CASE PRESENTATION
A 35year-old Filipino lady, who was previously healthy, presented to our hospital with five days history of severe occipital headache and dizziness. She described dizziness as vertigo. It was progressively worsening over the last two days. She complained of nausea, vomiting, and memory disturbance with difficulties in reading and naming objects. She reported no sensory or motor deficits. There was no trauma or fall. She started taking OCPs for three months. The patient has no personal or family history of coagulopathy. Physical examination revealed horizontal nystagmus in the right gaze with a fast component to the right side. She has mild dysmetria and ataxia. There is a problem with word-finding and dyslexia. The rest of the physical examination was unremarkable.
Laboratory investigations showed normal complete cell counts. Vasculitis screen, including antiphospholipid syndrome, was negative, and complement level was normal. Thrombophilia screen revealed normal protein C and S levels. Factor V Leiden mutation was absent, but she has high levels of factor VIII (243 % reference 70-150 % ) repeated factor VIII level within ten days from the first level was 231.7 %
Computed Tomography Image of the head with venogram suggestive of CSVT with hemorrhagic infarct and vasogenic edema in the left temporal-occipital and left vertebral occlusion with left PICA territory infarct (Figure 1).
Magnetic resonance image (MRI) and Magnetic resonance image with Venogram (MRV) were done 24 hours later. Both showed an acute PICA territory infarct involving the cerebellar vermis and left posterior-inferior cerebellar hemisphere with clots in the distal PICA branches. There was a stable left distal vertebral artery occlusion and stable left temporo-occipital venous hypertension, hemorrhage, and infarct. Echocardiogram was normal. (Figure 2)
The patient was initially admitted to the medical intensive care unit (MICU) for close observation. She was evaluated by a neurologist, who advised stopping OCPs and starting therapeutic anticoagulation with low molecular weight heparin (LMWH) enoxaparin (1 mg/kg subcutaneous twice per day) was initiated.
After two weeks of therapeutic anticoagulation, a follow-up CT scan showed almost total resolution of the occipital hyperdensity focus and slightly reduced temporal hyperdensity; and somewhat stable surrounding hypodensity and secondary mass effect on the adjacent sulci. There is a complete resolution of sinus thrombosis. Following this result, therapeutic anticoagulation was stopped, and the patient was started on Aspirin 100 mg and Atorvastatin 20 mg. She was transferred to a rehabilitation center. She received intensive physical and occupational therapy. Four weeks later, the patient was discharged with almost resolution of most of her deficits. She was able to walk with minimal assistant due to mild dizziness.