Cerebral venous sinus thrombosis: a diagnosis not to be missed

Abstract

A 47-year-old woman was admitted with a severe headache of 5 days' duration, vomiting and collapse with transient loss of consciousness in December 2002. She had been taking black cohosh, a herbal preparation containing plant oestrogen for menopausal symptoms, for 2 years. Her father had a history of pulmonary embolism and her sister had systemic lupus erythematosus. Clinical examination was normal except for slight neck stiffness and photophobia. Brain computed tomography was normal and lumbar puncture revealed normal CSF; CSF pressure was not recorded. Her symptoms improved slowly and she was discharged home with an appointment with the neurologist arranged as an outpatient. Five days post-discharge from the hospital, she was readmitted because of the persisting headache and was found to have papilloedema on neurological examination. Chest X-ray, full blood count, erythrocyte sedimentation rate, clotting screen, urea and electrolytes, liver function tests, serum glucose, immunoglobulins, complement and autoantibody screening were normal or negative. Magnetic resonance imaging and venogram showed deep venous thrombosis in the superior sagittal sinus (Figure 1). She was anticoagulated with heparin followed by warfarin. Her headaches settled and she was discharged home 8 days later. Further investigations confirmed heterozygosity for the prothrombin gene variant (G20210A). She continued to describe ‘pressure headaches’ with tinnitus. Repeat brain magnetic resonance imaging and venogram was normal in 2004. Her headaches recurred and the diagnosis of secondary intracranial hypertension was made and acetazolamide and bendrofluazide were commenced. Further magnetic resonance imaging of the brain with venogram in September 2007 revealed a hypoplastic left transverse sinus and patent superior sagittal sinus. She was referred to the neurosurgeons and had a lumbo-thecal peritoneal shunt insertion in November 2007 with improvement in her symptoms, despite a small frontal subdural collection on brain computed tomography postoperatively, which had resolved on repeat magnetic resonance imaging in March 2008. She is regularly followed up in the neurology and ophthalmology clinics for residual bilateral papilloedema and left amblyopia and continues on ramipril, bendrofluazide and warfarin.

Coexistence of High Fibrinogen and Low High-density Lipoprotein Cholesterol Levels Predicts Recurrent Cerebral Venous Thrombosis

“…The mortality ranges 5.5–30%. [ 3 ] After a first CVT, there is an increased risk of further venous thromboembolic events (VTE),[ 4 ] and 2–13% of all patients suffer CVT recurrence. [ 1 5 ] CVT should be an important consideration because of its potential serious consequences and recurrence.…”