An Unusual Cause of a Common Complaint: Extensive Dural Venous Thrombosis Presenting as a Headache

Case Presentation:

Dural venous thrombosis or cerebral vein thrombosis (CVT) is a rare but potentially fatal condition that can present as a severe headache and can be challenging to diagnose. A 46‐year‐old nonsmoking white female with no significant past medical history except menorrhagia and migraines as a teenager, was admitted with a progressively worsening headache of 1 week's duration. The headache was 10/10 on a pain scale, Ihrobbing, nonradiating, constant, located in the occipital region bilaterally, and associated with nausea and vomiting. Examination revealed a well developed female, fully alert and oriented, in a moderate amount of pain. The HEENT exam was normal except for mild tenderness in the occipital region. No papilledema or other ophthalmologic abnormalities were found. Patient did not have neck stiffness but did have slight pain with flexion. Neurologic exam was unremarkable including cranial nerves. Her vital signs were within normal limits and she was afebrile. The remainder of her physical exam was benign.

Discussion:

Given the duration and severity of her headache, a CT head was performed that showed hyper‐attenuation in the region of the straight sinus and medial left transverse sinus, suspicious for dural venous thrombosis. A CTA showed no contrast opacification within the straight sinus or left transverse sinus, whereas an MRV showed extensive venous thrombosis involving the vein of Galen, straight sinus, and left transverse sinus with reconstitution of Ihe left sigmoid sinus. The patient was started on a heparin drip, along with medications for nausea and vomiting, IV fluids, and morphine. Her condition improved throughout the hospitalization, and she was discharged on hospital day 4 on enoxaparin with a bridge to warfarin. Despite a thorough workup for hypercoagulable states, no cause of the dural vein thrombosis was identified.

Conclusions:

This case illustrates a rare cause of headache, but it stresses the importance of neuroimaging in a patient with a severe headache. Although dural venous thrombosis is relatively uncommon, it can be fatal, with a mortality of approximately 8.0%: therefore, diagnosis with imaging is required to direct appropriate treatment. Identifying risk factors — prothrombotic conditions, OCps, pregnancy and the puerperium, malignancy, infection, head injury, anc mechanical precipitants — is important, although no cause is found in approximately 13% of adult cases.

Author Disclosure:

C. Carringer, none.