S2265 A Subtle Headache: Cerebral Venous Sinus Thromboembolism in Young Patient With Ulcerative Colitis

INTRODUCTION: Cerebral venous sinus thromboembolism (CVST) is the presence of a blood clot in the dural venous sinuses. Inflammatory bowel disease (IBD) is a chronic inflammatory state that leads to increased risk of venous thromboembolism (VTE).The symptoms of CVST may be subtle; therefore a high sense of clinical suspicion is needed to diagnose this condition. CASE DESCRIPTION/METHODS: A 23-year-old man with history of ulcerative colitis presented with bloody diarrhea, headache and recent fall. He described feeling lightheaded, with blurry vision followed by loss of consciousness. Physical examination revealed left temporal laceration. Neurologic and abdominal exam were normal. Labs showed a white blood cell (WBC) count of 20.8, Hgb of 8.9, platelet count of 121, fecal calprotectin of 1394, and lactic acid of 2.5. Complete metabolic panel, and c-reactive protein were normal. Stool exam showed presence of WBC otherwise stool infectious workup was negative. Computerized tomography (CT) of the head showed left frontal lobe regions of decreased and increased attenuation (Figure 1). Magnetic resonance imaging (MRI) of the brain showed left frontal lobe areas of abnormal signal intensity (Figure 2). Magnetic resonance venography of the brain revealed bilateral venous thrombus involving the proximal jugular vein, sigmoid sinuses, left transverse sinus, and left superior sagittal sinus (Figure 3). The patient was started on intravenous methylprednisolone and unfractionated heparin. A flexible sigmoidoscopy showed a mayo endoscopic score of 3. He was started on infliximab with improvement of his symptoms. He was discharged on coumadin, azathioprine, prednisone taper and outpatient infliximab infusions. DISCUSSION: The symptoms of CVST may include headaches, seizures or any stroke like symptoms. IBD patients have a 3-fold higher risk of VTE compared with the general population and 6-fold higher risk during hospitalized IBD flares. Moderate-severe disease activity is an important factor that drives the increased risk of VTE in IBD. The diagnosis is made with CT scan, MRI with venography, or cerebral angiography. Treatment consists of anticoagulation (AC) but in some cases thrombectomy or thrombolysis may be pursued. Duration of AC varies from 3 months to indefinitely. Surgical intervention is warranted when intracranial pressures are severely increased. CVST is a rare presentation of VTE in IBD. Clinicians should be concerned for CVST in IBD patients who present with headaches, focal neurologic deficits or seizures.Figure 1.: CT of the head without contrast showing left frontal lobe regions of decreased attenuation suggestive of vasogenic edema and left frontal lobe increased attenuation suggestive of intracranial hemorrhage.Figure 2.: MRI of the brain showing left frontal lobe areas of abnormal signal intensity.Figure 3.: MRV head showing bilateral venous thrombus involving the proximal jugular vein, sigmoid sinuses, left transverse sinus, and left superior sagittal sinus.