Case Presentation:

A 27–year–old female with a h/o headaches presented to the ED with complaint of thunderclap headache that was the worst of her life. It was nine of 10 in severity and was located in bilateral frontal and occipital region. It was associated with photophobia, nausea and vomiting. Vital signs were normal and labs were significant for a mildly elevated white blood count. Lumbar puncture was unremarkable. CT showed an intensity at the area of the superior sagital sinus and therefore a follow up MR and MR venogram was ordered. Both revealed a significant, acute superior sagital sinus thrombosis. Patient was therefore place on anticoagulation with Coumadin with a heparin bridge. She improved with pain control and was discharged after 4 days. She remained on Coumadin for 3 months, and after repeat MR venogram showed resolution of the clot, anticoagulation was discontinued.

Discussion:

The dural sinuses are structures that drain the veins of the brain. They empty into the jugular vein which returns blood to the heart. In the past, thrombosis of the dural sinuses was only discovered post–mortem on autopsy. It was not until the advent of CT and MR that the disease could be diagnosed and treated. The most common site of thrombosis in the dural sinuses is the superior sagital sinus, as was seen in our patient. The disease can have a wide range of presentations, but headache is generally the initial presenting symptom. Other findings such as papilaedema, vision changes, dysphagia and seizures are commonly seen. Like any other site of venous thrombosis, patients in a hypercoagulable state are at risk for dural sinus thrombosis. Other causes include: local and regional infections such as, bacterial sinusitis and scalp cellulitis, bacteremia, intracranial malignancy, head trauma, puerperium state, severe dehydration of any cause, contraceptives and any medication that increases risk for VTE. In our patient, it was thought that the Nuva ring that and recent use of the Chinese weight loss supplement, which was recently taken off the market for risk of stroke, were the two likely inciting factors.

Conclusions:

Dural sinus thrombosis should be in the differential for a severe headache, especially if patient has risk factors for thromboembolism.