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A 47 year old woman presented to the emergency department with a two week history of a global headache and a one day history of vomiting, photophobia, and blurred vision. She also reported night sweats during that period. Her general practitioner had prescribed simple analgesics for the headache, but they had had little effect.
She had been healthy previously and was on no regular medication. General examination revealed temperature 36.8 °C, pulse 84 per minute, and BP 120/90 mm Hg, bilateral subconjunctival haemorrhages, and left axillary lymphadenopathy. Chest and abdominal examinations were unremarkable. Neurological examination revealed the patient to be fully alert and orientated with a Glasgow Coma Scale score 15/15. She had neck stiffness and positive Kernig’s sign suggesting “meningism”, but there were no signs of raised intracranial pressure at this stage.
Routine blood investigations revealed haemoglobin 8.9 g/dl, white blood cell count 23.0×103, platelets 18×106, international normalised ratio 1.59, and prothrombin time 16.3 seconds. An initial blood film identified blast cells of myeloid origin, later confirmed by bone marrow biopsy. An urgent CT scan was unremarkable with the exception of some fluid in the right sphenoid sinus.
A provisional diagnosis of acute myeloid leukaemia with sepsis was made and the patient was commenced on a regimen of broad spectrum antibiotics, ceftazidime, and gentamicin, and then later, cytotoxics. Despite treatment she continued to deteriorate with decreasing level of consciousness and a magnetic resonance imaging (MRI) scan (fig 1) confirmed superior sagittal sinus thrombosis with extensive surrounding oedema and an area of venous infarction. One week after admission, in spite of treatment, she developed a further large intracerebral bleed (fig 2) and died.
Superior sagittal sinus thrombosis is a rare but serious condition presenting with symptoms and signs of raised intracranial pressure, such as headache, vomiting, and papilloedema. Convulsions and haemorrhagic cerebral infarction are well recognised complications. The thrombosis may be a primary event or secondary to a neighbouring focus of infection. The investigation of choice for suspected cerebral venous thrombosis is MRI since a significant number will be missed on computed tomography.1 Initial treatment of a confirmed thrombosis involves administration of intravenous heparin followed by oral anticoagulation with warfarin. More recently locally introduced thrombolytics have been used with some success in deteriorating patients.
Although thromboembolic events in haematological malignancies are well known, the complication of superior sagittal sinus thrombosis is an extremely rare event and is usually secondary to treatment. In one retrospective study2 36 of 283 patients (11%) experienced a thromboembolic event over a 10 year period. These consisted of deep vein thrombosis, pulmonary embolism, and ischaemic stroke; there were no reports of intracranial venous sinus thrombosis.
Competing interests: none declared