SESSION TITLE: Critical Care Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare manifestation of the hypercoagulable state in ulcerative colitis (UC). We describe the case of a patient with a recent flare of UC who presented with acute onset of headache and altered mentation. Detailed workup revealed extensive CVT.
CASE PRESENTATION: A 41-year-old male with a history of UC maintained on certolizumab and 6-mercaptopurine in addition to prednisone for a recent flare presented with altered mental status and severe headache of 6-hours duration. Per his family he had been experiencing mild intermittent headaches for the prior 4 weeks without any fevers, chills, blurred vision, or neck stiffness. They denied any history of trauma, substance abuse, or ill contacts. Neurological exam revealed an attentive male with fluent but nonsensical speech. Motor and sensory examinations were nonfocal. Brain imaging showed acute hemorrhage in left temporal lobe lobe with surrounding vasogenic edema and mass effect on the underlying brain parenchyma and left lateral ventricle. Magnetic resonance venogram revealed absence of signal within the left vein of Labbe, left transverse and sigmoid sinus and left internal jugular vein consistent with extensive CVT. Anticoagulation was initiated. His mental status subsequently deteriorated and repeat imaging showed worsening hemorrhage with midline shift and uncal herniation. Emergent decompressive left hemicraniectomy was performed. Anticoagulation was re-started postoperatively. The patient had an encouraging post-operative course and was able to follow simple commands and move all extremities against gravity prior to discharge.
DISCUSSION: CVT is an uncommon cause of stroke and intracranial hemorrhage that can occur in association with sinus infections, hypercoagulable states, trauma, surgery, and collagen vascular diseases. Patient with CVT usually present with headache. However vomiting, altered mentation, and focal neurological signs can also be seen. Systemic anticoagulation is considered the primary therapy for CVT. In cases of severe neurological deterioration local thrombolytic therapy or thrombectomy may be considered. Herniation due to unilateral mass effect is the major cause of mortality, and requires decompressive hemicraniectomy. Fortunately, when recognized and treated in a timely fashion, CVT has better overall prognosis (62.5% full recovery in treated vs 29% in nontreated)1.
CONCLUSIONS: CVT is a rare manifestation of the hypercoagulable state in UC. Herniation is an uncommon manifestation of CVT. CVT has better overall prognosis when treated in a timely manner.
Reference #1: Smith AG, Cornblath WT, Deveikis JP. Local thrombolytic therapy in deep cerebral venous thrombosis. Neurology. Jun 1997;48(6):1613-9.
DISCLOSURE: The following authors have nothing to disclose: Muhammad Adrish, Amanda Barnhorst, Ryan Rios
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