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Cerebral venous sinus thrombosis (CVST) is a severe disease that is increasingly prevalent with a large range of clinical presentations. The use of oral contraceptive pills (OCPs) is one of the most prevalent causal factors of CVST. We report a case involving a 40-year-old woman who developed CVST after having just started a short course of OCPs to delay her menstrual cycle. The patient presented with a headache, vomiting, and right-sided weakness that was transient. CT angiography showed thrombosis of the right transverse sinus extending to the sigmoid sinus and the internal jugular vein. She was started on anticoagulation therapy and made an excellent recovery.
Cerebral venous sinus thrombosis is a rare disease with an annual incidence of 0.5-1 percent and is most common in women of childbearing age [1]. Most of the time, it is the result of the combination of multiple factors, which, as in the case of CVST, involve pregnancy, oral contraceptive use, and the presence of some form of thrombophilia, whether hereditary or acquired [2].
Oral contraceptive pills do indeed increase the cerebral venous sinus thrombosis (CVST) risk) and cause a hypercoagulable state, increasing blood viscosity and altering coagulation mechanisms. The use of OCPs increases the risk of CVST several times [3]. Given the potential seriousness of this condition, it is critical that time be of the essence in making a diagnosis as well as initiating treatment
A 40-year-old female with no notable history of past medical issues presented herself with 5-days of right-sided headache, which has progressively worsened, and multiple incidents of vomiting. Throughout the progression of this disease, she became weak on the right, which was at least partially improved by the time of the presentation. She described the headaches to be accompanied by blurred vision and some episodes of vertigo. Denies a history of seizure, loss of consciousness or febrile illness of any sort. On further examination, she was found to have an intact mental status, and all her vital signs were stable. No focal motor deficits were found and the neuro exam was intact. Papilledema was found, which was consistent with her presenting complaints, suggestive of increased intracranial pressure Investigations For her initial lab workup, including complete blood count and coagulation profile, all tests were found to be within normal limits. Non-contrast CT of the brain was also done for any acute abnormalities of the brain. Due to the persistent nature of the patient symptoms and clinician suspicion, CT angiography of the head and neck was obtained and revealed a filling defect within the right transverse dural venous sinus and extending into the right sigmoid sinus with further extension to the proximal segment of the right internal jugular vein. The radiological examinations were in line with massive cerebral venous sinus thrombosis Diagnosis Cerebral venous sinus thrombosis with extension to the right transverse sinus, sigmoid sinus, and internal jugular vein, and the most common possible causative factor was cited to be the recent use of oral contraceptives Management Oral contraceptive use was stopped as of the date of the diagnosis. The patient was started on therapeutic anticoagulation using low molecular weight heparin, which was later converted to oral anticoagulant therapy. Pain control, symptomatic antiemetics to relieve vomiting, and supportive management through adequate hydration and thorough neurological observation were also given. Anticoagulation, as is the case with CVST, is the foundation of therapy and is advised in the presence of intracranial hemorrhage, unless it is contraindicated [4]. Outcome and Follow-up The patient gradually improved during hospitalization, and the headache was fully resolved, the neurological deficits did not recur. The patient remained symptom-free at the 3-month follow-up. Repeat neuroimaging showed the expected recovery pattern consistent with partial recanalization of the venous sinuses affected and the use of appropriate anticoagulant therapy [4]
Cerebral venous sinus thrombosis presents a wide variety of clinical manifestations, among which headaches are most frequent and complaints of focal neurological deficits, seizures, and symptoms of increased intracranial pressure like vomiting and papilledema are also common [1,5]. The right-sided weakness of this patient is likely due to venous stasis or early venous dead tissue [venous] infarcts.
It is known that combined oral contraceptives (COCs) lead to a thrombogenic state due to increments of thrombogenic factors and decreases of anti-thrombotic factors [2]. Meta analyses state that the use of COCs may cause a CVST risk factor of about 7 [3].
For a diagnosis to be established, brain imaging is indispensable. Although MR Venography is the preferred method, CT Angiography and Venography are far more accessible. They also help make the diagnosis of venous sinus thrombosis by showing intraluminal filling defects [5]
It is also important to initiate anti-coagulation therapy promptly, which has been always reported to result in better outcome such as reduced morbidity and higher recanalization rates [4]).
The given case illustrates the danger of using oral contraceptives in the short-term and the aggravation of cerebral venous sinus thrombosis. Clinicians need to be alert to the likelihood of a new headache, vomiting, or focal changes in neurological functioning in patients that have recently undergone hormonal treatment. Early diagnosis and anticoagulation therapy play a key role in offering the most clinically favorable results.
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