Case Presentation:

45–year–old previously healthy male presented to the ED with progressively worsening headache of 5 days associated with dizziness and a questionable seizure activity per family members. There were no fever, motor, sensory or visual disturbances. Patient also denied any trauma or previous surgeries. Patient admitted usage of tobacco and alcohol regularly but denied any illegal drug usage. Patient’s initial clinical exam including a neurological exam was normal except for mildly elevated blood pressure of 150/105.Initial lab work including CT of the head were normal except for an elevated D–dimer. Patient was admitted to ICU under non–tPA protocol. Patient also had an MRI and MRA of the head done which was read as cortical edema and leptomeningeal enhancement in the left parietal lobe with possibilities of meningitis, encephalitis or a glioma. Patient was empirically started on antibiotics per neurology recommendation. Neurosurgery consult and review of MRI ruled out any possibility of intracranial tumor or bleed. Repeated attempts to do LP were unsuccessful. CT of the chest revealed a right side pulmonary embolism and patient was subsequently started on lovenox and Coumadin. Other investigations including LE Doppler, carotid Doppler and 2D ECHO were negative. Patient had a repeat MRI and MRV on day 4 of admission which showed sinus thrombosis in the left sigmoid and transverse sinus and abnormal signal in the left posterior parietal region consistent with venous infarction. Hypercoagulable panel returned showing a protein C deficiency. HIV was reported as reactive. Patient was discharged home on day 11 with a therapeutic INR in a stable condition with a plan to continue on Coumadin and follow up with hematology and ID as outpatient.

Discussion:

Cerebral Venous Sinus Thrombosis (CVST) is a rare and potentially life–threatening condition, accounting for about 0.5% of stroke cases and with estimated 3–4 cases per million annual incidences in adults. Early diagnosis requires a high degree of suspicion and prompt magnetic resonance venography (MRV) in conjunction with conventional MRI to confirm the diagnosis. These shown decrease early and late complication. A few years ago the first adequately large scale study on the natural history and long–term prognosis of this condition was reported; this showed that at 16 months follow–up 57.1% of patients had full recovery, 29.5%/2.9%/2.2% had respectively minor/moderate/severe symptoms or impairments, and 8.3% had died more likely in those aged over 37 years.

Conclusions:

Cerebral venous sinus thrombosis is a condition that can be mimicked by several other neurological entities. The difficulty in diagnosing it makes it a formidable challenge. Prompt diagnosis and anticoagulation definitely affect’s patient’s outcome as it is well illustrated in our case.