Elsevier

The Lancet

Volume 348, Issue 9042, 14 December 1996, Pages 1623-1625
The Lancet

Early Report
Thunderclap headache as first symptom of cerebral venous sinus thrombosis*

https://doi.org/10.1016/S0140-6736(96)07294-7Get rights and content

Summary

Background

Thunderclap headache raises the suspicion of subarachnoid haemorrhage, and it is not generally recognised as a symptom of cerebral venous sinus thrombosis (CVST). We describe ten patients who presented with thunderclap headache mimicking subarachnoid haemorrhage, who appeared to have CVST.

Methods

Medical histories of 71 patients who had CVST between 1992 and 1996 were collected. 48 of these took part in a randomised trial of treatment for CVST. The diagnosis was confirmed by conventional angiography or magnetic resonance imaging and angiography in all patients.

Findings

In all ten patients who presented with thunderclap headache, characteristics of the headache and clinical signs and symptoms were clinically indistinguishable from those of subarachnoid haemorrhage. Computed tomography at admission was interpreted as normal in five patients (one with single-dose contrast), as subarachnoid haemorrhage in three, and as multiple intracranial haemorrhages in the remaining patients (one with single-dose contrast). Cerebrospinal fluid (CSF) analysis was done in six patients, and showed erythrocytes and bilirubin in one. CSF pressure was high in the only patient for whom it was measured.

Interpretation

The best initial investigation in patients with thunderclap headache is emergency computed tomography. If no abnormality is detected, lumbar puncture should be done after at least 12 h (to detect or exclude subarachnoid haemorrhage). CSF pressure should be measured. If the CSF pressure is high or if a headache of unknown origin persists, the diagnosis of CVST should be considered.

Introduction

The characteristics of thunderclap headache are abrupt onset and very severe pain. In patients with thunderclap headache subarachnoid haemorrhage is a possible diagnosis. Other causes include migraine, dissection of a carotid or vertebral artery, or benign thunderclap headache. Cerebral venous sinus thrombosis (CVST) is generally not considered in these cases.1, 2 We report ten patients with proven CVST, who presented with acute severe headache mimicking subarachnoid haemorrhage.

Section snippets

Patients and methods

We collected medical histories of 71 patients who had CVST between 1992 and 1996. 48 of these patients took part in the Dutch-European Cerebral Sinus Thrombosis randomised trial of low-molecular-weight heparin for 3 weeks compared with placebo. In all patients CVST was confirmed by conventional angiography or magnetic resonance imaging plus magnetic resonance angiography. Ten patients presented with acute severe headache. This headache developed within seconds, and was the first or worst

Case reports

Patient 5, a 37-year-old woman (table), had a right-sided headache, radiating to the neck, for several weeks. On the day before admission she felt a left-sided headache after a cough (cough headache). The next day she experienced a sudden “snap” in the head and at the same time a very severe headache. She was transferred to a neurosurgical department with a diagnosis of subarachnoid haemorrhage. On examination she was conscious and fully oriented. General and neurological examinations found no

Discussion

Thunderclap headache raises the suspicion of subarachnoid haemorrhage caused by a ruptured aneurysm or by a benign perimesencephalic haemorrhage. If such haemorrhage is excluded by a normal computed tomography scan and normal CSF examination, the most likely diagnosis is benign thunderclap headache if the patient remains neurologically normal.3 In our patients with thunderclap headache, CVST caused headache and clinical signs and symptoms that were clinically indistinguishable from subarachnoid

References (10)

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