Clinical Image

Bilateral papilledema: A case of cerebral venous sinus thrombosis Suchi Shah, Devendra Saxena Department of Ophthalmology, Pramukhswami Medical College and Shree Krishna Hospital, Karamsad, Gujarat, India

Introduction The diagnosis of cerebral venous thrombosis (CVT) remains challenging due to a wide range of clinical manifestations. Headache is the most common presenting symptom and there can be other neurologic signs and symptoms,[1] like focal seizures with or without secondary generalization, unilateral or bilateral paresis, impaired consciousness or visual disturbance. Papilledema is present in about 28% of patients with CVT.[2]

Fundus fluorescein angiography showed leakage from disc in early phase which persisted through late phase depicting bilateral papilledema [Figure 3].

Case Report

A 29‑year‑old male patient presented with severe persistent headache of 1‑2 months duration which was acute in onset and was not relieved by any oral analgesic. There was no history of visual disturbance, diplopia, vomiting, seizures, trauma, or head injury. Patient had neither medical history of blood disorders nor was on any medications.

Figure 1: OD (right eye) color and red‑free fundus photographs show disc elevation, hyperemia with blurring of margins, obscuration of blood vessels, and Paton’s lines suggestive of disc edema

Distant and near visual acuity of the patient was 20/20 and N6 respectively in both eyes. Pupils were bilaterally central and reacting to light with no evidence of relative afferent pupillary defect. Anterior segment examination was within normal limits. Following are the colored and red‑free fundus photographs [Figures 1 and 2].

Figure 2: OS (left eye) color and red‑free fundus photographs show disc elevation, hyperemia with blurring of margins, obscuration of blood vessels, and Paton’s lines suggestive of disc edema

B‑scan was performed which ruled out optic nerve head drusen. Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.127924

Figure 3: Fundus fluorescein angiography shows leakage in early phase which persists through late phase suggestive of disc edema

Copyright:  2014 Shah S and Saxena D. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Correspondence: Dr. Suchi V. Shah, Department of Ophthalmology, Pramukhswami Medical College and Shree Krishna Hospital, Karamsad - 388 325, Gujarat, India. E‑mail: [email protected]

Oman Journal of Ophthalmology, Vol. 7, No. 1, 2014

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Shah and Saxena: Papilledema in cerebral venous sinus thrombosis A plain computed tomography (CT) scan brain was within normal limits. Magnetic resonance (MR) venography was performed with the following findings: • Partial thrombus involving cranial part of right sigmoid sinus, transverse sinus, sinus confluence, superior sagittal sinus, and terminal part of left transverse sinus [Figure 4]. Hematological investigations revealed haemoglobin at 18.4 g/dL (13-17) and red blood cell (RBC) count at 6.04 million (4.5‑5.5). Rest of histogram, prothrombin time, activated partial thromboplastin time, vitamin B12, serum total calcium, protein, thyroid stimulating hormone, VDRL, human immunodeficiency virus which were within normal limits. Hematology consultation was obtained which ruled out polycythemia as the patient had only raised RBC and hemoglobin with a normal erythrocyte sedimentation rate, platelets, and total counts without splenomegaly. Diagnosis of CVT was kept and a neurology consultation was obtained. Patient was started on treatment as per guidelines from the American Stroke Association.[3] A trial of aspirin was given first and LMW heparin therapy was kept in plan if the symptoms did not improve. After 2 days, patient was symptomatically better with relief from headache. On subsequent follow‑up visits, the visual acuity remained 20/20 with normal color vision. Fundus examination repeated 1 week later and 1 month later showed resolving papilledema [Figure 5].

Discussion Thrombosis most commonly affects the superior sagittal sinuses (SSS) and lateral sinuses[4] due to its high position, low pressure, and slow flow. Since CT scan is nonspecific, MR venography remains the diagnostic modality of choice and must be performed in such patients.[5] Bilateral hemorrhagic infarction of the cortex and adjacent white matter can be fatal consequence of SSS thrombosis. Early intervention is life‑saving in these patients. Thus, suspecting CVT and its early diagnosis and management plays an important role in preserving the visual function as well as neurological integrity of the patient.

34

Figure 4: Magnetic resonance venography showing partial thrombus involving cranial part of right sigmoid sinus, right transverse sinus, sinus confluence, superior sagittal sinus, and terminal part of left transverse sinus. (Red arrows)

Figure 5: OD (right eye) and OS (left eye) fundus photographs a month after starting anticoagulants show resolving papilledema with complete visualization of disc margins and surrounding vasculature

References 1. Kimber J. Cerebral Venpus Thrombosis‑ review. Q J Med 2002;95:137‑42. 2. Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F. Prognosis of cerebral vein and dural sinus thrombosis: Results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004;35:664‑70. 3. Saposnik G, Barinagarrementeria F, Brown RD Jr., Bushnell CD, Cucchiara B, Cushman M, et al. Diagnosis and management of cerebral venous thrombosis: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:1158‑92. 4. Daif A, Awada A, al‑Rajeh S, Abduljabbar M, al Tahan AR, Obeid T, et al. Cerebral venous thrombosis in adults: A study of 40 cases from Saudi Arabia. Stroke 1995;26:1193‑95. 5. Bousser MG, Chiras J, Bories J, Castaigne P. Cerebral venous thrombosis: Review of 38 cases. Stroke 1985;16:199‑213.

Cite this article as: Shah S, Saxena D. Bilateral papilledema: A case of cerebral venous sinus thrombosis. Oman J Ophthalmol 2014;7:33-4. Source of Support: Nil, Conflict of Interest: None declared.

Oman Journal of Ophthalmology, Vol. 7, No. 1, 2014

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Bilateral papilledema: A case of cerebral venous sinus thrombosis.

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