SUPERIOR SAGITTAL SINUS THROMBOSIS PRESENTING AS DETERIORATING RESIDUAL WEAKNESS

ABSTRACT

SESSION TITLE Imaging, ECMO, and other Procedures in the ICU Case Posters SESSION TYPE Case Report Posters PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: Superior sagittal sinus (SSS) thrombosis is a rare cause of stroke that is difficult to identify due to various clinical presentations. It is the most common form of dural sinus thrombosis, and common risk factors include hypercoagulable state, traumatic head injury, pregnancy/postpartum, and malignancy. More than 85 percent of adult patients have at least one risk factor for cerebral venous thrombosis. Some patients with SSS thrombosis do not have clearly identifiable risk factors, and this case highlights one such patient. CASE PRESENTATION A 60-year-old Caucasian male with hypertension, hyperlipidemia, and a recent intracranial hemorrhage with residual left-sided weakness, presented to the emergency department with worsening left-sided weakness. Upon admission, his physical exam was notable for 4/5 strength in the left upper extremity and 2/5 strength in the left lower extremity. This was a reduction in strength from a baseline of 4/5 in the left upper and lower extremities. Labs on admission were normal except for high-sensitivity troponin of 86 and WBC of 14.5. UA with a small amount of blood. An initial CT brain without contrast showed no acute changes, evolutionary changes in the right frontal temporal lobe, and subtle curvilinear hyperdensity near a site of the intracranial hemorrhage identified in the prior month. This curvilinear hyperdensity was thought to reflect early parenchymal calcification. MRI brain without contrast showed new and evolving areas of abnormal signaling and an evolving hematoma with surrounding vasogenic edema, all of which are in the right lobe. There was no apparent diffusion coefficient correlate. Thus, MRI with contrast and MRV was recommended. EEG showed no evidence of epileptiform activity. Additionally, transthoracic echo demonstrated new non-ischemic cardiomyopathy with an EF of 35-40%. The diagnosis was ultimately made after the patient had a Magnetic Resonance Venography (MRV) which showed evidence of the SSS thrombosis and an indication that the previously visualized curvilinear hyperdensity is suspected to represent slowed flow within a surface vein. Heparin was started to recanalize the sinus and prevent thrombus propagation. After the appropriate treatment was started, the patient's weakness improved dramatically. DISCUSSION: Typically, patients with SSS thrombosis have identifiable risk factors like hypercoagulable states, traumatic head injuries, pregnancy/postpartum, malignancy, and more recently association with COVID-19 infection. In this case, since the patient lacked identifiable risk factors, the MRV played a key role in the diagnosis. CONCLUSIONS: Like our patient, 30-40 percent of patients present with an intracerebral hemorrhage. Differentials of SSS thrombosis should be considered in etiologies for intracerebral hemorrhage, especially when an identifiable cause is lacking, in order to avoid delays in treatment and resolution. Reference #1 Abdalkader M, Shaikh SP, Siegler JE, Cervantes-Arslanian AM, Tiu C, Radu RA, Tiu VE, Jillella DV, Mansour OY, Vera V, Chamorro Á, Blasco J, López A, Farooqui M, Thau L, Smith A, Gutierrez SO, Nguyen TN, Jovin TG. Cerebral Venous Sinus Thrombosis in COVID-19 Patients A Multicenter Study and Review of Literature. J Stroke Cerebrovasc Dis. 2021 Jun;30(6)105733. doi 10.1016/j.jstrokecerebrovasdis.2021.105733. Epub 2021 Mar 4. PMID 33743411;PMCID PMC7931726. Reference #2 Rehman A, Husnain MG, Mushtaq K, Eledrisi MS. Cerebral venous sinus thrombosis precipitated by Graves’ disease. BMJ Case Rep. 2018 Jun 4;2018bcr2017224143. doi 10.1136/bcr-2017-224143. PMID 29866676;PMCID PMC5990097. Reference #3 Nakase H, Takeshima T, Sakaki T, Heimann A, Kempski O. Superior sagittal sinus thrombosis a clinical and experimental study. Skull Base Surg. 1998;8(4)169-74. doi 10.1055/s-2008-1058178. PMID 17171061;PMCID PMC1656696. DISCLOSURES No relevant rel tionships by Ken Johnson No relevant relationships by Nina Le No relevant relationships by Riaz Mahmood No relevant relationships by Ngoc Phan