A 44-Year-Old Male With Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare condition that can result in severe neurological complications when left untreated. Disease pathology results from thrombus development within the superficial cortical veins or the dural sinuses. Thrombosis impedes cerebral drainage leading to venous congestion and consequent increase in cerebral pressure, parenchymal damage, and blood-brain barrier disruption. Headache is the most common presenting symptom; other symptoms include focal neurological signs, seizures, papilledema, and altered sensorium. Diagnosis is typically made with visualization of obstructed flow in the cerebral venous system using one of three imaging modalities: computed tomography-venography (CTV), magnetic resonance imaging with venography (MRV), and diagnostic cerebral angiography. First-line therapy for CVST is anticoagulation, and the prognosis is generally favorable with early detection and prompt treatment. In this case report, we discuss a singular case of a patient presenting with loss of consciousness who was found to have CVST and treated with anticoagulation therapy in the setting of an intraparenchymal hemorrhage.

In this case report, we discuss a male patient presenting with loss of consciousness and found incidentally to have CVST with underlying intraparenchymal hemorrhage treated with anticoagulation.

Case Presentation
We present a case of a 44-year-old gentleman with a history of hypertension and dyslipidemia. He was an on-duty correctional officer escorting an inmate to the county hospital when he collapsed in the computed tomography (CT) scanner room. The event, witnessed by staff, was described as abrupt seizure-like activity, resulting in code stroke initiation. The patient spontaneously returned to consciousness within 1-2 minutes, followed by a 15-20-minute period of disorientation. Neurological examination in the emergency room (ER) noted a Glasgow Coma Score (GCS) of 15, no focal neurological signs, and the patient demonstrating postictal confusion. Otherwise, additional neurological testing, including sensory, motor, and cranial nerve examinations, were unremarkable.
Admission blood work and electrocardiogram were unremarkable. As part of the stroke workup, a noncontrast CT scan of the head revealed two small left parietal foci of intraparenchymal hemorrhage without ventricular extension, midline shift, or abnormalities of the basal cisterns ( Figures 1A-1B). Additional imaging with a CT angiogram of the head and neck with contrast revealed a flow defect in the SSS, indicating sinus thrombosis (Figures 2A-2B). CT perfusion study showed abnormal perfusion within the left parietal lobe without a core infarct and a volume mismatch of 6 milliliters ( Figures 2C-2D).  The patient was admitted to the neuro-intensive care unit (Neuro-ICU) with heparin infusion for anticoagulation and phenytoin for seizure prophylaxis. The initial coagulopathy screen was unremarkable. Additionally, a confirmatory diagnostic cerebral angiogram, ordered to assess the extent of the disease burden, reconfirmed posterior SSS thrombosis with good venous return via multiple collaterals ( Figure 4).

FIGURE 4: Diagnostic Cerebral Angiogram
Diagnostic cerebral angiogram showing flow defect in the superior sagittal sinus.
A subsequent repeat non-contrast CT head was stable. After two days of treatment, the care team transitioned therapy from heparin infusion to oral anticoagulation, and the patient was discharged after a full week in the inpatient ICU with a planned follow-up in the Neurology clinic. At the time of discharge, the exact etiology of the CVST was unclear as the workup for hypercoagulable states was thus far unremarkable. A more comprehensive workup was planned for the outpatient setting outside of the acute period.

Discussion
Most patients with CVST present with headache as the primary and often sole presenting symptom [1][2][3][4][5][6][7]. Though the patient in our report eventually had a seizure, his primary initial symptom was a persistent, unremitting month-long headache for which he had not sought medical attention. Many cases of CVST remain unrecognized due to the variability and nonspecific nature of presenting symptoms such as headaches, which are a common complaint in numerous conditions such as migraine, meningitis, sinusitis, and hemorrhagic stroke, to name a few [3][4][5][6]. CVST may also present with focal neurological deficits or seizures, causing further variability and diagnostic challenges for providers [1][2][3][4][5][6][7].
Due to the nonspecific clinical presentation of CVST, a high index of suspicion is necessary for diagnosis and treatment. Diagnosis requires visualization of the obstructive lesion in the cerebral venous system using three non-invasive modalities: CT-V, MR-V, and diagnostic cerebral angiography [2][3][4][5]. MR-V is the most sensitive and has the advantage of showing masses, lesions, and intracranial hemorrhage, especially when paired with standard MRI, though MR-V alone is prone to motion artifact [3][4][5][6][7]. CT-V and diagnostic cerebral angiography are also noted to have high sensitivity, allowing for adequate diagnosis of CVST [3][4][5][6][7]. As part of the stroke workup, an emergent non-contrast CT head revealed two small foci of intraparenchymal hemorrhages. Additional workup with a CT angiogram of the head and neck first noted abnormal flow in the SSS, signifying the likely presence of sinus thrombosis. CT perfusion with wedge-shaped mismatch defect without any arterial lesion raised suspicion for a venous entity and further exploration with MR-V and diagnostic cerebral angiogram. Due to these findings, the parietal lobe hemorrhages were likely secondary to persistent sinus thrombosis.
Contraindications for the use of heparin include thrombocytopenia, a history of heparin-induced thrombocytopenia, and the presence of active, uncontrollable bleeding [11]. It is important to note that while it may seem counterintuitive to employ anticoagulation in a patient with demonstrated intracranial hemorrhage, heparin is the standard of care in CVST treatment due to its demonstrated efficacy and safety. The randomized control trials and retrospective studies by Einhäupl et al. found that heparin did not cause or worsen IPH when treating CVST and decreased mortality in patients with or without concomitant IPH. As such, Einhäupl et al. reported that the presence of IPH is not a contraindication to heparin use when treating CVST [10]. Heparin is, therefore, the standard of care, even with concurrent IPH [1,2,[4][5][6][7]10].

Conclusions
This case report presents a patient with prolonged unremitting headaches and seizures secondary to CVST. The patient's hospital course highlights the various imaging modalities employed to diagnose his venous sinus thrombosis and anticoagulation therapy. Although heparin can complicate hemorrhage, it is the established first-line treatment. Due to the rarity and nonspecific presentation of venous sinus thrombosis, a high index of suspicion is necessary to include it in differential diagnoses for patients with headaches in the right clinical setting to ensure prompt management and a favorable outcome.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board Chair, Michael Neeki issued approval 23-07. Please be advised that the Institutional Review Board acknowledged receipt of the Case Study request. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.