Cerebral Venous Thrombosis

Given the variable and often nonspecific clinical presentations of these cases, unenhanced CT typically is the first imaging study ordered. According to the literature, noncontrast CT is not sensitive (25%-56%) in detecting CVT, and findings are normal in up to 26% of patients, rarely providing a specific diagnosis. ¹¹ Furthermore, visualization on MRI can be difficult during the acute phase of CVT, as the thrombus initially appears isointense on T1-weighted images and gradually becomes hyperintense over the course of the disease process. ¹² These difficulties with the usual first-choice imaging examinations often result in a delay in diagnosing CVT. However, several points on close examination of these imaging studies may help physicians establish a high index of clinical suspicion and order the appropriate follow-up studies for CVT.

The authors report the case of a patient who presented with a 1-week history of confusion, headaches, and dizziness. His nonspecific presentation along with the absence of obvious signs of CVT on imaging prolonged his diagnosis and the initiation of an appropriate treatment plan.

Case Report

A 57-year-old white air-conditioning mechanic presented to the emergency department (ED) with a 1-week history of gradual-onset confusion, severe headaches, dizziness, light-headedness, poor memory, and increased sleep. Two days earlier, he presented with similar symptoms to an outside facility, where he was admitted and underwent a workup for stroke, hemorrhage, and cardiac abnormalities—including noncontrast CT of the head. With nothing of clinical significance found, the patient was discharged and was advised to follow up on an outpatient basis.

Persisting symptoms brought the patient to the ED 1 day later, and he was admitted. He described severe, progressive, generalized headaches that were more severe when he was lying down at night and waking in the morning. He did not report that the headaches worsened with coughing or straining, and he reported no history of trauma, neck stiffness, vision change, seizures, and migraines. His medical history was significant for hypertension, dyslipidemia, and in 2011, an unprovoked deep vein thrombosis (DVT) in the right leg. He reported no history of tobacco, alcohol, or illicit drug use. He had served in the U.S. Navy, working in electronics, intelligence, data systems, and satellite communications.

On initial physical examination, the patient was afebrile and lethargic, and his blood pressure was mildly elevated (144/83 mm Hg). Cardiopulmonary examination was normal. Neurologic examination revealed no severe focal deficits, and cranial nerves II to XII were intact. Funduscopic examination was normal, with no papilledema noted. Motor strength was 5/5 bilaterally in the deltoids, biceps, triceps, radial and ulnar wrist extensors, iliopsoas, quadriceps, hamstrings, tibialis anterior and posterior, fibulares, and gastrocnemius. Pinprick sensation and light-touch sensation were decreased within the lateral bicipital region of the left upper extremity. Pinprick sensation was intact bilaterally in 1-inch increments at all other distributions along the medial and lateral aspects of the upper and lower extremities. Muscle tone and bulk were normal in all extremities. Reflexes were 2+ bilaterally in the biceps, brachioradialis, triceps, quadriceps, and Achilles. The Babinski sign was absent bilaterally, the finger-tonose and heel-to-shin tests were normal, the Romberg sign was absent, and there was no evidence of pronator drift. Laboratory test results were normal except for slightly elevated hemoglobin (17.5 g/dL) and D-dimer (588 ng/mL) levels.