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Rare Case of Isolated Intracranial Hyptertension Syndrome (IIHS) With Subsequent Cerebral Venous Sinus Thrombosis (CVST) FREE TO VIEW

Gautam Sikka, MD; Deepak Sharma, DO; Anne Valerie Allen, MD; Carlos Galvao Sobrinho, MD; Rupesh Kshetri, MD; Jeannette Cano-Landivar, MD; Jessica Stoeckel, MD
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Icahn School of Medicine at Mount Sinai (Bronx VAMC), Bronx, NY

Chest. 2015;148(4_MeetingAbstracts):270A. doi:10.1378/chest.2277458
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SESSION TITLE: Critical Care Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: CVST is rare form of stroke, with potentially devastating outcomes. 0.5 % of all strokes are CVSTs, which unexpectedly occur mostly in young females. We report a case of CVST secondary to pseudo-tumor cerebri-induced IIHS.

CASE PRESENTATION: A 26-year-old non-smoker female with history of migraines, asthma, obesity and 1 miscarriage presented to the hospital with worsening temporal headaches for 1 month, different from her usual migraines, and dizziness, nausea and vomiting for 1 day. She denied use of contraceptive pills. She was bradycardic, with a normal physical exam and was triaged to the step-down unit for close observation. On day 2, she developed bilateral vision loss. Eye exam revealed papilledema. Acute infarcts in the right peritrigonal occipital lobe and left parietal occipital lobe junction were seen on MRI. CT-venous protocol revealed a thrombus in the sagittal sinus, bilateral transverse sinus and parts of the right internal jugular vein. Anticoagulation was started. Neurology and Neuroradiology deemed she was not a suitable candidate for catheter-guided thrombolysis. Labs for hyper-coagulable work-up were negative. Her head was elevated and the room was kept dark to keep intracranial pressures (ICP) low. Pain was controlled with Fentanyl and Hydromorphone. Holter monitor revealed sinus bradycardia. On day 3, the patient developed complete blindness and underwent cerebral decompression via Lumbar Puncture (LP), with neurosurgery on standby. Opening pressure (OP) was over 60 cm H2O. Closing pressure was 14 cm H2O. Since headaches and vision loss persisted, intravascular thrombolysis was done. Post-procedural head CT showed no improvement. The OP increased again, so a lumbar drain was placed for continuous Cerebrospinal Fluid (CSF) drainage. The patient's symptoms improved. Upon discharge, she had persistent bilateral papilledema and visual acuity of 20/200 in both eyes.

DISCUSSION: CVST may be challenging to diagnose, since headache is the most common complaint. Clinical suspicion and evaluation of risk factors are crucial to establishing the diagnosis. Contrast imaging is diagnostic. Literature suggests that signs and symptoms can be bundled: IIHS presents with headache, with or without vomiting, papilledema, and visual changes; Encephalopathy and focal syndromes (deficits/seizures) may occur. Our patient had a classic presentation of IIHS. New bradycardia is also suggestive of high ICP. This patient likely had pseudo-tumor cerebri, which can cause IIHS and subsequent CVST. Early diagnosis and treatment with anticoagulation and/or endovascular intervention is key in preventing debilitating deficits and mortality.

CONCLUSIONS: In a patient with IIHS, the clinician must be mindful of recognizing signs of CVST. Early treatment with reduction of ICP and thrombolysis may prevent permanent deficits.

Reference #1: Biousse, V. et al. Isolated intracranial hypertension as the only sign of cerebral venous thrombosis. Neurology, 1999. 53(7): p. 1537-42.

DISCLOSURE: The following authors have nothing to disclose: Gautam Sikka, Deepak Sharma, Anne Valerie Allen, Carlos Galvao Sobrinho, Rupesh Kshetri, Jeannette Cano-Landivar, Jessica Stoeckel

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