Address: 1Nottingham University Medical School, Queens Medical Centre, Nottingham, UK and 2Department of Neurosurgery, National Institute
of Neurological and Allied Sciences, Kathmandu, Nepal
Email: Rishi K Gupta - mzyyrkg@nottingham.ac.uk; Aimun AB Jamjoom* - aabjamjoom@googlemail.com;
Upendra P Devkota - devkotaup@neuro.org.np
* Corresponding author
Abstract
Cerebral venous sinus thrombosis is a rare but dangerous condition, occurring with an incidence
of 3-4 cases/million/year. Cerebral venous sinus thrombosis presents a diagnostic challenge due to
its varied presentation patterns. We report a case of a 42 year old Nepali man diagnosed with
cerebral venous sinus thrombosis after presenting with a week long history of continuous
headache. He improved rapidly following prompt anticoagulation. Despite thorough investigation
no discernable underlying cause could be found. Our report highlights the value of prompt
diagnosis of cerebral venous sinus thrombosis through neuroimaging and the importance of
immediate anticoagulation as part of patient management.
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Figure
MRV
superior
2 days
1saggital
post sinus
admission
(arrows)
demonstrating thrombosis of the
MRV 2 days post admission demonstrating thrombo- Figure
MRV
the superior
8 days
2 post
sagittal
diagnosis
sinus following
showing anticoagulation
improved perfusion
(arrows)
of
sis of the superior saggital sinus (arrows). MRV 8 days post diagnosis showing improved per-
fusion of the superior sagittal sinus following antico-
agulation (arrows).
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the following few days. Seizures occur in 40% of patients The prognosis of CVST is usually favourable but is worse
and act as a helpful differentiator between venous and in extremes of age, those with underlying conditions such
arterial thromboses [5]. Raised intracranial pressure can as malignancy and sepsis, and in the presence of coma or
lead to visual disturbances and papilloedema on fundos- deep cortical venous thrombosis [4]. More than 80% of
copy [15]. patients, as in our case, have a good neurological outcome
[5].
Investigations are used in this condition in confirming the
diagnosis, and establishing any predisposing causes. Ini- Conclusion
tially, conventional CT scanning is usually performed to CVST is a challenging condition due to its wide range of
exclude other possible diagnoses such as subarachnoid clinical presentations. Clinicians should have a high index
haemorrhage. In 35% of published cases, CT scanning of suspicion, even in the absence of predisposing condi-
with contrast enhancement may demonstrate an 'empty tions, in order to facilitate a prompt diagnosis through
delta sign' which is a useful radiological sign for the diag- neuroimaging. Expedited standard management for the
nosis of superior sagittal sinus thrombosis [16]. Further- CVST should be employed to help ensure the best possible
more, the use of transcranial color-coded duplex outcome for patients.
sonography (TCCS) is becoming increasingly common as
a complement to other imaging techniques in the diagno- Abbreviations
sis of CVST [17]. Other initial investigations may include CSF: cerebrospinal fluid; CT: computed tomography;
lumbar puncture, which has been found to be abnormal CVST: cerebral venous sinus thrombosis; FDP: fibrinogen
in 84% of cases of CVST, and may also be helpful in ruling degradation product; GCS: Glasgow Coma Scale; MRV:
out other diagnoses. The CSF abnormalities noted in our magnetic resonance venography; TCCS: transcranial
patient (raised opening pressure) are well-recognized in color-coded duplex sonography.
CVST, along with increased protein content and pleocyto-
sis [18]. The preferred and most sensitive diagnostic inves- Competing interests
tigation is magnetic resonance venography (MRV) [19] The authors declare that they have no competing interests.
which allows the venous occlusion to be identified along
with any consequences such as cerebral oedema and areas Authors' contributions
of venous infarction, as was present in our patient's case. RKG helped gather information regarding the patient and
It has been suggested that CT venography detects CVST complete the manuscript. AABJ helped gather informa-
with equal accuracy and may be advantageous in allowing tion regarding the patient and complete the manuscript.
a prompt diagnosis immediately after the initial CT scan UPD supervised the case report and reviewed the final
[20]. If doubt remains following MRV, invasive cerebral manuscript. All authors read and approved the final man-
angiography may be performed. uscript.
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