Deep cerebral venous thrombosis: a challenging diagnosis.

CASE We report the case of a 47 years-old female patient with a last medical history for peripheral venous thrombosis. She denied smoking or alcohol habits but took oral contraceptives. No family history of similar events. She sought medical attention at the emergency department (ED) for headache, vomiting and confusional syndrome. She remained bedridden at home with persistent headache, vomiting and postural imbalance. The headache was holocranial, pressure type, at first gradual and then with progressive deterioration and no relieving or aggravating factors. Three weeks later noted a confusional syndrome. At the ED on physical examination found her awake, disoriented, with apathy following simple orders, but unable to execute complex orders; decreased fluency of speech, but without naming errors. A right hemiparesis was apparent. No other neurological signs were found. She was hemodynamically stable and afebrile. Brain CT scans (Fig A) revealed symmetrical thalamic and midbrain hypodensities associated with hyperdensity of Galen vein and straight sinus. MRI (Fig B) showed DCVT of Galen vein, rectus sinus, internal cerebral veins and right lateral sinus. Anticoagulation with intravenous heparin was started. Investigation was negative for thrombophilia, autoimune diseases or infections. She was discharged 14 days later, after presenting a steady improvement, only with a slight decrease of speech fluency. Warfarin and discontinuation of oral contraceptives were advised.