Background
Cerebral venous sinus thrombosis (CVST) is a rare neurological presentation of the peripartum period with a reported incidence of 12 in 100,000 patients. With more than 70% of pregnancy-related CVST occurring in the postpartum period, increased risk is related to overall peripartum hypercoagulability further amplified by risk factors such as underlying prothrombotic conditions, obesity, dehydration, infections and hypertensive disorders of pregnancy.
Case Report
A 33-year-old G1P1 Caucasian woman presented with seizures ten days postpartum with a three-day history of worsening generalized and retro-orbital headaches. Her medical history was significant for a chronic immune-mediated thrombocytopenia (possible Evan’s Syndrome) requiring IVIG prior to delivery, obesity (130kg), hypothyroidism and anxiety. She was also diagnosed with term pre-eclampsia with new onset hypertension and proteinuria at 39 weeks requiring two antihypertensive agents on discharge from hospital.
Admission CT and MRI brain and neck imaging revealed extensive dural venous sinus thrombosis involving the left transverse and sigmoid sinus extending to the distal internal jugular vein. There was also associated haemorrhage noted overlying the left cerebellar tentorium extending to the subdural space. A wedge-shaped area of delayed nephrogram was also identified within the upper pole of left kidney, later confirmed on CT Renal Angiography to be secondary to left renal vein thrombosis.
She was commenced on Levetiracetam (Keppra) and intravenous heparin infusion with close monitoring of the extent of haemorrhage on serial CT imaging. She was subsequently transitioned to therapeutic dose subcutaneous Clexane 110mg twice daily with anti-Xa level monitoring. Interventional radiology guided thrombectomy was considered however not performed due to overall neurological stability. Her platelet counts remained stable between 85-110 x 109/L during her admission. Thrombophilia screen performed revealed Heterozygous Factor V Leiden mutation with borderline lupus anticoagulant positivity of uncertain significance.
Conclusion
CVST is a rare yet important diagnosis to consider in the management of postpartum patients often presenting with a wide range of neurological symptoms. Timely diagnosis and intervention is crucial to prevent major consequences such as seizures, major haemorrhage and permanent disability from stroke.