HPI: 24 yo F, 2 weeks postpartum from full-term, uncomplicated pregnancy and SVD, no significant PMHx, presenting with severe headache and neck pain progressively worsening over 24 hours. Headache was worst in the back of her head and “behind her eyes,” but she denied vision changes.  She was mildly nauseous and had a single episode of NBNB vomiting. She denied fever, and there were no reported neurologic deficits, seizure activity or encephalopathy.  

Pertinent physical exam findings:

• Vitals: afebrile, HR 97, BP 146/72 
• General appearance: patient was lying supine on the stretcher 2/2 neck and head pain when she tried to hold her head upright
• 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 tremor or seizure like activity. No aphasia.

DDx:

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

Initial plan:

• Pertinent 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, which showed 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
• The clinical presentation of CVT 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.  
• Brain MRI/MRV is the best imaging modality for confirming diagnosis
• Anticoagulation with LMWH or unfractionated heparin ASAP (unless there is a contraindication to anticoagulate)