We discussed a case of a middle-aged man with uncontrolled diabetes, who presented with acute-subacute fevers, headache, L neck pain, L retroauricular pain, and was found to have L ophthalmoplegia, acute L eye swelling due to MRSA bacteremia, left skull base MRSA osteomyelitis, and septic cavernous sinus thrombosis.

We reviewed various frameworks for secondary headache.
Thunderclap headache = Abrupt onset and reaches its max intensity within 1 minute or less of onset

Cerebral venous thrombosis is a rare (1%) cause of strokes. It usually affects younger patients (20-50 y/o) with a female > male predominance.

In septic cerebral vein thrombosis, thrombosis most commonly arises from contiguous spread of infection (nasal, sinus, dental) into the veins/sinuses.

Risk factors for cerebral venous thrombosis include:

• Thrombophilia e.g. hx of prior VTE, oral contraceptives, obesity, pregnancy, autoimmune diseases (lupus, IBD, antiphospholipid), nephrotic syndrome
• Head and neck infections e.g. mastoiditis, sinusitis, otitis media, meningitis, cerebral abscess, Lemierre’s syndrome
• Mechanical causes e.g. trauma (at the skull base or jugular foramen), NSGY procedures, jugular vein procedures

Clinical manifestations to definitely watch out for include:

• Headache: acute to subacute, can be thunderclap headache
• Fevers
• Focal neuro symptoms: CN III, IV, VI palsies, paresis, dysarthria, diplopia…depending on where the clot is
• Seizure
• Encephalopathy

Treatment goals:

• Recanalize the occluded vein
• Prevent thrombus propagation
• Treat the underlying prothrombotic state

Treatment:

• Heparin (unfractionated or LMWH)
• Intracerebral hemorrhage is NOT a contraindication to anticoagulation.

References:

• CPS: secondary headache schema based on red flag symptoms
• CPS: thunderclap headache schema
• IBCC: cerebral venous thrombosis
• NEJM: septic cerebral venous thrombosis
• Uptodate: cerebral venous thrombosis – etiology, clinical features, and diagnosis
• Uptodate: cerebral venous thrombosis – treatment and prognosis
• Uptodate: septic dural sinus thrombosis