Rethinking Thunderclap Headaches: A Critical Look at Cerebral Venous Sinus Thrombosis
Isabella Canut1, Raquel Esquivel1, Suraj Malhan2
1Philadelphia College of Osteopathic Medicine, 2University of Maryland Medical Center
Objective:
To highlight the importance of early CVST identification to prevent long-term complications.
Background:
Cerebral venous sinus thrombosis (CVST) is a rare form of stroke, with an estimated annual incidence of 2 cases per 100,000 in the general population. It occurs when a clot forms in the brain’s venous sinuses, leading to increased pressure in the vessels, and can be further complicated with hemorrhage. CVST can be difficult to diagnose, especially when presenting with a thunderclap headache, which can be mistaken for more common conditions such as migraines or subarachnoid hemorrhage (SAH). The similarities in symptoms can lead to a delayed diagnosis, which increases the potential for risk of complications.
Design/Methods:
A systematic review of 12 case reports and clinical studies was conducted using PubMed and Google Scholar from 2005 to 2023. We focused on patients with thunderclap headaches initially misdiagnosed as migraine or SAH, examining modes of diagnosis and patient outcomes. Our study analyzed both typical and atypical presentations of CVST, especially in patients with risk factors such as oral contraceptive use or hypercoagulable states.
Results:
In certain instances, thunderclap headaches led to a misdiagnosis of SAH or migraine. Non-contrast CT scans, commonly used to rule out SAH, did not always prove sufficient for diagnosing CVST. When CVST was recognized early and treated with anticoagulation, most patients experienced favorable outcomes. Our findings suggest that having a high index of suspicion for CVST in patients presenting with thunderclap headaches can improve diagnostic accuracy and treatment efficacy.
Conclusions:
Thunderclap headaches should prompt clinicians to consider CVST, particularly in patients with risk factors such as oral contraceptive use or a hypercoagulable state. Early imaging with MRV or CTV is essential for an accurate diagnosis when initial non-contrast CT scans are negative. Timely diagnosis and management can dramatically enhance patient outcomes and reduce the risk of long-term complications.
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