Case Presentation: A 63-year-old woman was initially admitted for sore throat and dysphagia. At that time, workup revealed right parapharyngeal cellulitis, and she completed a 10-day course of levofloxacin. One month after discharge, the patient presented with a bilateral frontotemporal headache, blurred vision OS, and right otalgia for 2 days. Physical exam was remarkable for decreased visual acuity OS and facial tenderness to palpation over both mastoids and frontal/maxillary sinuses. There were no focal neurological deficits. A stat noncontrast CT of the head was unremarkable. Lab tests were pertinent for leukocytosis and elevated ESR and CRP. A maxillofacial CT showed extensive mucosal thickening in the left frontal sinus extending into the left anterior ethmoid air cells. MRI of the brain, orbit, face, and neck showed a right middle ear and mastoid effusion, cellulitis with osteomyelitis at the right skull base, and occlusion of the right transverse and sigmoid dural venous sinuses concerning for thrombosis. MR venogram (MRV) confirmed her diagnosis of cerebral venous thrombosis (CVT), which was attributed to the acute sinusitis, and she was started on enoxaparin for anticoagulation. She developed intermittent fevers and did not improve despite broadening antibiotics to ceftaroline and metronidazole for better gram positive and anaerobic coverage. Infectious disease reviewed her history and imaging with ENT to expand the differential for CVT to include otitis media given her complaint of right otalgia. Her regimen was changed to vancomycin and cefepime to cover Pseudomonas and treat her otomastoiditis. Her symptoms improved and the leukocytosis resolved, confirming the exact etiology of her septic CVT to be from her right ear and not the ethmoid sinuses. She was discharged on oral dabigatran and a 6-week course of intravenous cefepime.

Discussion: Cerebral venous thrombosis is a rare cerebrovascular disorder that affects young adults, women of childbearing age, and children. Its clinical presentation is variable and depends on the sinuses and veins involved, the extent of brain parenchymal injury, chronicity, and the effect on intracranial pressure. In 30% of cases, initial CT of the head may be normal or show nonspecific abnormalities; thus, a normal scan does not rule out CVT [1]. MRI/MRV is the most preferred imaging modality for making the diagnosis of CVT. The mainstay of acute treatment is anticoagulation to promote clot resolution and prevent clot expansion, but patients who deteriorate despite therapy can be considered for endovascular thrombolysis or decompressive craniectomy. The incidence of CVT is 3-4 cases per 1 million in adults and up to 7 cases per 1 million among children [3]. In a 2016 study involving 160 patients with CVT [2], the most common thrombosis sites were the superior sagittal sinus (65%) and transverse sinus (60.5%). Our patient presented with nonspecific findings of headache, vision changes, and ear pain. Her hospitalization was complicated with CVT involving the right transverse and sagittal sinuses. Her thrombosis was initially presumed to be secondary to sinusitis given her facial pain and CT findings; however, it was later identified to be from otomastoiditis.

Conclusions: CVT should be suspected in patients with unusual headaches or stroke-like symptoms without typical vascular risk factors, intracranial hypertension, seizures, and altered mental status. Earlier recognition and prompt treatment of CVT can prevent residual neurological deficits and unfavorable outcomes.

IMAGE 1: Figure 1. MRI Brain, Orbit, Face, and Neck. (A) Right middle ear and mastoid effusion. (B) Mucosal thickening in the maxillary sinuses and a small amount of fluid.

IMAGE 2: Figure 2. Cerebral MR Venography showing occlusion of right transverse and sigmoid dural venous sinuses compatible with thrombosis.