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.