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What Causes Pain And Pressure In Head, Nausea, Vomiting And CVST?
Question: Question 1: If a patient (female, 36 years old, diagnosed with Crohn's disease) entered within 1.5 hours of feeling popping sounds in her head - upon entering Emergency at Hospital - she told the nurse that her left side of her face was feeling heavy, had indicated she had head popping/pressure/pain in the head and felt nauseous - aren't those the general signs of a stroke (or at least should be consideration for further review) - although she did not have 'blurry vision'? However, the doctor gave her gravol through IV and basically concluded she must have 'sprained her neck' - as patient advised she had some neck pains a month ago (as doctor asked if she had "any pains recently"? As a result of the gravol IV - patient became very sleepy.
Question 2: Wouldn't the gravol made her sleepy (quickly) and instead generally mask her symptoms (as she only remained in ER for about 3 hours). Patient left for home and went straight to bed as she was exhausted with gravol/pain.
Conclusion: Next morning, she woke up vomiting (continuously) - end up in ER (again) at a different hospital. Found a clot (Cerebral Venous Sinus Thrombosis). Patient suffered a seizure.
Question 2: Wouldn't the gravol made her sleepy (quickly) and instead generally mask her symptoms (as she only remained in ER for about 3 hours). Patient left for home and went straight to bed as she was exhausted with gravol/pain.
Conclusion: Next morning, she woke up vomiting (continuously) - end up in ER (again) at a different hospital. Found a clot (Cerebral Venous Sinus Thrombosis). Patient suffered a seizure.
Brief Answer:
Difficult to label CVST at presentation in emergency room
Detailed Answer:
Hello dear,
I have gone through your question and understand your concerns.
The acute presentation of vertigo, nausea and headache may be a feature of posterior circulation stroke in appropriate settings like elderly, diabetes hypertension or cardiac illness. Such a symptoms in 38 year female usually suggest to some primary headache like basilar migraine.
As no objective signs of stroke was present at presentation, it is very difficult to suspect stroke in such a case.
Second query is about gravol related sleepiness which usually is its side effects.
Last part is diagnosis of cortical venous sinus thrombosis as ultimate manifestation.
In crohn's disease, CVST is uncommonly reported related to some genetic predisposition to hypercoagulation.
Apart from this there are many cause of cortical venous sinus thrombosis and must be evaluated properly to decide the duration and nature of treatment.
One clarification in last, diagnosis of stroke in acute presentation in window period of 4.5 hours may be treated with thrombolysis drugs with good results in indicated patients. But this treatment is for arterial stroke and not for venous obstruction and thus doesn't apply in your case. So don't feel as if you were not treated or diagnosed at first presentation in emergency room as such symptomatology is hard to relate straight forward to cortical venous sinus thrombosis.
CT is showing thrombosis, but preferred investigation would be Mri with MR venography.
Be in touch with your doctor.
Hope you found the answer helpful.
Do get back to me for further queries
Regards
Dr Neeraj Kumar
Difficult to label CVST at presentation in emergency room
Detailed Answer:
Hello dear,
I have gone through your question and understand your concerns.
The acute presentation of vertigo, nausea and headache may be a feature of posterior circulation stroke in appropriate settings like elderly, diabetes hypertension or cardiac illness. Such a symptoms in 38 year female usually suggest to some primary headache like basilar migraine.
As no objective signs of stroke was present at presentation, it is very difficult to suspect stroke in such a case.
Second query is about gravol related sleepiness which usually is its side effects.
Last part is diagnosis of cortical venous sinus thrombosis as ultimate manifestation.
In crohn's disease, CVST is uncommonly reported related to some genetic predisposition to hypercoagulation.
Apart from this there are many cause of cortical venous sinus thrombosis and must be evaluated properly to decide the duration and nature of treatment.
One clarification in last, diagnosis of stroke in acute presentation in window period of 4.5 hours may be treated with thrombolysis drugs with good results in indicated patients. But this treatment is for arterial stroke and not for venous obstruction and thus doesn't apply in your case. So don't feel as if you were not treated or diagnosed at first presentation in emergency room as such symptomatology is hard to relate straight forward to cortical venous sinus thrombosis.
CT is showing thrombosis, but preferred investigation would be Mri with MR venography.
Be in touch with your doctor.
Hope you found the answer helpful.
Do get back to me for further queries
Regards
Dr Neeraj Kumar
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Brief Answer:
not indicated in all cases but would have been better in your case
Detailed Answer:
Hello dear,
The decision to get imaging rest upon combined probability of some organic cause based on symptoms and sign examined by doctor. Sometimes it's difficult to differentiate.
Most cases with such presentation may have negative imaging and without substantial suspicion it may be hard call.
I will not blame the ER for not doing imaging. But if symptoms progress or seizure occurs as in your case it definitely require imaging.
In most setting imaging decision are to be taken based on patient load, insurance claims.
It would have been better if it was done earlier in your case but with a possibility of negative imaging finding in early stage of disease too
not indicated in all cases but would have been better in your case
Detailed Answer:
Hello dear,
The decision to get imaging rest upon combined probability of some organic cause based on symptoms and sign examined by doctor. Sometimes it's difficult to differentiate.
Most cases with such presentation may have negative imaging and without substantial suspicion it may be hard call.
I will not blame the ER for not doing imaging. But if symptoms progress or seizure occurs as in your case it definitely require imaging.
In most setting imaging decision are to be taken based on patient load, insurance claims.
It would have been better if it was done earlier in your case but with a possibility of negative imaging finding in early stage of disease too
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
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