A 20–year–old man with no past medical history was brought to the hospital with complaints of two witnessed episodes of generalized tonic–clonic seizures. He also complained of headaches which were diffuse, but denied any trauma, fever or chills. He had no prior history of seizures as a child and was not taking any medications. He drank alcohol occasionally smoked cigarettes and marijuana. His vitals were stable and exam was completely unremarkable. His laboratory workup including a urine drug screen was unremarkable. Imaging of brain including a CT scan and an MRI showed a focal right frontal lobe hypodensity. An electroencephalogram was normal with no seizure like activity. He was started on phenytoin and discharged home to be followed as an outpatient. Two weeks later he returned back with complaints of sudden onset headache and pain in his posterior neck associated with episodes of nausea and vomiting. He denied any trauma, fevers, change in vision, new seizure, weakness or any paresthesias. His vitals were within normal limits and exam showed an increased resistance to passive flexion of the neck. Kernig’s and Brudzinski’s signs could not be elicited. His fundoscopic exam was normal and had no focal neuro–deficits. A CT scan of the head was repeated which showed interval resolution of the lesion in the right frontal lobe. Lumbar puncture was done which showed an opening pressure of 30 cm of water and normal glucose, protein and 2 white blood cells predominantly lymphocytic. His MRI from previous admission was carefully reviewed which showed slow blood flow within the superior sagittal sinus. He underwent MRI and magnetic resonance venography which showed thrombosis in the superior and inferior sagittal dural venous sinuses. A hypercoagulable work up was initiated which was unremarkable. He was started on intravenous heparin as a bridge to warfarin and discharged home. He was seen in the clinic and is currently doing fine. His headache is better and did not report any new seizures.
Thrombosis of cerebral veins and sinuses most commonly affect young adults and children and is more common in women. The estimated annual incidence is 3–4 cases per million. A hypercoagulable state or a direct cause is found in majority of people affected. Headache is the most frequent symptom, can occur gradually or start in a split second mimicking subarachnoid hemorrhage. Other symptoms include seizures, hemiparesis, aphasia, delirium or coma. Though the presentation is very variable, the diagnosis must be suspected in all young adults presenting with unusual new onset headaches, seizures or stroke like symptoms. Magnetic resonance venogram is the test of choice to make the diagnosis. Treatment revolves around reduction of raised intracranial tension and anticoagulation.
Cerebral venous sinus thrombosis is a diagnostic challenge and needs a very high index of suspicion. It can be fatal if not treated in a timely manner.