James W. Guider, MD
Resident
Rutgers Health/Kessler Institute for Rehabilitation
Morristown, New Jersey, United States
Arshia Mahmoodi, BSc
Medical Student
St. George's University
Richmond Hill, Ontario, Canada
Sofia Terner, MD
Core Faculty
Overlook Medical Center
Summit, New Jersey, United States
Dural Venous Sinus Thrombosis
Case Description:
A 40-year old male with a history of hypertension and obesity presented with headache and vision changes for one month. The headache was sudden onset, pulsatile, non-radiating, localized to the frontal lobe, exacerbated by Valsalva and positional changes, associated with pulsatile tinnitus, vomiting and decreased vision. The patient was found to have papilledema, however MRI Brain was unremarkable. Idiopathic intracranial hypertension was suspected and a lumbar puncture demonstrated an elevated opening pressure, after which symptoms immediately resolved and acetazolamide was started. Subsequently, MR Venogram (MRV) showed a filling defect in the inferior superior sagittal sinus extending to the torcula, bilateral transverse sinuses, and sigmoid sinus, consistent with an initially unexpected diagnosis of dural venous sinus thrombosis (DVST). Patient was promptly anticoagulated and further workup was without any identifiable risk factors, other than obesity. Six months later, he was symptom free with functional improvement of headache and vision changes.
Discussions:
DVST is an uncommon diagnosis and known risk factors include prothrombotic hematologic conditions, hormonal etiologies, systemic illness, infections, or local trauma. Our patient had a thorough hematologic workup for thrombophilia, including hereditary causes, which failed to identify any clear predisposing risk factor, resulting in this unique case presentation. Ultimately, his most likely risk factor was obesity. Current literature on DVST emphasizes its rarity, but in the majority of cases conventionally accepted risk factors are identified. If an MRV was not obtained, the diagnosis of DVST could have been missed or delayed, potentially contributing to increased morbidity and negative functional outcomes.
Conclusions:
Physiatrists should be cognizant of this atypical presentation of DVST with headache, pulsatile tinnitus and vision changes; additionally obesity may increase risk for DVST. Obesity is a continually growing global epidemic and further investigation into sequelae of obesity is imperative to better improve patient outcomes and overall function.
