A Diabetic Patient with Headache and Puffy Eyes

Rob Orman, MD and Mizuho Morrison, DO

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The summary below is from an episode of ERcast: Clinical Perspectives

Cerebral venous thrombosis is an uncommon stroke mimic that often presents as persistent headache, vomiting, or papilledema rather than a focal deficit. Acute pericarditis and myopericarditis commonly raise high-sensitivity troponin, but echo remains the key test for immediate risk assessment and disposition.

Cerebral venous thrombosis clues

High-risk headache pattern: CVT should stay on the list when a young patient has a 5-day global headache with persistent vomiting and a miserable appearance, even with normal vitals and no classic focal deficit.
Thrombosis risk factors: Estrogen exposure, diabetes-related comorbidity, and possible autoimmune disease created a hypercoagulable frame that mattered more than the initially bland neurologic exam. We walk through that gestalt in the episode.
Periorbital edema clue: Bilateral periorbital puffiness without dependent edema or proteinuria was an atypical finding that signaled this was not a routine migraine, DKA, or simple viral syndrome.
Imaging pitfall recognition: Initial CT and MRI language pointed toward possible otomastoiditis, but the neuroradiology overread revealed extensive thrombi in the superior sagittal sinus, right sigmoid sinus, and right internal jugular vein.
Best confirmatory imaging: CT venography has about 95% sensitivity and specificity and is a reliable alternative to MRV for suspected CVT, while MRV may perform better when deep venous involvement is a concern.

Pericarditis troponin and echo

Troponin elevation context: High-sensitivity troponin is often elevated in pericarditis and myopericarditis, so a positive result does not by itself mean an occlusion MI pattern or a poor cardiac prognosis.
Older assay literature: Older studies found troponin elevation in roughly 38% to 49% of acute pericarditis cases, and modern high-sensitivity assays likely push that proportion even higher.
Echo as key modality: Echocardiography is the most useful immediate test in suspected myopericarditis or pericarditis because it helps separate reassuring presentations from patients who need admission.
Generally favorable prognosis: Myopericarditis is usually a good-prognosis disease; in one cohort of 486 patients, more than 90% had a normal ejection fraction and there were no deaths at 36 months.
Borderline disposition nuance: A mildly elevated high-sensitivity troponin with a normal echo does not automatically mandate admission if cardiology agrees and follow-up is solid. We get into the discharge nuance in the episode.

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References:

1.) Imazio M, et al. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003 Dec 17;42(12):2144-8. PMID: 14680742.

2.) Bonnefoy E, et al. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000 May;21(10):832-6.PMID: 10781355.

3.) Long B, ert al. An emergency medicine approach to troponin elevation due to causes other than occlusion myocardial infarction. Am J Emerg Med. 2020 May;38(5):998-1006. PMID: 31864875.

4.) Imazio M, et al. Good prognosis for pericarditis with and without myocardial involvement: results from a multicenter, prospective cohort study. Circulation. 2013 Jul 2;128(1):42-9. PMID: 23709669.

5.) Chiabrando JG, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Jan 7;75(1):76-92. PMID: 31918837

6.) Kociol RD, et al; American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology. Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association. Circulation. 2020 Feb 11;141(6):e69-e92.PMID: 31902242.

Faculty

Rob Orman, MD
Dr. Rob Orman is an emergency physician, educator, and executive coach specializing in physician performance and professional fulfillment. After more than 20 years in community emergency medicine, he now works with clinicians across specialties to address burnout, inefficiency, and career challenges. He earned his medical degree from Emory University School of Medicine and completed his residency at Denver Health Medical Center, where he served as chief resident. Dr. Orman is the founder of the Stimulus podcast and Orman Physician Coaching. He previously served as chief editor of ERcast and hosted Essentials of Emergency Medicine for nearly a decade.
Mizuho Morrison, DO
Dr. Mizuho Morrison is a board-certified Emergency Medicine physician practicing in Southern California. She played a leadership role in FeminEM, helping develop and support its speaker coaching program, and occasionally contributes to Rebel EM. Additionally, Mizuho is an entrepreneur, co-founding 3MD| Three Mommy Doctors, a medical device company that redesigned first-aid kits for children. She lives in Orange County, CA, with her two children.