Unusual Presentation of Cerebral Venous Sinus Thrombosis Associated with Contraceptive Usage

A 23-year-old woman was referred to our department complaining of intermittent double vision for 3 weeks. Best corrected visual acuity (BCVA) was 20/20 in both eyes (OU), the pupils were round and reactive to light with no relative afferent pupillary defect (RAPD), intraocular pressure (IOP) was 12mmHg OU; color vision by Ishihara pseudo-isochromatic plates and automated visual fields (Figure 1) were normal OU, as well. Orthoptic examination showed slight limitation of abduction and partial sixth nerve palsy in the left eye (OS). Dilated fundoscopy revealed bilateral optic disc edema (Figure 2). A high dose steroid (methylprednisolone) was initially administered with the clinical suspicion of an underlying neuro–inflammatory process. Magnetic resonance imaging (MRI) excluded intracranial masses, hemorrhage, meningitis or other similar conditions causing optic disc edema. Lumbar puncture revealed elevated cerebrospinal fluid (CSF) opening pressure at 46 mmHg (normal up to 16 mmHg) with no abnormal constituents, therefore papilledema was verified. There was no history of weight Fraxiforte® (nadroparin calcium) injections gain, obesity, migraine headaches or tobacco 0.4 ml once daily, Sintrom® (acenocoumarol) use. The patient had been using an oral birth and acetazolamide 250mg twice daily were control pill, Yasmin 28 (drospirenone and ethinyl administered as initial treatment and the steroid estradiol) over the past 5 months. was tapered. One week later, BCVA and color No abnormal findings were detected on vision were stable at 20/20 OU and 13/13 OU, an extensive hematology panel including respectively. Six months later the fundoscopic erythrocyte sedimentation rate (ESR), complete appearance improved, Sintrom® was blood count (CBC), kidney function, C-reactive discontinued and acetazolamide was reduced protein (CRP) and partial thomboplastin time to 250mg daily for 1 month and 125mg daily for (PTT). Magnetic resonance venography (MRV) the next month. Ten months after the episode, showed partial venous thrombosis of the right the patient was clinically stable and optic disc transverse and sigmoid sinuses (Figure 3). edema had completely regressed (Figure 4). Figure 1. Visual field testing (Octopus): no significant defects were detected in the right (upper image) and left (lower image) eyes.