A 34-year-old female presents with diffuse progressively worsening headache for the past 3 days associated with nausea and vision changes. She is otherwise healthy and only takes OCPs. She denies fever, neck stiffness, or head trauma. She appears uncomfortable but is otherwise awake and alert with normal vital signs. However, her neuro exam is significant for CN VI palsy. What is the best imaging study to obtain in the ED at this time?

A. CTA neck

B. CTA head

C. MRI brain with DWI 

D. CT venogram 

D.CT venogram. This young female on OCPs has a history and exam concerning for cerebral venous sinus thrombosis. This disease is rare and can be a diagnostic challenge if it is not on your differential. The most common chief complaint for CVST is headache, and it is more common in younger women who are on estrogen contraceptives, pregnant, or postpartum. CTV is highly sensitive for CVST and fast to obtain therefore it is the correct study choice in the ED among the answer choices. MRV can also be helpful to diagnose CVST however it is more difficult to result quickly and may be less appropriate in the ED setting during initial evaluation and stabilization. Note that a non-contrast CT head is often normal in patients with CVST. In consultation with your neurosurgery colleagues, this patient will require anticoagulation, aggressive ICP management, and a hypercoagulability workup in the hospital.

Filippidis, Aristotelis & Kapsalaki, Eftychia & Patramani, Gianna & Fountas, Kostas. (2009). Cerebral venous sinus thrombosis: Review of the demographics, pathophysiology, current diagnosis, and treatment. Neurosurgical focus. 27. E3. 10.3171/2009.8.FOCUS09167. 

Take a look at this case from a prior EM Daily post: https://emdaily.cooperhealth.org/content/whats-diagnosis-dr-katie-selman-2