A 30-year-old Ethiopian woman presented after 2 weeks of generalized headache, accompanied by blurred vision, dizziness and nausea. She explained that since developing the headache, she also struggled to find words to express herself. Over-the-counter medications did not relieve her headaches or other symptoms.
Her medical history included delivery of a fetus that had died 2 months previously. She had no other history of stillbirth or miscarriage. She had not been diagnosed with diabetes, high blood pressure or heart disease. She noted that she was not using oral contraceptives.
On physical examination, clinicians noted that her blood pressure was 130/70 mm Hg, pulse 92 beats per minute, respiratory rate 13 breaths per minute, and temperature 36.5°C (97. 7°F).
Clinicians performed a neurological assessment. The patient was fully conscious and oriented; his coma score in Glasgow was 15/15; and examination of his cranial nerves, motor, and sensory functioning produced no remarkable findings. Fundus ophthalmologic examination identified grade 2 papilledema affecting both eyes.
Cognitive assessment of the patient using a 60-second word generation test indicated significantly impaired performance; she could only name one wild animal in 60 seconds.
Other aspects of the patient’s language skills – including fluency, comprehension, repetition, writing and reading – were normal. Brain imaging findings were suggestive of cerebral venous thrombosis (CVT): magnetic resonance imaging (MRI) revealed left lower temporoparietal ischemia and magnetic resonance venography (MRV) showed thrombosis of the left transverse and sigmoid sinus as well as the corresponding cortical veins.
Routine laboratory test results were unremarkable. The patient declined to have further evaluations recommended due to financial difficulties, so clinicians were unable to perform detailed thrombophilic workups such as factor V, protein C, and protein S.
Clinicians confirmed their diagnosis of CVT and admitted the patient to the medical ward. She started bridging anticoagulation with heparin 17,500 IU subcutaneously twice daily for 4 days, followed by warfarin 5 mg daily.
After 7 days of hospitalization, the patient’s symptoms began to improve and she was discharged home with instructions to continue oral anticoagulant therapy.
At a follow-up assessment a month later, she reported that her headache was resolved and her difficulty finding words had improved significantly, which clinicians confirmed using the word generation test. of 60 seconds.
At her second follow-up at 6 months, clinicians noted complete resolution of her clinical signs and symptoms, although her financial constraints precluded follow-up MRI and MRV evaluations. Clinicians discontinued oral anticoagulation at this time, based on their suspicion that her CVT was due to transient risk factors, such as postpartum.
Discussion
Clinicians reporting this case of a patient who developed reversible anomia as a complication of cerebral venous thrombosis noted that prompt diagnosis and treatment are essential for a benign prognosis.
They explained that this cerebral vein and sinus thrombosis is rare and easily misdiagnosed. Typical clinical features of CVT include focal cerebral edema, cerebral venous infarction, seizures, and intracranial hypertension.
It can occur in the postpartum period “in association with inappropriate perinatal care, metabolic disorders, and infections associated with childbirth,” the case report authors noted. Peripartum-associated CVT is reported in 11.6 per 100,000 deliveries.
Overall, CVT is a rare and life-threatening type of stroke – affecting around 5 in 1 million people, often women and younger women (average age 30-40). Without proper treatment, 4.3% of patients die during the acute phase of CVT.
Risk factors for CVT include “inherited thrombophilia, acquired hypercoagulable and hyperviscosity states such as hyperhomocysteinemia, antiphospholipid antibody syndrome, Behcet’s disease, and hematological disorders,” the authors noted, adding that it has also been associated with pregnancy and early postpartum. period, as well as with the use of oral contraceptives.
The case authors noted that while they attributed this case of CVT to transient postpartum effects, other researchers linked the condition to protein C and protein S deficiency and the use of oral contraceptives. They acknowledged that their report was limited by the lack of a thorough thrombophilic workup, due to the patient’s financial situation.
80% to 90% of CVT cases present with headache; anomie is seen less frequently, they wrote, citing the only two other reports of isolated anomie in patients with CVT, one in a 52-year-old woman.
In a 1985 review of 38 cases of CVT, the most common signs were headache (74%) and papilledema (45%). Among the focal neurological deficits, the most common was hemiplegia (34%), followed by seizures (29%), confusion or coma (26%) and dysphagia (1%).
“In the present case, the presence of headache, nausea, vomiting and bilateral papilledema indicated increased intracranial pressure, which occurs as a result of obstruction of cerebrospinal fluid absorption” , the authors noted, which is consistent with findings from other research studies. Less commonly, word-finding problems occur in patients with CVT “when the parietotemporal region of the dominant hemisphere is affected following thrombosis of the transverse, superior, and sigmoid sinuses,” the group explained.
The complex language function of naming requires the involvement of many cortical regions, the authors write: “However, anomie is usually associated with lesions involving the inferior temporal gyrus and adjacent parieto-occipital lobes of a dominant hemisphere” , areas of the brain that are drained by the ipsilateral transverse sinus, cortical sites, and sigmoid sinuses.
In this case, as in the other two previously reported, anticoagulant treatment was associated with “significant clinical improvement, including reversal of anomie.”
Disclosures
The authors of the case report noted no conflict of interest.
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