Presented by
Clara Raquel Epstein, M.D., Cerebrovascular Fellow
Presentation
A 41-year-old right-handed female was transferred to The Mount Sinai
Medical Center from Long Island for evaluation of sagittal sinus
thrombosis and papilledema. One week prior to admission the patient
was diagnosed with bronchitis and sinusitis and was given Levaquin
for four days. The patient reported that on Sunday, prior to admission
she developed a severe occipital headache associated with nausea
and vomiting. She went to the emergency department and was administered
toradol (IM) with significant relief and was sent home with a
diagnosis of migraine headaches. The next day the headaches worsened,
and she progressively developed difficulty writing and difficulty
moving her right upper and lower extremities.
Her past medical history was non contributory. She was not taking
oral contraceptive agents.
Diagnostic Procedures
Hospital Course
The patient was transferred to The Mount Sinai Medical Center and
admitted to the Neuroscience Intensive Care Unit. She was found
to have bilateral papilledema, and right upper extremity pronator
drift. She had obvious impairment of handwriting but was otherwise
neurologically intact.
The patient was started on heparin and Diamox, and on hospital
day 3 was switched to coumadin. The heparin was continued until
the INR was within a therapeutic range. Her headaches, and visual
disturbance, and weakness all improved and she was dishcarged on
hospital day 7.
The patient will continue coumadin for a duration of one year with repeat studies
to be performed in six months.
Discussion
Superior sagittal sinus thrombosis is often accompanied or precipitated by thrombosis of the transverse sinus.
Propagation of infection from the petrous bone to cause thrombophlebitis
of the sigmoid and transverse sinuses can be a cause of increased
intracranial pressure ("otitic hydrocephalus") that
used to be seen in children prior to the widespread use of antibiotics.
This etiology of dural sinus thrombosis is still observed in cases
of chronic otitis media.
The etiology was not clear in this patient. The majority of patients
respond to systemic anticiagulation. Rarely intraluminal thrombolysis
using interventional neuroradiology techniques are required. This
patient responded well to anticoagulation.
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