Case Presentation: A 26-year-old female with PMH migraines presented to the ED with a 3-day history of headaches unlike her migraine headache. The headache was located in the occipital region, pressure-like, not alleviated by acetaminophen, and was associated with blurred vision, left ear throbbing, and neck pain. She also reported recent head trauma. She denied nausea, vomiting, neck rigidity, muscle weakness, speech difficulty, use of OCP/hormonal medications, pregnancy, or family history of hypercoagulability/clotting disorders. On physical examination, her BMI was 51.49 and she was hypertensive (BP 162/88); all other vital signs were within normal limits. She had photophobia, bilateral painful eye movements, visual field deficits, and bilateral mastoid tenderness; she had no focal neurological deficits in the upper or lower extremities. A CT head revealed an acute left cerebral sinus thrombosis and a subsequent CTA head and neck demonstrated a left transverse sinus thrombosis with no bleed. A brain MRI showed stable thrombosis of the left transverse and sigmoid sinuses and superior left internal jugular vein and a MRV brain showed filling defect in the torcula, left transverse sinus, left sigmoid sinus, and left internal jugular vein. She was started on intravenous heparin and was transferred to a tertiary care center. There, her headache persisted but visual deficits resolved and the decision was made for conservative management. The rest of her hospital course was uneventful; she was discharged home on apixaban and with outpatient follow-up.

Discussion: Central venous thrombosis is a rare form of stroke with an incidence of 0.5 to 1% of all strokes[1 ]. It occurs more frequently in women and in the younger population[2l]. Risk factors for CVT include hypercoagulable states, obesity, malignancy, pregnancy, OCPs, head trauma, hormonal treatments, and substance abuse[3,4,5 ]. Symptoms are varied; most present with a headache while others may have focal neurological deficits or evidence of increased intracranial pressure[5,6]. Treatment options include anticoagulation and/or mechanical thrombectomy[7 ]. Even though advances have been made in the detection of cerebral venous thrombosis further research is needed to compare the different interventions 7]. This case highlights the importance of identifying red flag symptoms of headache and initiating early treatment.

Conclusions: Headaches are a common symptom and this case illustrates the need to consider CVT in patients who present with headaches and associated risk factors such as obesity and head trauma.

IMAGE 1: Fig 1. CTA without IV contrast showing focal high density in left transverse and sigmoid sinus extending to a small portion to the posterior inferior aspect of the sagittal sinus

IMAGE 2: Fig 2. MRV showing filling defect in the torcula, left transverse sinus, Left sigmoid sinus and left internal jugular vein.