An Atypical Presentation of Cerebral Venous Sinus Thrombosis In a 19-Year-Old Woman

Introduction. A 19-year-old woman presented to the hospital after she was discovered to be unresponsive by her family.

History. The patient had a medical history of anxiety, depression, untreated pediculosis capitis of 1-year duration, and bulimia-purge-type disorder. Her psychiatric history included anxiety episodes of dermatillomania and stereotypic movement disorders, such as head-banging. She was last evaluated by a medical professional a year prior but was lost to follow-up and not receiving any treatments for her conditions. She had previously been in normal health except for a few days of increased anxiety and episodes of head-banging. The patient’s family denied any associated recent traumatic event. There was no history of substance abuse or tobacco use. There was also no history of hypercoagulable disorders, brain aneurysms, or autoimmune conditions in her or her family. 

Upon arrival to the hospital, the patient exhibited generalized seizure-like activity consistent with status epilepticus. Physical examination revealed no visible signs of trauma. Her Glasgow Coma Scale score was 6, with 1 point scored for best verbal response, 1 for best eye response, and 4 for best motor response. Musculoskeletal examination was within normal limits for muscle tone in bilateral upper and lower extremities. Deep tendon reflexes were intact and adequately evoked at the biceps and knees bilaterally. All other aspects of her physical examination were unremarkable, including cardiopulmonary and abdominal examination.

She was intubated for airway protection due to persistent loss of consciousness and concern for inability to protect her airway. Antiepileptic medications and subsequent antiseizure prophylactic medications were administered.

Diagnostic testing. Laboratory workup was remarkable for severe microcytic anemia with a hemoglobin level of 4.8 g/dL. The patient required multiple blood transfusions to increase her hemoglobin level above 7 g/dL. A pelvic ultrasound revealed an endometrium that measured 12.3 mm in thickness. The findings correlated the anemia to her menstrual cycle. A urine toxicology screening was negative.

An initial computerized tomography (CT) scan of her brain without contrast showed a combination of subarachnoid hemorrhage as well as bilateral cortical petechial hemorrhages (Figure 1).  After approximately 5 hours, a magnetic resonance venography (MRV) was performed due to high clinical suspicion and the patient’s age. The MRV showed a filling defect within the anterior portion of her superior sagittal sinus, indicating a thrombus (Figure 2).  The MRV findings led to an ultimate diagnosis of cerebral venous sinus thrombosis (CVST) and an angiogram was ordered.

Figure 1. Brain CT without contrast shows the area of subarachnoid blood (arrow) and an area of noticeable cortical and white matter edema (bracket).