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
Exams LITFL ACEM 700

Examination Library

CICM

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.