379.3 🏥 內科專科考前版

379.3.1 Mechanistic Deep Dive

379.3.1.1 CVST Pathophysiology

  • Thrombus in venous sinus
  • ↑ venous pressure
  • ↑ ICP
  • Cerebral edema
  • Venous infarct (different from arterial — doesn’t follow territory)
  • Hemorrhage common (high pressure, ischemia)

379.3.1.2 Pregnancy Hypercoagulability

  • Estrogen → ↑ clotting factors
  • Venous stasis (gravid uterus)
  • Endothelial injury (delivery)
  • Highest risk postpartum

379.3.2 Recent Trials & Updates

379.3.2.1 TO-ACT (2020)

  • Endovascular treatment for CVST
  • Mixed/negative
  • Reserve for severe/refractory

379.3.2.2 COVID-19 and CVST

  • Increased risk during infection
  • Cytokine storm
  • Endothelial dysfunction
  • COVID-19 vaccine VITT (adenoviral)

379.3.2.3 CHANCE-2 (2021)

  • Ticagrelor + ASA vs clopidogrel + ASA
  • CYP2C19 LOF carriers
  • Ticagrelor better in this group

379.3.3 High-Yield Specialist Points

379.3.3.1 Empty Delta Sign

  • On contrast CT
  • Thrombus in superior sagittal sinus
  • Surrounded by enhanced dura

379.3.3.2 Cortical Vein Thrombosis

  • May occur without sinus involvement
  • Local cortical hemorrhage
  • Seizures, focal deficits
  • Imaging can be subtle

379.3.3.3 Treatment Duration

  • Provoked (transient risk): 3-6 months
  • Idiopathic: 6-12 months
  • High-risk thrombophilia (APS, AT III deficiency): often indefinite
  • Recurrence: indefinite

379.3.3.4 DOACs for CVST

  • Limited evidence vs warfarin
  • RESPECT-CVT (small trial), EINSTEIN-Jr
  • Generally acceptable for non-pregnant
  • Pregnancy: LMWH

379.3.3.5 Pregnancy CVST Management

  • LMWH throughout
  • Plan for delivery
  • Postpartum continue for several months
  • Future pregnancy: LMWH prophylaxis

379.3.3.6 CVST in IBD

  • Increased risk
  • Anticoagulate cautiously (GI bleeding)

379.3.3.7 CVST Sequelae

  • Recurrence ~ 3-5%
  • Chronic headache
  • Seizure
  • Cognitive impairment
  • Idiopathic intracranial hypertension-like syndrome
  • Visual loss

379.3.3.8 TIA Detection Trials

  • Many “TIAs” are actually small strokes on DWI
  • ~ 30-50% have DWI lesions

379.3.3.9 Crescendo TIA

  • Recurrent TIAs in short period
  • High stroke risk
  • Admission, urgent intervention

379.3.3.10 Capsular Warning Syndrome

  • Recurrent transient lacunar TIAs
  • High risk of completed lacunar stroke
  • May need DAPT, BP optimization

379.3.4 Pearls

  • CVST risk: pregnancy/postpartum, OCP, infection, cancer, COVID, VITT
  • MRV for diagnosis
  • Anticoagulation even with hemorrhage
  • VITT: non-heparin anticoag + IVIG
  • TIA: tissue-based definition (no DWI lesion)
  • High stroke risk after TIA — urgent workup
  • ABCD2 stratifies
  • DAPT 21 days for high-risk minor stroke/TIA
  • Secondary prevention = same as stroke