Cerebral sinus venous thrombosis is an uncommon condition with different causes and variable clinical presentation that affect cerebral venous drainage . Several factors can lead to cerebral venous thrombosis including mechanical injuries, infectious, inflammatory, hormonal and hematologic disorders . Relation of cerebral venous thrombosis and Multiple Sclerosis documented in patients with history of lumbar puncture and intravenous high dose methylprednisolone treatment in some studies [3,4]. Here we present a case of definite multiple sclerosis that developed cerebral venous thrombosis after high dose intravenous corticosteroid therapy.
A right-handed 24 years old woman with history of definite relapsing remitting MS for 4 years presented with numbness in lower limbs. After taking a precise history and detailed examination, brain MRI was performed and based on clinical and imaging findings the multiple sclerosis attack was confirmed so we initiated intravenous methylprednisolone at a dosage of 1 gr/day for 5 days. She had no history of known illness except multiple sclerosis from 4 years ago. There is no history of oral contraceptive consumption, previuos corticosteroid intake (oral or intravenous) or lumbar puncture. In first visit she complained numbness, paresthesia and reduced muscle strength in lower limbs. Systemic examination was unremarkable. Cranial nerve including fundoscopic exam and mental status was normal. We detected 3.5 muscle force in both legs. Deep tendon reflexes were hyperactive in patellar and Achilles tendons. Plantar reflexes were extensor in both sides. Sensation of pain and light touch was reduced in lower extremities. Cerebral MRI revealed hyper intense plaques on T2 and FLAIR sequences in periventricular and cervical spine with one ring enhancing lesion adjacent left posterior ventricle. Cervical plaques were non-enhancing Figure 1. Lab data were normal.
Figure 1: (a): Axial Flair MRI reveals hyper intense periventricular plaques in favor of MS lesions (b): cervical MRI demonstrates hyper signal plaques (c): MRI with gadolinium and gadolinium enhancing lesion.
The patient set on intravenous methylprednisolone treatment at a dosage of 1gr/day for five days (with divided dosage twice a day). Two days after treatment completion she complained severe headache with superiority in occipital regions accompanied nausea and vomiting without proper improvement with supportive treatment next day seizure complicated the patient general condition. Considering the cerebral venous thrombosis possibility brain MRI and MRV performed immediately. Thrombosis in superior sagittal sinus was determined (Figure 2,3). Therefore anticoagulant treatment initiated with the diagnosis of cerebral venous thrombosis. After 4 days headache was improved significantly and she discharged with oral anticoagulant. All lab tests that may precipitate the patient to thrombosis formation in venous sinuses were requested results were normal.
Figure 2: (a): Coronal T2 MRI demonstrates signal change in superior sagittal sinus. (b): Superior sagittal sinus hyper signal flow in axial view, T2.
Figure 3: Increased signal in superior sagittal sinus in magnetic resonance venography.