Diagnosing deep cerebral venous thrombosis

Abstract

Cerebral venous thrombosis (CVT) is a relatively rare vascular disorder involving the formation of a thrombus in the venous system of the cerebral vasculature. The nonspecificity of clinical symptoms seen with CVT elicits significant diagnostic challenges with the potential of serious morbidity and mortality associated with delays in therapeutic intervention. We present a case of CVT in a young patient who presented with loss of consciousness with no headache or focal deficits, the usual type of presentation.

Full text

Diagnosing deep cerebral venous thrombosis
Usaamah Mahmood Khan, BSc
a
, Crystal S. Janani, MD
b
, and Marian P. LaMonte, MD
b
a
Ross University School of Medicine, St. Agnes Hospital, Baltimore, Maryland;
b
Department of Neurology, St. Agnes Hospital, Baltimore, Maryland
ABSTRACT
Cerebral venous thrombosis (CVT) is a relatively rare vascular disorder involving the formation of a thrombus in the venous system of
the cerebral vasculature. The nonspecificity of clinical symptoms seen with CVT elicits significant diagnostic challenges with the
potential of serious morbidity and mortality associated with delays in therapeutic intervention. We present a case of CVT in a young
patient who presented with loss of consciousness with no headache or focal deficits, the usual type of presentation.
KEYWORDS Cerebral venous thrombosis; loss of consciousness; seizure; thrombus
Cerebral venous thrombosis (CVT) is an infrequent cere-
brovascular disorder caused by the formation of a blood
clot in the venous sinuses, accounting for »0.5% to
1%
1
of strokes. Although the presentation of CVT is
highly variable, headaches and focal neurological deficits are
the usual presenting features.
CASE DESCRIPTION
A 37-year-old woman was brought to the emergency room
after being found on the floor at home unresponsive with uri-
nary and fecal incontinence. In the emergency room, the
patient was encephalopathic and dyspneic. She was oriented
to month but not to year or location, was unable to correctly
state her age or recent holidays, and had decreased speed of
cognition with poor concentration. There were no focal cra-
nial nerve findings, motor weakness, sensory loss, or cerebellar
findings. Reflexes were 3C/4Cand symmetric. She denied
headache or any other neurologic complaints. Further investi-
gation revealed that she did visit the emergency room a week
earlier with complaints of headache and lethargy. At that visit,
the patient had refused further workup and left against medi-
cal advice with a presumptive diagnosis of dehydration. The
patient’s urine pregnancy test, head computed tomography
(CT) scan, and electroencephalogram were negative. Hemo-
globin was 7.4 g/dl, urinalysis was normal, cerebral spinal
fluid and opening pressure was not recorded. Her cerebrospi-
nal fluid had a glucose level of 64 mg/dL, leukocytes of
3 M/mL, and protein of 110 mg/dL. Magnetic resonance
imaging (MRI) demonstrated CVT involving the straight
sinus, vein of Galen, and the internal cerebral veins with sub-
sequent venous infarction of the basal ganglia, thalami, central
portion of the splenium, and scattered areas of white matter
(Figures 1a–1d). The extent of the thrombosis was clearly
evident on the MRI and therefore magnetic resonance venog-
raphy was not done. The patient was immediately started
on a continuous heparin infusion on day 2. A complete hyper-
coagulable panel was ordered to investigate any underlying
etiology, which also came back negative. On day 3 of admis-
sion, the patient reported occipital headaches for the first
time. The patient continued to improve on heparin infusion
and was discharged on day 7 with 6 months of anticoagulation
therapy.
DISCUSSION
CVT is a rare cerebrovascular disorder with an incidence of
about 5 per million and accounts for roughly 0.5%–1% of
strokes.
1
The incidence is greater in the younger population,
and roughly three-fourths of the cases occur in those under the
age of 50 years.
2
The occurrence of CVT is most common in
the third decade of life, with 75% of the cases being in
women.
3
Risk factors for CVT include hypercoagulable disor-
ders, pregnancy, oral contraceptive pills, malignancy, and dehy-
dration. The patient was not on any oral contraceptive pills.
Nearly 90% of patients present with symptoms of headache.
4
Of patients found to have CVT on imaging, only roughly 15%
are found to have involvement of the deep venous structures.
5
Seizures occur in almost 40% of patients with CVT. Such
patients therefore require antiepileptic drug treatment.
6
Our
patient’s loss of consciousness with urinary and fecal inconti-
nence supports the possibility of a seizure that may have been
triggered by CVT. Timely diagnosis of CVT remains challeng-
ing due to its diverse presentations. Our case highlights an atyp-
ical presentation of CVT in a patient with few risk factors and
demonstrates the importance of considering this diagnosis in
Corresponding author: Usaamah Khan, Ross University School of Medicine, St. Agnes Hospital, 4614 Pen Lucy Road, Baltimore, MD 21229
(e_-mail: Usaamah.khan@gmail.com)
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ubmc.
January 2018 59
PROC (BAYL UNIV MED CENT)
2018;31(1):59–60
Copyright © 2018 Baylor University Medical Center
https://doi.org/10.1080/08998280.2017.1391611

young encephalopathic patients. The case further demonstrates
the inevitable limitations of imaging modalities.
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Figure 1. (a) MRI sagittal view with evidence of thrombosis in straight sinus, vein of Galen, and possibly the internal cerebral veins. (b) MRI axial view with evidence
of venous infarction of the basal ganglia, thalami, central portion of the splenium, and scattered areas of white matter. (c) Sagittal CT view with hyperdensity in the
internal cerebral vein. (d) Coronal CT comparison of the normal superior sagittal sinus (upper arrow) and the hyperdense thrombosed straight sinus (lower arrow).
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