A 35-year-old female presented with subacute onset right hemiparesis, fever, headache, and seizures over the past three days. Imaging revealed a cerebral venous thrombosis involving the superior sagittal and right sigmoid sinuses. She was treated with anticoagulation and antiepileptic medications.

1. Presented by Maj Gaurav Pathania
Moderated by Col YS Sirohi
SATURDAY CLINICAL MEETING

2. Personal Particulars
• 35 years/ Female
• Right handed
• Educated up to Class 10th
• Homemaker
• Resident of Pune
• Informant: self and husband
• Reliability: Good
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3. Presenting Complaints
• Headache x 3 days
• Fever x 3 days
• Seizures (3 episodes of GTCS) x 2 days
• Weakness right side of body x 2 days
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4. History of Presenting Complaints
• Fever x 3 days(since 17 Aug)
-low grade
-continuous
-associated with chills
• Headache(since 17 Aug)
-occipital
-moderate in intensity
-throbbing in nature
-Increased on coughing/sneezing
-associated with 3-4 episodes of vomiting
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5. History of Presenting Complaints
• 3 episodes of seizures
• 1st episode on 18th Aug -> 2nd episode (19 Aug)->
3rd episode (20th Aug)
• Associated with tonic clonic movements of body
• Loss of consciousness of approx 5 minutes
• No tongue bite/incontinence
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6. History of Presenting Complaints
• Weakness x 2 days duration
-subacute onset:
-involving right upper and lower limb
-progressed over 2 days
Associated with facial deviation to the left
and double vision.
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7. No history of:
• Loss of temperature, pain, touch sensations
• Vertigo, incordination
• Bowel or bladder involvement
• Severe physical exertion/ dehydration
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8. Past History
• No h/o
-Hypertension
-Type 2 Diabetes Mellitus
-IHD
-Trauma/recent surgery
-BOH, OCP use, exposure to high altitude.
-
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9. MENSTRUAL HISTORY
• Menarche at the age of 13 years
• Two living issues
• No h/o foetal loss
• Normal menstrual cycle 28 days/ 4 days
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10. Personal History
- Mixed diet
- No alcohol/ tobacco consumption
- Sleep pattern normal
- No h/o high risk behavior
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11. Summary
• 35 yr old female with subacute onset right
hemiparesis with UMN VII N and bilateral VI
nerve palsy in a background of fever ,
headache and seizures without sensory ,
cerebellar ,autonomic or extrapyramidal
involvement.

12. Diagnosis
• Functional- Rt hemiparesis, dysarthria,diplopia
• Physiological- Corticospinal, corticobulbar
• Anatomical- Cortex
• Etiologic- infective, demyelinating, vascular

13. General Examination
• Height: 160 cm; Weight: 60 kg
• BMI: 23.43 kg/m2
• Pulse: 80/ min, regular, normal volume, normal
character, no radio radial, no radio- femoral delay
• BP: 112/70 mm Hg RAS( no postural fall)
• RR: 14/ min, regular
• Temp : 101 F
• JVP : →not raised
• No external spine deformity
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14. General Examination
• No pallor/ icterus/ cyanosis/ clubbing/ pedal
edema /lymphadenopathy
• No dysmorphic features
• No neuro-cutaneous markers
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15. • CVS: S1 S2 heard
No S3 S4 murmurs heard
• Resp: B/L vesicular breath sounds heard
No adventitious sounds
• P/A : Soft, non-tender;
Liver/ spleen: not palpable
Bowel sounds: present
No free fluid
Systemic Examination
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16. Systemic Examination
• CNS
- Right handed
- Conscious, cooperative , well oriented in
time , place and person
- Speech: Dysarthria
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17. Systemic examination
Cranial nerve examination
I - Olfactory sensation intact
II - Near vision b/l - N/5
Distant vision b/l – finger count at 1m
Colour vision – Normal
Pupils B/l equal and reacting to light
Fundus B/L papilloedema +
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18. • III, IV, VI
-Diplopia at 1 m lateral horizontal fields B/L
- External ocular movements – Abduction
restricted b/l
-No nystagmus
-No ptosis present
-Accomodation and ciliospinal reflex present
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19. • V Sensation over the face intact
• VII Facial muscle weakness + on the right side
Taste sensation Ant 2/3 rd of tongue intact
• VIII Normal
Forced whisper test
Rinne’s test- AC>BC b/l
Weber’s test – No lateralization to either side
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20. IX, X Uvula central
Palatal movements (b/l) equal and normal
Gag reflex +
XII Tongue central
No wasting and fasciculation
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21. • Motor system:
- Bulk : normal
- Tone reduced on the right side
-Power : Grade 3 in all muscle groups on the
right side and Grade 5 on the left side with
truncal muscle weakness.
Systemic Examination
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22. • Reflexes
BICEPS TRICEPS SUPINATOR KNEES ANKLE PLANTAR
RIGHT - - - + +
LEFT ++ ++ ++ ++ + ↓
Systemic Examination
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23. CNS Examination cont…………….
• Sensory system: normal
- Touch, pain, temperature
- Position, joint sense and vibration
- Cortical sensations :Tactile localization ,tactile
discrimination and stereognosis normal
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24. • Cerebellar signs: Negative
• Autonomic system : Normal
• No skull and spine abnormality
• No thickened nerves
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25. Summary
• 35 years old female presenting with sub acute
onset Rt hemiparesis, associated with facial
and neck weakness, dysarthria, B/L VI nerve
and UMN VII nerve palsy . Without sensory,
cerebellar, autonomic or extrapyramidal
involvement.

26. Diagnosis
• Functional- Rt hemiparesis, dysarthria,diplopia
• Physiological- Corticospinal, corticobulbar
• Anatomical- Cortex
• Etiologic- infective, demyelinating, vascular

27. Investigations (17 August 16)
Parameter Patient Value Normal range
Hb 8.2 g/dL 15.5 ± 2.5 g/dl
TLC 11000/cumm 4000-11000 /cumm
DLC P72 L22 P 40-75, L 20-45, M2-8,
E 0-4, B 0-1
Platelets 4.19 lakhs/cumm 1.50 – 4.00 lakhs/cumm
Urea 25mg/dl 10-50 mg/dl
Creatinine 0.7 mg/dl 0.8-1.4 mg/dl
Na 138 mEq/dl 135-145 mEq/l
K 3.8 mEq/dl 3.5 – 4.5 mEq/l
Ca 8.8 mg/dl 9 -11 mg/dl
PO4 2.8mg/dl 2.5 – 4.0 mg/dl
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28. Investigations (17 August 16)
Parameter Patient value Normal Range
Bilirubin (Total) 0.8mg/dL 0.1 – 1.0 mg/dl
AST 24 IU/L 0-40 IU/L
ALT 16 IU/L 0-40 IU/L
Total proteins
Alb/Glob
6.6 g/dl
3.3/3.3 g/dL
6-8 g/dl
3.5-5.5/1.8-3.6 g/dl
PT/PTTK/INR 13.8/32/1.08 0-170 IU/L
B Sugar R 108mg/dL
ESR
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29. Chest X-ray – WNL
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30. ECG
Standardization – normal
Rate – 100/ min
Rhythm - Regular
Axis – 90 degrees
P wave- Normal
QRS complex - Normal
T wave - Normal
PR interval – 0.12 sec
QT/QTc -0.36 sec/ 0.40 sec
Any other abnormality – Nil
Impression - NAD
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31. NCCT Brain(19/09/16)
• Non hemorrhagic venous infarction in bilateral
high parietal region
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32. CECT BRAIN(18/09/16)
• Hyperdense lesion of superior sagittal sinus,
right sigmoid sinus and draining veins in high
parietal region with filling defect suggestive of
cortical venous thrombosis.
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33. MRI BRAIN
• Cerebral venous thrombosis involving deep
venous system with consequent parenchymal
haemorrhagic subacute changes left frontal
and bilateral parietal lobes (left>right).
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34. Investigations (29 Aug 16)
Parameter Patients’s Value Normal range
Hb 9.3 g/dL 15.5 ± 2.5 g/dl
TLC 10300/cumm 4000-11000 g/dl
DLC P70 L29 P 40-75, L 20-45, M2-8,
E 0-4, B 0-1
Platelets 5.3 Lakhs/cumm 1.50 – 4.00 lakhs/cumm
Ures 16 mg/dl 10-50 mg/dl
Creatinine 0.7 mg/dl 0.8-1.4 mg/dl
Na 134mEq/dl 135-145 mEq/l
K 3.9mEq/dl 3.5 – 4.5 mEq/l
Ca 8.6 mg/dl 9 -11 mg/dl
PO4 4.3mg/dl 2.5 – 4.0 mg/dl
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35. Investigations (29 Aug 16)
Parameters Patient’s Value Normal value
Bilirubin (Total) 0.6 mg/dl 0.1 – 1.0 mg/dl
AST 36IU/L 0-40 IU/L
ALT 81 IU/L 0-40 IU/L
Total proteins
Alb/Glob
6.3 g/dl
3.1/3.2 g/dL
6-8 g/dl
3.5-5.5/1.8-3.6 g/dl
PT/PTTK/INR 15.8/31.8/1.26
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36. Procoagulant workup
• Extractable nuclear antigens : negative
• Sr Homocysteine : 9.36umol/l(4.44-13.56)
• Factor V leiden mutation : not detected
• APLA: negative
• ACLA : negative
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37. INITIAL MANAGEMENT
• Seizure Precautions
• IV FLUIDS NS 100ml/hr
• Inj Mannitol 200ml 8 hourly
• Tab Levetiracetam 1 gm BD
• Inj Sodium Valproate 500 mg BD
• Inj LMWH 60 mg s/c BD
• Tab PCM 650 mg BD
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38. FURTHER MANAGEMENT
• Started on oral anticoagulation(Tab Warfarin
5mg @ 1600 hrs from 22 Aug 16
• Tab Valproate ER 500mg BD
• Tab Levetiracetam 1gm BD
• Tab Domstal 1 BD
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39. Aim
• Discuss the approach to a patient with
headache, seizures,
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40. THANK YOU
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