379.2 🩺 國考版

379.2.1 高頻考點

379.2.1.1 CVST Risk Factors

  • Pregnancy/postpartum (top)
  • OCP
  • Infection
  • Cancer
  • Trauma
  • Thrombophilia
  • VITT (adenoviral COVID vaccines)
  • COVID-19

379.2.1.2 CVST Presentation

  • Headache (most common, ~ 90%)
  • Papilledema
  • Focal deficits
  • Seizures (more than arterial)
  • Altered LOC

379.2.1.3 CVST Diagnosis

  • MRV (gold standard)
  • CTV alternative
  • Empty delta sign on contrast
  • MRI shows venous infarcts ± hemorrhage

379.2.1.4 CVST Treatment

  • Anticoagulation cornerstone (even with hemorrhage)
  • Heparin/LMWH → warfarin or DOAC
  • Duration 3-6 months (provoked)
  • Longer for unprovoked or high-risk thrombophilia
  • Thrombectomy for severe (TO-ACT mixed)

379.2.1.5 CVST Locations

  • Superior sagittal: bilateral parasagittal infarcts, leg weakness
  • Transverse-sigmoid: headache
  • Cavernous sinus: chemosis, proptosis, painful ophthalmoplegia
  • Deep venous: bilateral thalamic, devastating

379.2.1.6 Cavernous Sinus Thrombosis

  • Often infectious (S. aureus from face/orbit)
  • Chemosis, proptosis
  • CN III, IV, V1, V2, VI palsies
  • Antibiotics + anticoagulation + drainage of source

379.2.1.7 TIA Definition

  • Tissue-based (no infarct on DWI MRI)
  • Old: time-based < 24 hr (abandoned)
  • Average ~ 1 hr

379.2.1.8 TIA Stroke Risk

  • 5% within 48 hr
  • 10% within 90 days

379.2.1.9 ABCD2 Score

  • Age ≥ 60: 1
  • BP ≥ 140/90: 1
  • Clinical: 1-2
  • Duration: 1-2
  • DM: 1
  • High risk ≥ 4

379.2.1.10 CHANCE / POINT Trials

  • ASA + clopidogrel × 21 days
  • For TIA or minor stroke (NIHSS ≀ 3)
  • Then ASA monotherapy

379.2.1.11 THALES

  • ASA + ticagrelor × 30 days
  • Alternative DAPT

379.2.1.12 TIA Urgent Workup

  • Within 24-48 hr
  • Brain MRI with DWI
  • ECG, troponin
  • Echo
  • Carotid imaging
  • Hypercoagulable in select

379.2.2 Specific Issues

379.2.2.1 Pregnancy/Postpartum CVST

  • Highest risk postpartum (especially 1st month)
  • Estrogen + procoagulant state
  • LMWH preferred (warfarin teratogenic)

379.2.2.2 VITT (Vaccine-Induced Immune Thrombotic Thrombocytopenia)

  • Adenoviral COVID vaccines (Astra-Zeneca, J&J)
  • 5-30 days post-vaccine
  • Thrombocytopenia + thrombosis (often CVST, splanchnic)
  • HIT-like
  • High mortality
  • Treatment: IVIG + non-heparin anticoagulation (argatroban, bivalirudin, fondaparinux, DOACs)

379.2.2.3 Lemierre Syndrome

  • Septic thrombophlebitis of internal jugular vein
  • Often Fusobacterium necrophorum
  • After pharyngitis
  • Antibiotics + anticoagulation controversial

379.2.2.4 Idiopathic Intracranial Hypertension (IIH)

  • Mimics CVST
  • Always rule out CVST first
  • See Ch363

379.2.3 TIA Mimics

  • Migraine with aura
  • Seizure (Todd’s paralysis)
  • Hypoglycemia
  • Conversion
  • Vestibular
  • Syncope/presyncope