Cerebral Venous Thrombosis (CVT): A case report

Rengaraj. G

Physician Assistant, Kauvery Hospital, Cantonment, Trichy

Abstract

Cerebral venous thrombosis (CVT) is a relatively rare neurological disorder that may result in significant morbidity if not diagnosed and managed promptly. The clinical presentation of CVT is nonspecific and highly variable with acute, subacute, or chronic onset. It most often presents as a headache but may present with focal neurological symptoms, symptoms of intracranial hypertension, or encephalopathy. The predisposing factors for CVT are mainly acquired and genetic hypercoagulable conditions. However, the epidemiology, predisposing factors, and clinical presentation of CVT are not clearly established given the rare nature of the condition. We present a case of a young patient who did not have any classic underlying etiology for CVT or any prior diagnosis of venous thrombosis. We want to report this to show that a high index of suspicion should be maintained regardless of the absence of risk factors.

Background

Cerebral venous thrombosis (CVT) is defined as a thrombus of the cerebral veins and/or cavernous sinuses. The incidence is 0.22-1.32/100,000/year accounting for 0.5% of all strokes. Since CVT is a rare clinical entity, it can be a challenge to diagnose.

Case Presentation

A 35 year- gentleman, working as accountant clerk in railways, with history of alcohol abuse since long and hypertension not on regular medication, presented with progressive headache and vomiting episodes of 1 week duration.

CT brain done outside had indicated S/O superior sagittal sinus and right transverse sinus thrombosis. He was referred here for further management.

History of Present Illness: No history of seizure, weakness, LOC, trauma

History of travel around 10 hours every Friday and Saturday for 6 months.

Medication History: T. Dart (a combination of Caffeine, Paracetamol, and Propyphenazone) was taken for headache

Past Medical History: Systemic hypertension 1.5 years, not on regular medication

Social History: Occasional smoker

On Examination

On arrival at ER, his GCS was E4 V5 M6 with no focal neurological deficit. On evaluation here, MRI brain with MRV showed acute CVT in the right transverse, sigmoid and superior sagittal sinus. Blood investigation revealed polycythemia; hematologist consultation was sought and venesection was done.

Vital Signs

  • BP: 110/70 mmHg, HR: 86 b/min, RR: 22 b/min, T: 98.7°f, SPO2: 98% with room air
  • Systemic Examination;
  • CVS – S1 S2, RS: BAE, P/A: Soft
  • CNS – GCS E4 V5 M6, Power – Normal
  • Pupil – bilateral PERL (+), DEM (+)

Lab Investigation

  • Hb – 20.2 g/dl
  • PCV – 60.5 g/dl
  • TLC – 9900 cell/mm3
  • Platelet – 286000 cell/mm3
  • Creatinine – 1.53 mg/dl
  • USG Abdomen – Hepatic Hemangioma
  • Bilateral mild renal parenchymal changes.
  • Repeat Hb – 17.7 g/dl

CT brain, done outside (17/03/2024)

Impression

Hyperdense contents in posterior one third superior sagittal sinus and right transverse.

MRI Report

Impression

Acute CVT in right transverse, sigmoid and superior sagittal sinus

Management

  1. Investigations sent to rule out hypercoagulable states were normal.
  2. He was started on LMWH 60 mg SC twice a day,
  3. Anti-cerebral oedema , antihypertensive and other supportive.
  4. Nephrologist opinion sought for deranged RFT. USG abdomen showed hepatic haemangioma, bilateral mild renal parenchymal changes, managed with his advice.
  5. Surgical gastroenterologist advised nil surgical intervention for hepatic hemangioma.
  6. A repeat CBC done on day 4 and venesection repeated. We continued LMWH for 5 days, then started him on oral anticoagulation with dabigatran 110 mg twice a day during discharge.
  7. Patient was stable during his stay.

Follow-up and outcomes

Regular follow-up was conducted 6 months after discharge. Follow-up and outcomes data were collected through clinical outpatient visits with a standardized questionnaire. Residual symptoms, such as headache, residual visual impairment, current work status, were collected according to the proposed criteria. Brain and ophthalmological characteristics were assessed using radiological imaging modalities. MRS (Modified Rankin Score) at the 6-month after discharge was used as the primary endpoint of efficacy. A MRS score less than 2 was defined as a relatively favorable outcome, whereas a MRS great than 3 indicated a poor prognosis.

Conclusion

The patient presenting with increased ICT features, one of the causes to be ruled out in CVT. The recent pandemic, recent literature has focused on COVID-19 infection and/or its vaccine as possible etiologies for the development of CVT. Some have linked it to the development of thrombosis-thrombocytopenia syndrome following COVID-19 vaccination. Thrombosis-thrombocytopenia syndrome and CVT were reported as very rare adverse events in patients who received SARS-CoV-2 adenoviral vector vaccines. Further research did note that COVID-19 vaccines are safe for patients with a history of CVT.

 

Rengaraj. G
Physician Assistant