Cerebral Venous Thrombosis
Diagnosis and Management
A 42-year-old woman with a history of Crohn disease presented with left temporal headache for 1 week. On the day of presentation, she had transient word finding difficulty, lasting for 1 to 2 minutes and worsening headache. The patient reported starting prednisone 10 days earlier for a flare of Crohn's disease associated with dehydration. She had been using the Nuva ring (ethinyl estradiol vaginal ring) for birth control. Neurological examination was significant for moderate expressive aphasia. Emergent computed tomography (CT) head revealed a hyperdense focus with surrounding hypodensity in the left temporoparietal lobe. Subsequent MRI of the brain revealed a venous infarct in the anterior left temporal lobe with surrounding edema and areas of hemorrhagic transformation. Magnetic resonance venography (MRV) showed left transverse and sigmoid thrombosis. Hypercoagulable studies were sent including Protein C & S, factor V leiden, prothrombin G20210A gene mutation, lupus anticoagulant, anticardiolipin antibody, homocysteine, and antithrombin III. Systemic anticoagulation (unfractionated heparin drip) was started immediately. Prednisone was continued for Crohn disease. For the next 2 days, her aphasia improved. At the time of discharge, she was transitioned to warfarin with low molecular weight (LMW) heparin bridge. After 1 month, the aphasia and headache completely resolved. Hypercoagulable workup revealed that she was heterozygous for prothrombin G20210A gene mutation, whereas other laboratory tests were unremarkable. Repeat MRV at 3 months showed partial recanalization of the left transverse sinus.
Cerebral venous and dural sinuses thrombosis (CVT) is an uncommon and frequently unrecognized, representing ≈0.5% to 1% of all strokes.1 CVT is potentially serious and life threatening.
Symptoms in CVT are usually secondary to increased intracranial pressure or focal brain injury from venous infarction or hemorrhage. Headache is often localized and is the most frequent and usually the first symptom. Isolated headache without focal neurological findings or papilledema occurs in …