Ep181 Cerebral Venous Thrombosis, Idiopathic Intracranial Hypertension, Giant Cell Arteritis and Peripartum Headaches

This is part 2 of our 2-part podcast on red flag headaches that do not readily appear on plain CT head. In Part 1 we covered cervical artery dissections. In this episode, Dr. Roy Baskind and Dr. Ahmit Shah answer such questions as: when is an LP opening pressure required? When should we pull the trigger on ordering a CT venogram in the patient with unexplained headache? What is the value of D-dimer to screen for Cerebral Venous Thrombosis (CVT)? Which older patients who present with headache require an ESR/CRP to screen for Giant Cell Arteritis (GCA)? How do the presentations of CVT and idiopathic intracranial hypertension (IIH) compare and contrast? When is it safe to start steroids in the ED for patients suspected of GCA; will starting steroids in the ED affect the accuracy of a temporal artery biopsy? How soon should patients suspected of GCA get a temporal artery biopsy? When should we consider posterior reversible encephalopathy syndrome (PRES) and pituitary apoplexy in the peripartum patient? How should we think about the differential diagnosis of vascular headaches? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman, April, 2023 Cite this podcast as: Helman, A. Shah, A. Baskind. R. Red Flag Headaches: Cerebral Venous Thrombosis, Idiopathic Intracranial Hypertension and Giant Cell Arteritis. Emergency Medicine Cases. April, 2023. https://emergencymedicinecases.com/red-flags-headache-cvt-iih-gca. Accessed [date] Go to part 1 of this 2-part podcast on red flag headaches Differential diagnosis of acute headache in the peripartum period While migraine is common in the peripartum period, do not assume that all new onset headaches in this period are caused by migraine. Life threatening causes of headache to consider in the paripartum patient * Pre-eclampsia/eclampsia/HELLP Syndrome – highest risk is in first 48hrs however can occur up to 6 weeks after delivery, BP can be only mildly elevated, have a low threshold to check for proteinuria (deep dive into pre-eclampsia and preterm labour on CritCases) * PRES – Posterior Reversible Encephalopathy Syndrome * A misnomer as it may include the parietal lobes and frontal in addition to the occipital lobes and it is not always reversible (mortality rate 15%), * Presents with headache, seizures, altered mental status and visual loss * Diagnosed on MRI (white matter vasogenic edema) * Overlap with Pre-eclampsia/eclampsia as it is associated with acute hypertension * Cerebral venous thrombosis – see below * Pituitary apoplexy – rare abrupt severe headache (similar to SAH) with loss of visual field or diplopia, nausea, neck stiffness, altered LOA, some have underlying pituitary adenoma, incited by enlargement of pituitary in peripartum period leading to infarction/hemorrhage, may lead to adrenal insufficiency, diagnosed on MRI (may see hemorrhage on plain CT) * Cervical artery dissection – see Part 1 of this podcast series Non-life threatening causes of headache to consider in the peripartum patient * Migraine is the most common peripartum cause of headache that presents to the ED, but do not assume that a new acute headache in peripartum period is migraine – consider it a diagnosis of exclusion