Brain Clot Score – Cerebral Venous Thrombosis Rule

Written by Clay Smith

Spoon Feed
A new scoring system was developed for cerebral venous thrombosis (CVT). It is not ready for implementation until externally validated, but it was encouraging that none with a score of 0-2 and D-dimer <500 had CVT.

Why does this matter?
Dural venous sinus thrombosis or CVT is a difficult diagnosis to make. It may result after trauma or may be spontaneous. It is in the differential diagnosis of thunderclap headache but may have more gradual onset as well. It is just tricky. Imaging with CTV or MRV can get the diagnosis, but you have to think of it to diagnose it.

Brain clot score
This was a prospective study to determine a workable scoring system to diagnose CVT and to see what D-dimer threshold would be best from a lab standpoint. The prevalence of disease was 25.8% (94/359). Using multiple logistic regression, they made the following scoring system, 0-14 points (or 0-17 points if D-dimer was added):

  • seizure(s) at presentation (4 points)

  • known thrombophilia (4 points)

  • oral contraception (2 points)

  • duration of symptoms >6 days (2 points)

  • worst headache ever (1 point)

  • focal neurological deficit at presentation (1 point).

  • *alternately may consider D-dimer ≥500 (3 points)

No patient with CVT had a D-dimer <500 microgram/L. PPV was 100% with a score 9-17 (when a D-dimer ≥500 was worth 3 points). No patient with a score of 0-2 and D-dimer <500 had CVT. This score needs external validation before we rely on it. But look at those score components; those are the items we need to be assessing in our headache patients. I need to think about OCPs and thrombophilia. This helps me weigh whether I should order a CTV or MRV, even if I may not rely on the actual score yet in practice. I think it is helpful as an objective way to guide imaging choices.

Source
Prediction of Cerebral Venous Thrombosis with a new clinical score and D-dimer levels. Neurology. 2020 Jun 23:10.1212/WNL.0000000000009998. doi: 10.1212/WNL.0000000000009998. Online ahead of print.

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