379.4 📋 章末速蚘 Summary

379.4.1 🔑 䞀句話瞜結

CVST (cerebral venous sinus thrombosis) = thrombosis of cerebral venous sinuses (superior sagittal, transverse, sigmoid, cavernous) ± deep cerebral veins (straight sinus, internal cerebral, Galen); rare (3-4/million/yr) but underdiagnosed; female > male 3:1, often young; risk factors — pregnancy/postpartum (highest risk, postpartum 1st month especially) + OCP/HRT + infection (mastoiditis, sinusitis, otitis, meningitis, dental, periorbital) + malignancy + trauma + dehydration + nephrotic + systemic disease (lupus, IBD, Behçet, vasculitis) + COVID-19 + VITT (vaccine-induced immune thrombotic thrombocytopenia from adenoviral COVID vaccines 5-30 days post) + genetic thrombophilia (factor V Leiden, prothrombin G20210A, protein C/S/antithrombin deficiency, antiphospholipid syndrome); presentation variable — headache most common ~ 90% (progressive, may be thunderclap, worse with Valsalva) + papilledema (↑ ICP) + focal deficits (don’t fit arterial territory!) + seizures (more common than arterial stroke) + altered LOC + cranial nerve palsies + encephalopathy; location-specific — superior sagittal sinus (bilateral parasagittal infarcts + leg weakness) + transverse-sigmoid (headache) + cavernous sinus (chemosis + proptosis + CN III/IV/V1/V2/VI palsies + painful ophthalmoplegia, often infectious S. aureus from face/orbit) + deep venous (bilateral thalamic + ↓ LOC + devastating); diagnosis — MRV gold standard (direct visualization + empty delta sign filling defect) or CTV alternative (faster, comparable accuracy) + MRI venous infarcts don’t follow arterial territory + hemorrhage common 30-40% + dural sinuses bright on T1/T2 (thrombus); workup — pregnancy test + D-dimer + thrombophilia workup (after acute phase ideally) + infection + malignancy imaging; treatment cornerstone is ANTICOAGULATION EVEN WITH HEMORRHAGE — IV heparin or LMWH acutely → warfarin INR 2-3 or DOAC (apixaban, rivaroxaban emerging) for 3-6 months provoked, 6-12 months idiopathic, indefinite for high-risk thrombophilia (APS, AT III) or recurrent; severe/deteriorating → endovascular thrombolysis or thrombectomy (TO-ACT 2020 mixed) + decompressive craniectomy life-saving for massive infarct; symptomatic anticonvulsants + analgesics + ↑ ICP management; underlying treat infection + stop OCP + address malignancy; VITT-specific = IVIG + non-heparin anticoagulation (argatroban, bivalirudin, fondaparinux, DOACs) + AVOID heparin; prognosis generally favorable (75-80% functional recovery, mortality 5-10%, worse with deep venous/coma/deterioration/hemorrhage); TIA (transient ischemic attack) = TISSUE-BASED DEFINITION = transient neurological deficit + NO acute infarct on DWI MRI (previously time-based < 24 hr abandoned); average duration ~ 1 hr; high short-term stroke risk — 5% within 48 hr + 10% within 90 days → URGENT; ABCD2 score (Age ≥ 60 1 + BP ≥ 140/90 1 + Clinical unilateral weakness 2 or speech 1 + Duration ≥ 60 min 2 or 10-59 min 1 + DM 1 = 0-7, high risk ≥ 4); urgent workup within 24-48 hr — brain MRI with DWI (distinguishes TIA from stroke) + ECG + troponin + echocardiogram (consider TEE) + carotid imaging + Holter/ILR (occult AF) + glucose + lipids + hypercoagulable select + BP optimization; management — DAPT (ASA + clopidogrel × 21 days, CHANCE/POINT) for high-risk TIA (ABCD2 ≥ 4) or minor stroke (NIHSS ≀ 3) then ASA monotherapy; alternative ASA + ticagrelor × 30 days (THALES) + CHANCE-2 (2021) ticagrelor + ASA better than clopidogrel + ASA in CYP2C19 LOF carriers; secondary prevention = stroke prevention (statin high-intensity + BP < 130/80 + DM + lifestyle + carotid + PFO closure + AF anticoagulation); TIA mimics — migraine with aura + seizure (Todd’s) + hypoglycemia + conversion + vestibular + syncope。

379.4.2 💊 治療粟芁

  • CVST anticoagulation cornerstone (EVEN with hemorrhage)IV unfractionated heparin (target aPTT 1.5-2.5x normal) or LMWH (enoxaparin 1 mg/kg BID) acutely → transition to warfarin INR 2-3 or DOAC (apixaban, rivaroxaban) for 3-6 months provoked + 6-12 months idiopathic + indefinite for high-risk thrombophilia or recurrent
  • CVST severe/deterioratingendovascular thrombolysis (catheter-directed) or thrombectomy (TO-ACT 2020 mixed evidence — reserve for severe) + decompressive craniectomy for massive infarct + herniation
  • CVST symptomaticanticonvulsants for seizures + analgesics + ↑ ICP management (head elevation, osmotherapy, CSF drainage)
  • VITT (vaccine-induced immune thrombotic thrombocytopenia)IVIG 1 g/kg × 2 days + non-heparin anticoagulation (argatroban, bivalirudin, fondaparinux, DOACs apixaban/rivaroxaban) — AVOID heparin + monitor platelets + serotonin release assay for HIT
  • cavernous sinus thrombosis (often infectious)IV antibiotics (vancomycin + ceftriaxone or other broad-spectrum, target Staph aureus) + anticoagulation + drainage of source (paranasal sinuses, mastoid, dental)
  • TIA acuteABC monitor + BP optimization (not too aggressive) + glucose + immediate aspirin 325 mg load + 81 mg/d
  • TIA DAPT for high-risk (ABCD2 ≥ 4 or minor stroke NIHSS ≀ 3)aspirin + clopidogrel 75 mg/d × 21 days (CHANCE/POINT) then aspirin monotherapy; alternative aspirin + ticagrelor × 30 days (THALES); CHANCE-2 ticagrelor + ASA preferred in CYP2C19 LOF carriers (Asian population particularly)
  • TIA secondary preventionsame as stroke — antiplatelet + high-intensity statin (atorvastatin 80 or rosuvastatin 20-40, LDL < 70) + BP < 130/80 + DM A1c < 7% + lifestyle + carotid intervention + PFO closure + AF anticoagulation
  • pregnancy CVSTLMWH throughout pregnancy (warfarin teratogenic) + plan for delivery + postpartum continue several months + future pregnancy LMWH prophylaxis
  • IIH (idiopathic intracranial hypertension) DDx CVSTalways rule out CVST first with MRV; if true IIH → acetazolamide + weight loss + LP

379.4.3 🎯 盧醫垫的考前提醒

  1. CVST risk factors (memorize): pregnancy/postpartum (highest) + OCP/HRT + infection (mastoiditis, sinusitis, dental) + malignancy + thrombophilia (genetic + APS) + COVID-19 + VITT (adenoviral COVID vaccines) + dehydration + IBD/lupus/Behçet
  2. CVST presentation atypical: headache most common (~ 90%, progressive or thunderclap) + seizures (MORE common than arterial stroke) + papilledema (↑ ICP) + focal deficits don’t fit arterial territory; cavernous sinus thrombosis — chemosis + proptosis + painful ophthalmoplegia (CN III/IV/V1/V2/VI), often infectious S. aureus from face/orbit
  3. CVST diagnosis: MRV gold standard or CTV (empty delta sign on contrast); MRI shows venous infarcts (don’t follow arterial territory) + hemorrhage common 30-40%
  4. CVST treatment cornerstone: ANTICOAGULATION EVEN WITH HEMORRHAGE — heparin/LMWH → warfarin (INR 2-3) or DOAC; duration 3-6 months provoked, 6-12 months idiopathic, indefinite for high-risk thrombophilia/recurrent
  5. VITT specific treatment: IVIG + non-heparin anticoagulation (argatroban, bivalirudin, fondaparinux, DOACs) — AVOID heparin (HIT-like mechanism with PF4 antibodies)
  6. TIA tissue-based definition: transient neurological deficit + NO acute infarct on DWI MRI (previously time-based < 24 hr abandoned); average ~ 1 hr
  7. TIA stroke risk: 5% within 48 hr + 10% within 90 days → urgent workup within 24-48 hr; many “TIAs” actually small strokes on DWI (~ 30-50%)
  8. ABCD2 score for stroke risk after TIA: Age ≥ 60 (1) + BP ≥ 140/90 (1) + Clinical (unilateral weakness 2 or speech 1) + Duration (≥ 60 min 2 or 10-59 min 1) + DM (1) = 0-7; high risk ≥ 4
  9. DAPT for high-risk TIA/minor stroke: aspirin + clopidogrel × 21 days (CHANCE 2013 + POINT 2018) for ABCD2 ≥ 4 or minor stroke (NIHSS ≀ 3) then ASA monotherapy; alternative ASA + ticagrelor × 30 days (THALES); CHANCE-2 (2021) ticagrelor + ASA preferred in CYP2C19 LOF carriers (relevant for Asian population — high prevalence)
  10. TIA urgent workup within 24-48 hr — brain MRI with DWI (distinguishes from stroke) + ECG + troponin + echocardiogram + carotid imaging + Holter/ILR for occult AF + hypercoagulable in select + initiate aspirin immediately; TIA mimics to consider — migraine with aura + seizure (Todd’s paralysis) + hypoglycemia + conversion + vestibular + syncope/presyncope