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CASE REPORT |
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| Depression in a case of cerebral venous sinus thrombosis |
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Therissa Benerji1, Shailaja Bandla2, Krishna Mohan Parvathaneni2
1 Senior Resident, Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India
2 Associate Professor, Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India
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| Date of Submission | 30-Apr-2022 |
| Date of Acceptance | 24-Jun-2022 |
| Date of Web Publication | 27-Sep-2022 |
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Venous hemorrhagic infarct due to cerebral venous sinus thrombosis (CVST) is associated with poor prognosis. A 30-year-old woman was brought to the emergency room with an episode of generalized tonic–clonic seizure, diagnosed with CVST involving superior sagittal sinus and right transverse sinus, and referred to psychiatry in view of symptoms of depression. Mental state examination revealed poor eye contact, decreased personal hygiene, hopelessness, and worthlessness in thought content with a sad mood and affect. A diagnosis of organic depressive disorder was made and managed with sertraline 50 mg/day. Timely diagnosis along with methodical therapeutic management of CVST reduces mortality and morbidity. This case report highlights the importance of being familiar with varied presentations and neuropsychiatric manifestations of CVST.
Keywords: Cerebral venous sinus thrombosis, depression, neuropsychiatric complications
| Introduction | |  |
Venous infarcts due to cerebral venous sinus thrombosis (CVST) account for <1% of all strokes. Studies reported a 3:1 ratio of females to males in CVST and 70%–80% % of cases in women of childbearing age, which may be due to the use of oral contraceptives, pregnancy, and puerperium, three risk factors that tend to increase thrombosis.[1],[2] Other risk factors include hypercoagulable state, dehydration, infections, low cerebral blood flow, and hormone replacement therapy.[3] CVST is frequently overlooked resulting from the wide spectrum of signs and symptoms, which may evolve suddenly or over weeks.[3],[4]
Nearly 80% of all CVSTs are located in the superior sagittal sinus.[5] Headache is the most frequent symptom seen in combination with other neurological symptoms and signs including focal seizures with/without secondary generalization, focal neurological deficits, unilateral/bilateral paresis, signs of intracranial hypertension, and papilledema.[5] Cranial nerve syndromes seen with CVST include vestibular neuronopathy, pulsatile tinnitus, unilateral deafness, facial weakness, diplopia, and obscuration of vision.[4] Some patients may present with isolated neuropsychiatric manifestations, such as delirium, psychosis, depression, anxiety, irritability, personality change, apathy/abulia, or cognitive deterioration which can particularly be misleading.
The aim of this case report is to provide an example of how early suspicion of CVST is critical, as any delay in diagnosis and treatment can increase morbidity and mortality.
| Case Report | | |
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
A 30-year-old woman was brought to the emergency room with an episode of loss of consciousness which lasted for about 5 min after which the patient regained consciousness spontaneously followed by involuntary movements of both upper and lower limbs and uprolling of the eyes. There was no history of tongue bite, frothing from the mouth, involuntary micturition/defecation, deviation of the mouth, and slurring of speech. There was a history of one episode of nonbilious vomiting consisting of food particles.
The patient had no past history of hypertension, diabetes, thyroid disorders, epilepsy, autoimmune disease, hematologic-oncologic disease, surgeries, or invasive procedures.
At the time of admission, the patient was conscious but irritable and uncooperative. Her vitals were stable. She had a normal neurological examination with Glasgow Coma Scale 15, without meningeal signs of irritation, cranial nerves without deficit, and no ataxia.
Computed tomography (CT) scan brain plain study revealed possible venous infarct within the left frontoparietal region and hyperdensity in the superior sagittal sinus suggestive of superior sagittal sinus thrombosis [Figure 1]. Magnetic resonance imaging (MRI) brain with magnetic resonance venography confirmed CVST involving superior sagittal sinus and right transverse sinus with hemorrhagic infarcts in the left frontal and parietal lobes [Figure 2]. Hematologic tests to rule out coagulation and hematological disorders, infectious diseases, malignancies, and systemic inflammatory tissue diseases detected no pathology. Electrolyte and liver, renal, and thyroid function tests were normal. The patient was admitted and treatment commenced with an anticoagulant. Cardiological consult and electrocardiogram were normal. Ophthalmological consult including visual acuity and fundoscopy was normal. The treating neurologist observed the patient to be preoccupied and moody so ordered for a psychiatric referral after 7 days of her admission. | Figure 2: CVST involving superior sagittal sinus. CVST: Cerebral venous sinus thrombosis
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History revealed the patient to be feeling increasingly low day by day with frequent crying spells for the past 2 months. Low mood of hers was persistent, and she gradually lost interest in her surroundings and was withdrawn. She felt markedly tired after slight effort at home and work associated with generalized weakness which started to affect her functionality. Her sleep was disturbed and appetite diminished. She suffered throbbing headaches at times, more so during evenings in the frontal region radiating all over the head. She has had death wishes. There was a gradual socio-occupational decline and poor self-care for the past 2 weeks.
There was no past history of medical and psychiatric disorders. There was no family history of neurological and psychiatric disorders.
Born by normal vaginal delivery at term, she had normal developmental milestones.
She is a primary school teacher by occupation and is married for 7 years with no children.
Mental status examination revealed the patient to be conscious, oriented with poor eye contact, decreased personal hygiene, hopelessness, and worthlessness in thought content with a sad mood and affect. Her memory, ability to do simple calculations, comprehension, judgment, intelligence, and abstract ability were intact. There were no perceptual abnormalities and delusions. She had no insight into her condition.
On the basis of the above clinical and neuroimaging findings, she was diagnosed as having a psychiatric disorder due to a medical condition, and a diagnosis of F06.32 organic depressive disorder was made. Her HAM-D score at the time of diagnosis was 19 representing moderate-to-severe depression.
She was begun on sertraline 50 mg and called for follow-up. She reported improvement in her symptoms 1 month after commencement of treatment.
| Discussion | | |
CVST must be considered in young women presenting with neurologic manifestations. A high degree of suspicion remains the best tool for rapid diagnosis of CVST, offering the opportunity for early therapeutic measures. In general, correcting the cause can prevent complications.
Psychiatric disturbances are sometimes the only presenting symptoms in CVST. Diagnosis of CVST depends on the combination of clinical and neuroradiological findings. The most common findings on noncontrast head CT are hyperdensity of cortical vein/dural sinuses; however, 10%–40% of patients with CVST can have a normal head CT.[5] MRI is more sensitive than CT for CVST.[4],[6] MR venogram/CT venogram can provide the most reliable information.[3],[5] A lack of flow in the cerebral veins consists of a positive venogram study. For laboratory studies, complete blood count, chemistry, D-dimer, partial thromboplastin time, prothrombin time/international normalized ratio, antithrombin, protein C, protein S, Factor V Leiden, lupus anticoagulant, anticardiolipin, and anti-β2 glycoprotein-I antibodies should be performed for the underlying prothrombotic state.
Management consists of treating the underlying cause of CVST; however, 15% of patients may not have an obvious cause.[6]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in [correction of who are] carriers of hereditary prothrombotic conditions. The Cerebral Venous Sinus Thrombosis Study Group. BMJ 1998;316:589-92.  |
| 2. | Panagariya A, Maru A. Cerebral venous thrombosis in pregnancy and puerperium – A prospective study. J Assoc Physicians India 1997;45:857-9. |
| 3. | Bousser MG, Ferro JM. Cerebral venous thrombosis: An update. Lancet Neurol 2007;6:162-70. |
| 4. | |
| 5. | Bentley JN, Figueroa RE, Vender JR. From presentation to follow-up: Diagnosis and treatment of cerebral venous thrombosis. Neurosurg Focus 2009;27:E4. |
| 6. | 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. |
Correspondence Address:
Therissa Benerji,
Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_68_22
[Figure 1], [Figure 2] |
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