion, learning difficulties Focal neurological abnormalities and evidence of raised intracranial pressure	Surgical exploration including biopsy (histological confirmation)	CT & MRI will show: Focal radiation necrosis Diffuse white matter injury Contrast-enhancing mass surrounded by edema and mass effect	PET scan Radiation necrosis is hypo metabolic and will have decreased uptake of fluorodeoxyglucose.