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CVT: Curious Vein Thrombosis. A unique presentation of cerebral vein thrombosis.
Abstract Number: F-58
Abstract Type: Case Report/Case Series
Background: Headaches are common during pregnancy and divided into two major categories: primary which are idiopathic; and secondary which result from underlying disease.1 Cerebral venous thrombosis (CVT), while rare in the general population with an incidence of ~1/100,0002, may be as common as 11.6/100,000 in pregnancy.3 Here we discuss a patient who presents with atypical headache eventually diagnosed as CVT.
Case: A 34 year old G1P0 woman at 38 weeks pregnancy presented with complaints of headache (HA). The headache’s intensity increased with valsalva and recumbency and BP was 118/63. The patient was discharged to home on oral analgesics. The headache persisted and she was seen by neurology 2 days later. The neurologist found a non-focal exam before performing blocks of the greater occipital, supraorbital, supratrochlear, and auricotemporal nerves. The neurologist also started prednisone and scheduled an MRI. The following day the patient presented to the labor floor with a worsening headache and BP was 118/70. The neurologist again found a non-focal exam, but the MRI revealed bilateral occluded internal jugular veins suspicious for thrombus and the development of collateral vessels. The extensive collateral network suggested chronic occlusion that likely predated the pregnancy. The headache was felt to be related to the increased intravascular volume during pregnancy that was not being drained properly from the brain. The decision was made to perform an urgent cesarean delivery (CD) with further workup after delivery. At the time of CD, a neurologist performed a diagnostic and therapeutic lumbar puncture in the lateral position, measured a normal opening pressure, and collected CSF for analysis, which proved normal. The spinal anesthetic for CD was delivered by the anesthesiologist via the neurologist’s large bore needle. The CD proceeded without complication, and the patient had an uneventful post-operative course with almost immediate headache relief. Subsequent MRIs demonstrated nearly complete resolution of her bilateral jugular occlusions over the next 3 months.
Discussion: The postpartum resolution of the jugular occlusion suggests that the patient had developed an acute onset of CVT due to the pregnancy. In hindsight, the collateral flow likely developed during the pregnancy and anticoagulation should have been initiated following the CD. This case demonstrates some prototypical aspects of CVT as well as CVT’s variability, the need for a high index of suspicion in pregnancy, and the benefits of a multi-disciplinary approach to headache.
1 Aegidius K, et al. Headache 2009; 49:851.
2 Coutinho JM, et al. Stroke 2012; 43:3375.
3 Lanska DJ, Kryscio RJ. Stroke 2000; 31:1274.