Cerebral Venous Sinus Thrombosis (CVST) in a Middle-Aged Female with Clustering of Risk Factors

Abstract

Thrombosis of cerebral venous channel is a known complication of hypercoagulable states. Hyperhomocysteinaemia is a known hypercoagulable state. Obesity is a modern-day global epidemic. Disorders such as myocardial infarction (MI), stroke, and venous thromboembolism are on the rising trend and its increased morbidity and mortality is being associated with obesity. To date, however, the knowledge about the association between obesity and adult cerebral venous thrombosis (CVT) is sparse. We report a 44-year-old young morbidly obese metabolically unhealthy female who presented with headache, nausea, vomiting and giddiness. On evaluation, magnetic resonance venogram showed cerebral venous sinus thrombosis. On investigations, she had concomitant hyperhomocysteinaemia and metabolic syndrome. Cerebral venous sinus thrombosis causing stroke in young adults is uncommon with various conditions precipitating it.1,2,3 Severe headache (70 - 90 %), focal lateralized signs (25 % - 75 %), seizures (30 – 40 %) as well as behavioural symptoms such as delirium, amnesia, and disturbances in consciousness are the various associated clinical symptoms. The known inherited hypercoagulable risk factors that cause CVST are gain of function mutations in the genes encoding factor V (factor V Leiden) and prothrombin, Protein C, S and antithrombin III deficiency. Hyperhomocysteinaemia, is a known risk factor for causing venous thrombosis of the lower limbs. However, till date there is no data available showing its role in causing cerebral venous thrombosis. The interaction between genetic and acquired determinants result in high plasma levels of total homocysteine (tHcy).4,5,6 Vitamins such as folic acid, pyridoxine, and cobalamin are involved in the metabolic pathways of homocysteine and its deficiencies represent the acquired determinants. Venous thromboembolism (VTE) comprises of deep vein thrombosis of the leg and pulmonary embolism and obesity is now being recognised as one of the risk factors causing it. The risk of VTE is approximately increased to 2-fold in an individual with a body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) of 30 or more compared with a normal BMI (< 25), and higher BMIs increase more risk with approximately 3 times higher risk in individuals with a BMI greater than 40.7, 8,9 Again obesity as a risk factor for CVST is less known.