Cerebral venous sinus thrombosis differential diagnosis

• 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]

• 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.

• 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

• 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

• Headache  
• Neck stiffness
• Fever

• Photophobia 
• Phonophobia  
• Irritability, altered mental status (in small children)

• 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.

• Headache
• Nausea
• Vomiting
• Change in mental status
• Seizures
• Focal symptoms of brain damage
• Associated comorbid conditions like tuberculosis, etc

• 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.

• Headache, vomiting, and depressed level of consciousness from increased intracranial pressure (ICP)  

• Progressive focal neurological deficits

• 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.

• 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). 

• 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.

• Headache
• Confusion
• Drowsiness
• Personality change
• Seizures
• Nausea and vomiting
• Loss of consciousness
• lucid interval

• CT scan is the first test to identify cerebral hemorrhage (appears as hyperattenuating clot) after head injury.

• MRI is time-consuming, expensive, and is done in cases with nonspecific findings in CT scans.

• The Glasgow Coma Scale is used to determine the severity of the injury.
• The Pediatric Glasgow Coma Scale is used in young children.

• Mass lesion effect such as headache or visual field defects
• Hypopituitarism

• CT & MRI are helpful to identify a pituitary mass.

• Lymphocytic infiltration in pituitary biopsy confirms the diagnosis.

• 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

CT & MRI will show:

• Focal radiation necrosis
• Diffuse white matter injury
• Contrast-enhancing mass surrounded by edema and mass effect

• Radiation necrosis is hypo metabolic and shows reduced uptake of fluorodeoxyglucose.