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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 181-183

Isolated cortical vein thrombosis from lumbar puncture: High suspicion yields high diagnostic yield


Department of Neurology, Foothills Medical Hospital, University of Calgary, Canada

Date of Submission13-Mar-2013
Date of Decision30-Mar-2013
Date of Acceptance17-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Sweta P Adatia
Department of Neurology, Foothills Medical Hospital, University of Calgary
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111146

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How to cite this article:
Adatia SP, Nambiar VK. Isolated cortical vein thrombosis from lumbar puncture: High suspicion yields high diagnostic yield. Neurol India 2013;61:181-3

How to cite this URL:
Adatia SP, Nambiar VK. Isolated cortical vein thrombosis from lumbar puncture: High suspicion yields high diagnostic yield. Neurol India [serial online] 2013 [cited 2020 Dec 3];61:181-3. Available from: https://www.neurologyindia.com/text.asp?2013/61/2/181/111146


Sir,

Of the cerebral venous sinus thromboses (CVTs), isolated cortical vein thrombosis is very rare. This report presents a case of isolated cortical vein thrombosis due to an unusual cause, a lumbar puncture.

A 43-year-old gentleman, a known case of idiopathic intracranial hypertension (IIH) underwent a lumbar drainage as part of therapy for IIH. He experienced improvement following the lumbar tap for few days. He underwent a scheduled tap two weeks prior to the current admission. Immediately following the tap, he noted a change in the character of the headache: Holocranial, throbbing, and more intense than the IIH-related headache. It was the worst in sitting position and did not respond to analgesics. His family physician attributed the change in the characteristics of the headache to the lumbar puncture and advised plenty of fluids and analgesics. Two days later, he developed sudden-onset numbness in the left thumb and index finger followed by numbness of face and arm. He had a transient blurring of vision in his right half of the visual fields. The symptoms lasted for 25 minutes with complete recovery. He denied any weakness, loss of consciousness, seizures, or disturbance in speech. In the emergency room, neurological examination was essentially normal. However, he continued to have a headache which was holocranial, diffuse, and throbbing, with a pain scale of 6/10 and no change with change in position. The physician in the emergency room sought neurology consultation for further evaluation of the patient. In view of the change in the characteristics of the headache and focal neurological deficits and a recent lumbar puncture, the possibility of intracranial hypotension was entertained. Other differentials considered included subarachnoid hemorrhage (SAH), dissection with embolic stroke, venous sinus thrombosis, and meningitis. Initially, he underwent noncontrast computed tomography (CT) of the brain and CT angiogram (CTA). CT of the brain revealed a hemorrhage in the right perirolandic region, suggestive of SAH [Figure 1]. The CTA was normal [Figure 2]. MRI brain GRE sequence, Flair and Contrast [Figure 3], [Figure 4] and [Figure 5] suggested an enlarged and engorged dilated vein near the hemorrhage, suggestive of possible cortical vein thrombosis. Magnetic resonance venogram (MRV) confirmed isolated cortical vein thrombosis. Workup of the procoagulant was negative. The isolated cortical vein thrombosis was attributed to the mechanical collapse of the veins secondary to lumbar puncture. He was treated with analgesics for his headache and anticoagulated with intravenous heparin. He was discharged on day 7 with a plan to continue oral anticoagulants for three months.
Figure 1: Computed tomography brain plain, suggestive of hyperdensity in the right parietal region

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Figure 2: Normal cerebral computed tomography angiogram

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Figure 3: Magnetic resonance imaging graded echo sequence showing right high parietal blood and a tubular susceptibility artifact indicating a right parietal thrombosed cortical vein

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Figure 4: Magnetic resonance imaging fluid attenuated inversion recovery image showing the hemorrhage distinctly seen on the graded echo sequences

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Figure 5: Post - gadolinium contrast showing extravasation of the blood products in the high parietal region

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Lumbar puncture, and spinal and epidural anesthesia with accidental dural puncture have been reported to cause venous sinus thrombosis. [1],[2] Majority of the patients developing CVT following lumbar puncture have had predisposing factors like hypercoagulable states. There are reports of patients with multiple sclerosis who had lumbar taps and high-dose intravenous methylprednisolone developing CVT. [3] In our patient, there was no hypercoagulable state; the headache was possibly due to the dural tear and related leakage of cerebrospinal fluid (CSF) causing intracranial hypotension. Intracranial hypotension can induce a downward shift of the brain and the resultant traction and disruption of the veins/sinus can result in venous dilatation and thrombosis. [4]

The neuroimaging features of isolated cortical vein thrombosis include thrombosed cortical vein (cord sign) and localized hemorrhage or venous infarction. On CT, the cord sign is a very uncommon finding. MRI equivalent of the cord sign is very difficult to detect early, as the clot is often isointense. Between day 3 and day 7, the clot becomes hyperintense on the T1/T2 images and thus easier to identify. Sometimes a conventional angiogram is required to delineate subtle vasculitic changes, small dural arteriovenous malformations (AVMs) or small AVMs which can present with intracerebral hemorrhage. [5] Our patient highlights the point that if there is any change in the characteristics of headaches following a lumbar puncture, one should evaluate the patient to exclude CVT.

 
  References Top

1.Mourax A, Gille M, Dorban S, Peters A. Cortical venous thrombosis after lumbar puncture. J Neurol 2002;249:1313-5.  Back to cited text no. 1
    
2.Ozlem KY, Hatice B, Gulsum C, Ibrahim O, Ertugrul B, Saut T. Isolated cortical vein thrombosis after epidural anaesthesia: Report of three cases. Int J Neurosci 2010;120:447-50.  Back to cited text no. 2
    
3.Aidi S, Chaunu MP, Biousse V, BousserM. Changing patter of headache pointing to cerebral venous thrombosis after lumbar puncture and intravenous high-dose corticosteroids. Headache 1999;39:559-64.  Back to cited text no. 3
    
4.Albayram S, Kara B, Ipek H, Ozbayarak M, Kantarci F. Isolated cortical venous sinus thrombosis associated with intracranial hypotension syndrome. Headache 1999;49:916-9.  Back to cited text no. 4
    
5.Vijay S, Hock T. Isolated cortical venous thrombosis: Cord Sign. Radiol Case 2009;3:21-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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