Transient Neurologic Deficit Presenting with Cortical Vein Thrombosis Caused by Intracranial Hypotension: Case Report (P1.028)

Abstract

OBJECTIVE To describe an atypical cause of a cortical vein thrombosis that was associated with simple partial seizures. BACKGROUND. Cortical vein thrombosis is rare form of stroke that usually affects young individuals. Predisposing conditions are commonly medical disease (inflammatory bowel disease, infections), transient physiologic changes (pregnancy), iatrogenic (oral contraceptive), and head trauma. However, only small series have shown an association of cortical vein thrombosis with spontaneous intracranial hypotension. DESIGN/METHODS A 44-year-old white man with Grave’s disease presented with recurrent, brief, fluctuating episodes of aphasia and right hand and arm numbness, and new onset orthostatic headaches. Basic labs and pro-coagulable work-up were unremarkable. Magnetic resonance imaging (MRI) and venography (MRV) showed a thrombosed cortical vein in the superior left frontoparietal region with surrounding vasogenic edema; diffuse dural enhancement and small bilateral subdural fluid collections were consistent with intracranial hypotension. Cervical spine MRI showed high signal within the posterior neck soft tissues (i.e., atlantoaxial articulation), representing non-specific edema rather than cerebrospinal fluid leakage from a dural defect. RESULTS The patient was diagnosed with intracranial hypotension that caused cortical vein thrombosis, which then resulted in simple partial seizures. With treatment of aspirin, anticonvulsants, and empiric lumbar epidural blood patch, his headaches and seizures quickly resolved. CONCLUSION We hypothesized that intracranial hypotension led to venous engorgement (based on the Monroe-Kelli doctrine) and the subsequent cortical vein thrombosis, which then produced vasogenic edema, cortical irritability, and focal seizure that mimicked ischemic stroke. Based on our findings, clinicians should consider intracranial hypotension in patients presenting with dural sinus or cortical vein thrombosis, and orthostatic headache or imaging findings of dural enhancement.

Disclosure: Dr. Plancher has nothing to disclose. Dr. Flaherty has received personal compensation for activities with CSL Behring as a consultant and an advisory board member.