case of intracranial sinus thrombosis

ABSTRACT

A male patient, 26 years old, presented at internal medicine clinic at GMC hospital with severe headache, blurred vision and double vision. He was given medical treatment and was referred to a neurologist the next day. After re-evaluation he gave a past history of repeated gastroenteritis which he claimed as typhoid, and recurrent sinusitis with right side mastoiditis, with frequent oral aphthous ulcers. His father had recurrent lower limb DVT. General examination was normal, while the neurological examination showed injury of left sixth cranial nerve, and horizontal diplopia with convergent squint. Fundus examination showed papilledema. This clinical picture was suggestive of increased intracranial pressure. Urgent CT brain was done, which showed right transverse and superior sagital sinus thrombosis. The patient was hospitalized as a case of superior and transverse sinus thrombosis. MRI brain and MRV showed right mastoiditis, and thrombosis of right transverse sinus without secondary hydrocephalic changes. Laboratory investigations were normal apart from low antithrombin three with normal protein S and C. Collagen battery, was within normal range. Treatment was started immediately with low molecular weight heparin, oral anticoagulant and antiplatelets. The patient subjectively showed improvement as regards clarity of vision, headache and diplopia. But his frequent fundus examination showed progression of papilledema and involvement of the right medial rectus muscle, which explained why dipolpia was less at this stage. Urgent follow up MRI brain and MRV showed stationary course of disease with failure of canalization of the sinuses, yet no hydrocephalic changes. The future plan involves increasing and adjusting the dose of anticoagulant and diuretics, and considering lumbar puncture for decreasing optic nerve compression. Diagnosis Antithrombin three dysfunction with sinus thrombosis