Can Pseudotumor Cerebri be an Initial Sign of Cortical Venous Thrombosis?

Abstract

The case report describes a very unusual case of a 30-year-old female with the clinical history of a 3 months progressively worsening headache, occasional blurred vision, diplopia, and vomiting. She had taken hormonal drugs for a few gynecology complaints. Neutral eye movements showed bilateral lateral rectus palsies, and there was bilateral papilledema. Magnetic resonance imaging (MRI) of the brain and venogram were normal in the 1^st day of disease onset. He was started on steroids but had an exacerbation of symptoms. A diagnosis of pseudotumor cerebri (PTC) was given, and he underwent a lumbar–peritoneal shunt procedure for the relief of intracranial pressure. The papilledema became almost normal. In the postoperative period, she developed hypertension, change in mental status, seizures, after which ventilation was instituted. A computed tomography scan of the brain done in emergency found a parieto-occipital hemorrhage. A repeat MRI and MR venogram done on the patient confirmed cortical venous thrombosis (CVT). The patient was given heparin and was thereafter mechanically ventilated for 3 days and taken off the tube. This case report brings out the problems of diagnosis and the possibility of PTC and CVT in this patient. Although not commonplace, other research has included and documented that PTC may be an indication of the onset of CVT. The precise relationship between cortical vein thrombosis and pseudotumor cerebri remains unclear. However, it is thought to be partially influenced by risk factors such as hormonal fluctuations, which were present in our case, as well as hypercoagulation and inflammation. Our patient first presented with symptoms that are characteristic of PTC, which gave preliminary indication of idiopathic intracranial hypertension. However, the progress of seizures allowed us to consider the diagnosis of CVT. The normal initial MRI findings presented in our patient are compatible with other case reports; MRI may not be sufficiently specific to identify CVT during initial presentation.