Headaches Presenting in the Emergency Department (Continued)

CEREBRAL VENOUS THROMBOSIS

Cerebral venous thrombosis (CVT) most often has a subacute presentation; however, a minority of patients present with thunderclap headache. Headaches are persistent and tend to be worse in the morning, in a recumbent position, and with Valsalva maneuvers, such as coughing or straining. Headaches may be accompanied by other signs of increased intracranial pressure, such as papilledema, seizures, and altered mentation. If venous infarction occurs, focal neurologic deficits may be present. If the venous thrombosis is in the superior sagittal sinus, a CT scan with contrast may show a filling defect around the thrombus, called the “empty delta” sign. However, CT and MRI may be unremarkable, requiring MR venography for diagnosis. When diagnosis is established, causative or predisposing conditions need to be identified, including thrombophilic states or occult malignancy. Patients are generally treated with anticoagulation.

PITUITARY APOPLEXY

Acute pituitary apoplexy is an uncommon syndrome due to hemorrhage or infarction of the pituitary gland in the setting of a pituitary macroadenoma. Patients may present with a sudden and severe headache, ophthalmoplegia, visual disturbance, nausea/vomiting, altered mentation, meningismus, and sometimes fever. In the emergency room, this may mimic a severe migraine or aseptic meningitis, and in severe cases may cause adrenal crisis, coma, or death. Although pituitary pathology is usually noted on a noncontrast CT scan of the head, an MRI is more sensitive.

COLLOID CYST

A colloid cyst is a benign cyst that arises in the anterior third ventricle just posterior to the foramen of Monro. Because of its location, it can act as a ball-valve transiently obstructing the ventricular outflow and causing obstructive hydrocephalus. Patients may present with intermittent symptoms of increased intracranial pressure, including sudden and severe headaches with nausea/vomiting; these often improve in a recumbent position. If obstructive hydrocephalus is prolonged, deterioration with altered mentation, seizures, coma, and death may occur. Diagnosis is made by CT or MRI, and early surgical intervention is necessary for symptomatic colloid cysts.

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