Cerebral venous thrombosis presenting as vision loss & multiple cranial palsy - A rarity

Ashok Vardhan Reddy Taallapalli; Subasree Ramakrishnan

doi:10.4103/ijmr.IJMR_2128_19

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Clinical Image

152 (

Suppl 1

); S83-S84

doi:

10.4103/ijmr.IJMR_2128_19

Cerebral venous thrombosis presenting as vision loss & multiple cranial palsy - A rarity

Ashok Vardhan Reddy Taallapalli, Subasree Ramakrishnan^,*

Department of Neurology, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru 560 029 Karnataka, India

*For correspondence: subasree.ramakrishnan@gmail.com

Received: 2019-11-19,

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Disclaimer:
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.

† Patient's consent obtained to publish clinical information and images.

A 27 yr old male† presented to the department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India in September 2017, with headache, blurring of vision, slurring of speech, difficulty in closing eyes and weakness of the right upper limb for three days. Examination revealed bilateral severe papilloedema, visual acuity of perception of light, abduction restriction, lower motor neuron facial palsy (inability to blow, suck and purse lips) (Fig. 1A, Video), absent gag reflex and deviation of tongue to the right (Fig. 1B) and right upper limb proximal weakness with areflexia.

(A) The patient was unable to close eyes completely; nasolabial folds were obliterated along with bilateral lower motor neuron seventh nerve palsy. (B) Tongue deviates to the right on protruding, suggestive of the right 12th nerve palsy.

Computed tomography and magnetic resonance imaging (Fig. 2A-F) revealed cerebral venous thrombosis (CVT) involving superior sagittal and right transverse sinuses. He received mannitol, heparin and acenocoumarol and subsequently underwent theco-peritoneal shunt due to refractory nature of illness. His symptoms improved in three weeks. At follow up after two years, he was normal except for visual acuity of 6/9 bilaterally.

(A) Computed tomography (CT) head plain axial image showing hyperdense right transverse sinus (blue arrow). (B) CT head axial contrast image showing filling defect in the right transverse sinus. (C) CT contrast sagittal image showing filling defect in the superior sagittal sinus, suggestive of venous thrombosis. (D) T1 contrast axial showing filling defect in the right transverse sinus (red arrow). (E) T2 sagittal sequence showing hyperintensity in the superior sagittal sinus suggestive of the absence of flow voids. (F) Magnetic resonance venogram showing filling defects in superior sagittal and right transverse sinus.

CVT presenting with vision loss, multiple cranial paresis and radiculopathy is unique. Clinical suspicion, imaging and appropriate decision to surgically intervene are crucial in avoiding blindness.