Dr. Ahmed Tanjimul Islam. MSc. (Leeds, England); MD (Neurology) Rajshahi Medical College Hospital, Bangladesh. 01554333026

1. A Middle Age Woman
with
Chronic Headache,
Convulsion & Vision Loss
Presented By:
Dr. Ahmed Tanjimul Islam (Ovi)
MSc .(Leeds, England); MD (Neurology),
Rajshahi Medical College Hospital, Bangladesh

2. Particulars of the Patient:
• Name: Rehana Begum
• Age: 38 yrs
• Occupation: Housewife
• Marital Status: Married
• Address: Rajshahi
• Date of Admission: 18/03/19

3. Chief Complaints
• Headache for 2 years
• Convulsion for 9 months
• Loss of Vision for 6 months

4. H/O Presenting Illness
• According to the statement of the patient, she
was relatively alright 2 years back. Then she
developed Headache which was diffuse,
persistent, daily, severe in intensity, throbbing
& associated with nausea. It caused significant
impairment in daily activities.
• The Headache was aggravated by movement
& partially relieved by taking analgesic . The
pain was radiated towards neck & left ear.

5. • Convulsion was generalized, 3-4 times in a
month. There was tongue biting & urination in
several occasions. The patient was never
hospitalized for convulsion.
• There was also decreased Vision for 3 months.
Patient complaints of blurring of vision &
decreased vision for near objects. There is
also frequent episodes of Diplopia.
H/O Presenting Illness

6. • She also had Evening rise of Temperature
for last 6 months which was low grade,
daily, not associated with chills & rigor.
• There was also episodic Vertigo &
Generalized Weakness for last 6 months.
Patient also complains of unilateral Facial
Numbness for last 1 month.
H/O Presenting Illness

7. • She had history of repeated visits to
Eye & ENT specialists for Eye & Ear
complains.
• 2 years back, she was diagnosed as CSOM
(Left) & treated with Myringotomy
Surgery. No culture sensitivity done during
the period.
H/O Presenting Illness

8. • There was No complaints of thunderclap
headache, aura, rhinorrhea, lacrimation,
transient total blindness.
• No aggravating factors like bright light, loud
noise. Rest, sleep had given no relieve from
Headache. No history of Painful Eye movement.
No history of Cough, vesicles, localized headache,
trigger points, or psychiatric problem. No history
of OCP drugs. No complains of ear pain, tingling,
fullness or Ear discharge.
• With the above complaints, the patient was
admitted to RMCH for better management.
H/O Presenting Illness

9. YES NO
HEADACHE •Diffuse, Persistent
•Daily
•Severe in intensity
•Throbbing
•Nausea
•Radiated towards
neck & left ear
•Aggravated by
head movement
•Thunderclap headache
•Rhinorrhoea
•Lacrimation
•Eye pain
• Sweating,
•Loss of consciousness,
•Transient Blindness.
•Rest, sleep, NSAIDs
had given no relief.

10. YES NO
CONVULSION • Generalized
• Tongue biting
• No Status epilepticus
• No Hospital
Admission
•No Epileptic drug.
VISUAL LOSS •Blurring Vision
•Vision for Near
objects.
•Transient
diplopia attacks.
•Not painful
•No total loss of Vision

11. NO
Features absent in admission:
• Cough, Respiratory Distress
• Vesicles
• Localized Headache
• Trigger points
• OCP, Recent Pregnancy
• No Ear complaints at present:
Fullness, Tinnitus, Discharge
• No history of head injury.
• No Psychiatric Problem

12. History of Past Illness
• Hypertensive for 5 years.
• Diabetic for 3 years.
• No history of :
• Asthma, COPD, Jaundice.
• Tuberculosis
• Allergy
• Trauma

13. `
Family History:
• All her family members are well.
Drug/ Treatement History:
• Antibiotics, NSAIDs
• Metformin 500 BD for DM
• Amlodipine 5 mg daily
• Surgery (Myringoplasty) for CSOM (Lf)

14. Personal History:
• Bettel nuts, leaves: 10/day
Socio economic History:
• Lives in Semi pakka House.
• Housewife
Immunization & Allergy History:
• No history.

15. General
Examination:

16. General Examination
Appearance Anxious/ Ill looking
Body Built Lean Thin
Co operation Co operative
Dicubitus On choice
Anaemia Mild
Jaundice Absent
Cyanosis Absent
Oedema Absent
Dehydration Absent
Koilonychia Absent
Leuconychia Absent

17. Lymph Nodes (Cervical,
Axillary, Inguinal)
Non Palpable
(Abscess in Post
Auricular Region)
Bony Tenderness Absent
Respiratory rate 18 / min
Pulse 100 / min
Blood pressure 150/90 mm Hg
Postural drop Absent
Temperature 100.5 F
Weight 38 Kg

18. SYSTEMIC
EXAMINATION

19. Higher Cerebral Function
Consciousness Level of Consciousness
Attention
Concentration
Orientation
Normal
Affect Mood, Behavior Normal
Cognition Language
Memory
Reasoning
Judgment
Abstract Thinking,
Insight
Normal
MMSE 28/30 Normal
Emotional Lability Absent

20. Upper & Lower Limb Examination:
• Inspection
INSPECTION OF UPPER &
LOWER LIMB
Rt & Left
Muscle Atrophy
Thigh, forearm
Absent
Fasciculation Absent
Dorsal guttering Absent
Skin Changes Absent
Hair Changes Absent
Scar Mark Absent
Pigmentation Absent
Joint Deformity Absent

21. Motor System Examination:
• Bulk of the muscle:
• Tone: Normal
• Power: MRC Grading
Upper Limb Lower Limb
Right Left Right Left
12cm 12cm 13 cm 12 cm
LIMBS Right Left
UPPER LIMB 5 4
LOWER LIMB 5 5

22. Reflexes :
Jerks Findings
Deep Reflexes Rt Lf
Planter Flexor Flexor
Ankle ++ ++
Knee ++ ++
Supinator ++ ++
Biceps ++ ++
Triceps ++ ++
Superficial Reflexes
Abdominal, Cremesteric ++ ++
Cornael, conjuctival Reflex ++ ++

23. Sensory System Examination
Superficial Sensations: Intact (Normal)
Touch, Pain, Temperature N
Deep Sensations: Intact (Normal)
Proprioception, Vibration N
Discriminative sensory
function
N
Steriognosis, Localization
of touch
Two point discrimination
N

24. Co ordination:
• Finger nose test: Normal
• Heel knee test: Normal
• Involuntary movements: Absent
Gower’s Sign: Absent
Rhomber’s test: Negative
Gait:
• Wide based gait
• Tandem walking: Positive
• Tendency to fall towards left side.

25. Nerve Impingement test:
Medial Nerve
Phalans test Negative
Tinel’s sign Negative
Ulner Nerve Test
Fromet’s Sign Negative
Ulnar Stretch Test Negative
Radial Nerve Test
Nerve Thickening Absent
Addson’s Menuaver Negative

26. Spine Examination
Tenderness Absent
Deformities Absent
Range of motion Absent
Meningeal Signs
Neck rigidity
Kernig’s Sign
Brudzinski’s Sign:
Absent

27. Cranial Nerve Examination
Optic (II) Visual Acuity: 6/12
Fundoscopy:
Bilateral Papilloedema with
Optic Atrophy
Trigeminal (V)
3rd, 4th, 6th
8th, 9th, 10th, 11th, 12th

28. Cranial Nerve Examination
Optic (II) Visual Acuity: 6/12
Fundoscopy:
Bilateral Papilloedema with
Optic Atrophy
Trigeminal (V) Sensory Loss
V1, V2 distribution (Rt)
Jaw Jerk: Normal
3rd, 4th, 6th Normal
Nystagmus (horizontal ) Both
Diplopia: False image (Outer)
8th, 9th, 10th, 11th, 12th Normal

30. • Cardiovascular system examination:
• Apex Beat: 5th ICS, MCL
• Heart sounds: Normal.
• Murmur, Thrill: Absent
• Respiratory system examination:
• Trachea: Central
• Breath sound: Vescular with prolonged expiration
• Added sound: No

31. • Abdominal Examination:
Liver, spleen, kidney : Not palpable
Ascites: Absent
• Muskuoskeletal system examination: NAD
Bony deformity: Absent
• Dermatological Examintaion: NAD
Ear Examination:
External Ear: Normal
Discharge: Present (Scanty, sero sanguinous)
Tympanic Membrane: Normal
Posterior Auricular region: Redness with pus point.

32. Positive Findings
YES
• Anemia
• Weight Loss
• Fever (Low grade, everyday)
• Abscess in Post Auricular Region
• Visual Acquity (decreased)
• Nystagmus
• Diplopia
• Sensory Loss V1 V2 Distribution (Left)
• Fundoscopy:
• Bilateral Papilloedema with Optic Atrophy

33. Provisional
Diagnosis
?

34. Provisional Diagnosis
Cerebral Venous
Sinus Thrombosis
(CVST)

35. DIFFENTIAL
DIAGNOSIS
?

36. Differential Diagnosis
1. Cerebral Venous Sinus Thrombosis
2. Brain SOL (Cerebellar)
3. Chronic Meningitis
4. ?

37. INVESTIGATIONS:

38. 1st Line Investigation
• CBC:
• Hb: 9 gm/dl
• WBC: 9000/ cumm
• Platelet: 2.6 lac/ cumm
• ESR: 55 mm 1st hour
• CRP: 12.6
• RBS: 6.8 mmo/l
• S. Creatinine: 0.9 mmol/l
• Urine R/E : Normal Study
• Chest X ray P/A: Normal study
• ECG : Normal Study

39. Chest X ray ECG

40. 2nd Line Investigations
• :
• TSH: 4.8
• S. Electrolytes: Normal
• Audiometry:
• Sensori-neural Hearning loss (Left)

41. 2nd Line Investigations• :
Imaging Study
• CT Scan brain
• MRI with MRV (brain)
FNAC:
• FNAC from Mastoid bone

42. CT Scan: Normal (01/06/18)

43. MRI Brain: 12/06/18
Result: Cerebritis

44. MRI: 12/06/18

46. MRI with MRV: 20/02/19

47. MRI with MRV: 20/02/19

49. Result of MRI with MRV:
• Chronic Mastoiditis with
• Cerebellar Nodular Rim Enhancing Lesion (Left)
• Tubercular Inflammation
• Evidence of Sigmoid Sinus Thrombus

50. CSF Menometry:
• Result:
CSF pressure: 14 mm H2O

51. CSF Menometry

52. FNAC from Left Mastoid:

53. FNAC from Left Mastoid:
Granulomatous Inflammation:
Tuberculosis

54. Confirmed Diagnosis:
Cerebral Venous
Sinus Thrombosis
(CVST)
Due to Infection (Tuberculosis)

55. Management :
General Management Specific Management
• Analgesics • Inj. Enoxaperine 60 U sc bd
• Antipyretics • Tab. Warfarine 5 mg
• Abscess: Drain • Anti TB for 1 year
• Control DM, HTN • Steroid for 1 month(Taper)
• Phenytoin 100 BD

56. Cerebral Venous
Sinus Thrombosis
(CVST)

57. Cerebral Venous System

58. Cerebral Venous System

59. Cerebral Venous System

60. Presentation of CVST:
Throbbing Headache (Chronic) 75 %
Visual (Papilloedema) 50 %
Seizure 35 %
Confusion, Coma 30 %
Focal Signs (motor, Sensory) 30 %
C= Confusion, Coma
V= Visual (Papilloedema)
S= Seizure
T= Throbbing Headache

61. Etiology of CVST
1. Prothrombotic Conditions (Genetic/ Acquired)
2. OCP
3. Pregnancy, Puerperium
4. Malignancy
5. Infections (Head, Face & Ear)
(Cavernous, Transverse & Sigmoid)
6. Head Injury

62. CVST Area
Venous Sinuses %
SSS 55 %
Transverse Sinus 35 %
Deep Venous System 7 %
Sigmoid Sinus < 1%

63. Approach to CVST
Sign Symptoms of CVST
Confirm by Blood work up
MRI & MRV
Identify Risk Factors
Symptomatic
Treatment
Treatment of
Cause
Thrombolysis/
Anticoagulation

64. Anti Coagulant Treatment Duration
Duration
•Provoked CVST 3-6 Months
• Idiopathic CVST 6-12 Months
• Recurrent CVST Indefinite
INR Target: 2-3

65. CVST
Anticoagulants
Stable Rapid Deterioration
Warfarin ThrombectomyEnoxaperine
Warfarin
Hemicraniectomy

66. Endovascular
Thrombectomy
With Fibrinolysis

68. Pakistan College of Physicians & Surgeons
(PCPS) 2019

69. Publication in ‘BIRDEM’ Journal 2019

70. Published 2018

71. Thank You