Endgames Case Review

Sudden onset headache in a 50 year old woman

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4016 (Published 21 September 2017) Cite this as: BMJ 2017;358:j4016
  1. Divyansh Gulati, specialty registrar in emergency medicine,
  2. Michael William Shea, senior house officer in obstetrics and gynaecology,
  3. James Ray, consultant in emergency medicine
  1. Emergency department, John Radcliffe Hospital, Oxford, UK
  1. Correspondence to M Shea m_w_shea{at}hotmail.com

A 50 year old woman presented to the emergency department several hours after the sudden onset of a severe headache with associated neck stiffness, photophobia, and vomiting. She reported having a dental abscess, and was taking norethisterone regularly for persistent vaginal bleeding. She had a 50 pack year smoking history. She was afebrile, alert (Glasgow coma scale 15), and had no focal neurological signs. Blood tests were unremarkable, in particular her white blood cell and neutrophil counts were within the normal range. A non-contrast computed tomography (CT) scan of the head was obtained in the emergency department (fig 1).

Fig 1 Non-contrast computed tomography (CT) scan of the head: (A) axial and (B) sagittal views

Questions

  • 1. What is the diagnosis based on the history and CT scan?

  • 2. What are the risk factors for this condition?

  • 3. What is the treatment for this condition?

Answers

1. What is the diagnosis based on the history and CT scan?

Short answer

Cerebral venous thrombosis, seen by the “dense triangle sign,” a hyperdensity at the posterior part of the superior sagittal sinus (fig 2a), and the “cord sign” (fig 2b), a homogenous hyperdensity that fills a sinus. Diagnosis is usually made from magnetic resonance (MR) or CT venography.

Fig 2 Non-contrast CT scan of the …

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