CICM SAQ 2015.2 Q26
Question
A 27-year-old female presents to the Emergency Department after a collapse at work that was followed by a brief tonic-clonic seizure. She is 30 weeks pregnant with no previous pregnancies or other significant medical history. She currently localises bilaterally to painful stimulus but does not open her eyes or vocalise.
Her blood pressure is 170/50 mmHg, her urine analysis is unremarkable, and the cardiotocogram (CTG) is ‘reassuring’. A CT brain scan shows a sigmoid and transverse venous sinus thrombosis, with some temporal lobe parenchymal haemorrhage.
- a) List the major risk factors, other than pregnancy, for this condition. (30% marks)
- b) Briefly outline the management priorities for this patient? (70% marks)
Answer
Answer and interpretation
a) List the major risk factors, other than pregnancy, for this condition. (30% marks)
- Prothrombotic conditions – genetic or acquired
- Oral contraceptive
- Malignancy
- Parameningeal Infection e.g. ear, sinus
- Head trauma
- Surgery
- Mechanical precipitant
- Autoimmune disease e.g. SLE, antiphospholipid
- Other drugs e.g. androgens
b) Briefly outline the management priorities for this patient? (70% marks)
Resuscitation:
- Consider intubation
- Check gas exchange (expect slight respiratory alkalosis)
- BP currently a bit on the high side, maybe careful hydralazine to SBP 140-160
Specific therapy for cerebral venous sinus thrombosis
- Therapeutic anticoagulation
- Can use LMWH or UFH
- Intracranial haemorrhage with CVT is not a contraindication to anticoagulation
- Continued for remainder of pregnancy and usually for further 6-12 weeks postpartum
- Aspirin – no evidence of benefit. Occasionally used as alternative if firm CI to therapeutic
anticoagulation
- Potential therapies include thrombolysis (systemic or catheter-directed), mechanical clot
extraction, decompressive craniectomyAssess for underlying cause that may require specific therapy e.g., - Assess for underlying cause that may require specific therapy e.g.,
- Antiphosphoplipid syndrome
- Sinus or parameningeal infection
- May need an anticonvulsant; consider neurology inputPregnancy related:
Pregnancy related:
- Involvement of obstetric service, regular CTG, ultrasound
- ? steroids to allow for early delivery if needed
- Shielding for X-ray and CT limit as able
- Blood conservation given physiological anaemia of pregnancy
- Need to keep family up to date
- Pass rate: 67%
- Highest mark: 8.8
Examination Library
CICM
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC