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Abstract Details

Cerebral Sinovenous Thrombosis (CSVT) – Tales Of Caution: Cerebro Spinal Fluid (CSF) analysis and Distinct Radiologic Pattern.
Cerebrovascular Disease and Interventional Neurology
P12 - Poster Session 12 (12:00 PM-1:00 PM)
4-010
Highlight the misleading potential of Cerebro Spinal Fluid (CSF) analysis in non-infectious causes of Cerebral Sinovenous Thrombosis (CSVT). Also underscore a distinct radiologic pattern of CVST that can also mimic viral encephalitis
NA
A 32 year-old G2P2 woman presented with two weeks of headaches, intermittent double vision, one day of bilious vomiting, lethargy and seizure like activity. On arrival patient was intubated, paralyzed, sedated and loaded with 4 grams of Levetiracetam. Temperature-Afebrile. Neurological examination noted symmetric withdrawal to pain in all limbs, otherwise non-focal and limited by the sedation. Past medical history was significant for ovarian induction 3 weeks ago in addition to ongoing supplementation of estradiol.

MRI Brain noted bilateral thalamic (left greater) T2/FLAIR hyperintensities with enhancement. MR venogram was initially read to be normal. CSF analysis: opening pressure 40 cm of water, 38 nucleated cells with 82% neutrophils, 138 red cells, Protein 439.4, Glucose 77 (serum glucose 119). Given the imaging findings and CSF analysis, empiric antibiotics were initiated with presumed infectious etiology. However given the patient’s history of hormonal supplement use, MR venogram was repeated which revealed CSVT involving the bilateral internal cerebral veins, vein of Galen, and straight sinus. Extensive infectious, hyper-coagulable work up turned negative and etiology of CSVT was determined to be secondary to estrogen supplementation. 
While bithalamic T2/FLAIR hyperintensities with patchy enhancement on MRI Brain is well known pattern in viral encephalitis, it is also seen in CSVT albeit under-recognized. CSF analysis (Protein, nucleated cells, red cells, glucose) can be abnormal in 25% of CSVTs and can mimic infectious meningoencephalitis as in our case. These caveats are extremely important as clinical manifestations of CSVT can otherwise mimic that of infectious meningoencephalitis. Although most CSVT are caused by non-infectious etiologies, it should be remembered that rarely it can be secondary to infection(mostly local). 
Authors/Disclosures
Anusha Mangalampalli, MD
PRESENTER 		Dr. Mangalampalli has nothing to disclose.
Sri Raghav S. Sista, MD (UTHouston) Dr. Sista has nothing to disclose.
Gregory M. Blume, MD (University of Illinois College of Medicine) No disclosure on file