HPI:

• 22 yo F 3 weeks postpartum after uncomplicated SVD presents with severe headache and neck pain  worsening over 24 hours
• Headache localized posterior and retro-orbital
• One episode vomiting
• No vision changes, fever, or neurologic complaints

Physical exam:

• Vitals: afebrile, HR 97, BP 146/72
• General appearance: Pt appears uncomfortable, supine on stretcher
• Neuro: awake, alert and oriented. CN 2-12 intact, no oculomotor palsies or visual field deficits, no facial droop or slurred speech. No focal weakness. Gross sensation intact. No dysmetria. Normal tandem gait

DDx:

• Primary headache, Cerebral venous thrombosis (CVT), Preeclampsia, Post-dural puncture headache (patient had epidural during labor), Idiopathic intracranial hypertension (pseudotumor cerebri), Meningitis,  Intracranial mass lesion (tumor vs abscess), Intracranial hemorrhage

Initial workup:

• Lab findings: normal D-dimer, no leukocytosis, mild anemia
• Urgent imaging: non-contrast CT head, which showed focal hypodensity concerning for edema vs venous infarct

Next steps:

• Contrast enhanced MR venography: abnormally low signal/absence of flow in the left transverse sinus, suggesting thrombosis

Management:

• Early anticoagulation! Patient was started on subcutaneous LMWH, admitted and bridged to Warfarin

Take home points:

• Cerebral venous thrombosis is rare, but should always be considered in patients with prothrombotic conditions
• Clinical presentation is highly variable - onset can be acute, subacute, or chronic.
• Headache is the most frequent symptom.
• Head CT scan is normal in up to 30 percent of CVT cases, and most of the findings with CVT are nonspecific.
• CTV or MRV is the best imaging modality for confirming diagnosis
• Tx = Anticoagulation with LMWH or unfractionated heparin