A presentation on Sagittal sinus thrombosis

1. A 18-year-old boy presenting with severe
headache and neck pain
Presented by:
Dr. Nasrin Akter
Intern Doctor
Shaheed Syed Nazrul Islam Medical College
Hospital

2. Name: Jahangir
Age: 18 years
Sex: Male
Religion: Muslim
Patient Profile

3. Marital Status: Unmarried
Occupation: Medical Technologist
Address: Katiarchar, Kishoreganj
Date of Admission: 6-5-2023
Date of Examination: 8-5-2023

4. Chief Complaints
• Severe Headache for 3 days
• Neck Pain for 2 days

5. History of Present Illness
According to the history of the patient he was apparently healthy
3 days back. Then he developed headache which was sudden,
severe, diffuse, throbbing and diurnal in nature. Pain
exaggerated in the morning especially soon after waking up but
relieved at night. It was associated with photophobia and
nausea. It was subsided by taking medication ( Paracetamol ) but
reappeared after 2/3 hours. It was associated with neck pain.

6. Patient had no history of fever, limb weakness, blurring of vision,
neurological deficit, vomiting or any head injury. He also gave no
history of ear infection, eye infection or nose infection. With
these complaints patient admitted to Male Medicine Ward of
SSNIMCH for better management.

7. History of Past Illness
Patient gave history of appendectomy four days back. He gave no
history of Diabetes Mellitus, Hypertension, Tuberculosis and
Cardiac Disease.

8. Family History
His father is hypertensive and mother is a patient of bronchial
asthma. Rest of the family members gave no significant medical
history.

9. Personal History
Patient is non smoker, non alcoholic and non beetle-nut chewer.

10. Immunization History
All vaccinations were done as per EPI schedule.
He is also vaccinated against COVID-19 and completed 3 doses.

11. Socio-Economic History
Patient come from a middle-class family.

12. Occupational History
He is a medical technologist.

13. Drug History
After appendectomy patient took cefixime, metronidazole,
omeprazole, Rolac and paracetamol.

14. General Examination
Appearance : Ill looking
Body built : Average
Cooperation : Cooperative
Decubitus : On choice
Nutritional status : average
Pulse : 82 beats/minute
Blood pressure : 120/80 mm(Hg)
Respiratory rate :16 breaths/min
Temperature : 98F
Anemia : Absent
Jaundice : Absent

15. • Clubbing : Absent
• Cyanosis : Absent
• Oedema : Absent
• Dehydration : Absent
• Koilonychia : Absent
• Leukonychia : Absent
• Body hair : Normal
• Bony tenderness : Absent
• Neck Rigidity : Present
• Lymph node : Not palpable
• Neck vein : Not engorged
• Thyroid gland : Not enlarged

16. Systemic Examination
• Central nervous system :
• Higher psychic function : Normal
• Examination of cranial nerves : All are intact
• Examination of sensory system : Intact
• Examination of motor system :
• #Muscle tone & power – Normal
• #Reflexes : Normal
• #Planter : Bilateral flexor
• #Cerebellum (Gait) – Normal
• #Fundoscopy : Bilateral Papilloedema

17. Cardiovascular system:
S1 & S2 audible
Respiratory system:
Breath sound : Vesicular
Added sound : Absent
Alimentary system:
No abnormality was detected

18. Salient Feature
Mr. Jahangir 18 years old male, muslim, unmarried, medical
technologist normotensive, non diabetic, no alcoholic, non
smoker hailing from Katiarchar Kishoreganj got admitted to
MMW at SSNIMCH with complaints severe headache for 3 days
followed by appendectomy and associated neck pain for 2
days.He developed headache which was sudden, severe,diffuse,
throbbing and diurnal in nature.

19. Pain exaggerated in the morning especially soon after waking up
but relieved at night. It was associated with photophobia and
nausea. It was subsided by taking medication (Paracetamol) but
reappeared after 2/3 hours. It was associated with neck pain.
Patient had no history of fever, limb weakness, blurring of vision,
neurological deficit, vomiting or any head injury. He also gave no
history of ear infection, eye infection or nose infection

20. Patient gave history of appendectomy four days back. He gave no
history of Diabetes Mellitus, Hypertension, Tuberculosis and Cardiac
Disease. On general examination he ill looking, non anaemic and non
icteric. Neck rigidity was present and vitals were within normal limit.
Nervous system examination revealed papilloedema was present. All
other systemic examinations reveal normal findings.

21. PROVISIONAL DIAGNOSIS
?

22. Differential Diagnosis
• Subarachnoid Hemorrhage
• CVST
• Meningitis
• Idiopathic Intracranial Hypertension
• Migraine
• Intracranial Space Occupying Lesion

23. Investigation Profile
Name of the Investigations/Results
CBC
• Hb% : 14
• ESR : 15
• Total count : 9400/cmm
• Neutrophil : 67%
• Total Platelet : 245000/cmm

24. • X – ray of Cervical Spine: Normal
• CT scan of Brain: Hyper dense Dural venous sinuses
• MRI of Brain: Unremarkable brain parenchyma
• MRV of Brain: Suggestive Superior Sagittal Sinus Thrombosis

25. CT scan of brain

26. MRI&MRV of brain

27. CBC

28. Xray of cervical spine

29. Confirmatory Diagnosis
Superior Sagittal Sinus Thrombosis

30. Treatment
Anticoagulation: (Low molecular weight heparin)
-Inj. Cardinex (60mg) BD for 7 days
Followed by Warfarin or Rivaroxaban daily for 6 months
General Management:
Inj. Ceftriaxone 1gm 12 hourly
Inj. Omeprazole 40mg 12 hourly
Tab. Napa 500mg 8 hourly
Tab. Flexilax 5mg 8 hourly
Tab. Rivotril 0.5mg OD at bedtime

31. Thank You