2. Case presentation:
A 30-year-old female patient referred from a suburban hospital of western Nepal presented to the emergency department with chief complaint of left-sided weakness which she noticed on waking up. She mentioned that before waking up with weakness, she had experienced a gradual onset debilitating frontal headache for the preceding 4 days but not relieved with over-the-counter medications (Paracetamol and ibuprofen). The headache was continuous, of throbbing nature but not associated with fever, visual or sensory aura, photophobia, photophobia, nausea, or vomiting. There was no diurnal or nocturnal variation in headache, not associated with neck rigidity; however, it was associated with bilateral ocular pain without double vision or vision loss. Her weakness was progressive, gradually involving the right side of the body, and was associated with an inability to speak and bladder/bowel incontinence. There was no history of ear /nasal discharge, dental infection, cough, sinus pain, surgery, or trauma. Further elaboration of history revealed that she had been diagnosed with UC 18 months back and was on immunosuppression under prednisolone and azathioprine. She had no abdominal complaints including diarrhea recently. She had no other comorbidities and was doing fine until this event. She is a non-smoker, non-alcoholic. She was using a levonorgestrel implant as a birth control method for the last 3 years. Her menstrual period was regular. She had a positive family history of stroke in her mother in her 50s.
At presentation, her score on the National Institute of Health Score Scale (NIHSS) was 7 and on the modified Rankin Scale (mRS) was 2. Her vital signs were within normal limits. During the examination, she was disoriented. Power was reduced in bilateral lower limbs (4+/5) whereas it was normal in bilateral upper limbs (5/5). The sensation was not assessable, neck rigidity was absent, and reflexes were intact. The plantar response was flexor bilaterally. Thorough cranial nerves and eye examination were unremarkable, and there was no noticeable change in fundoscopy. She had no cognitive deficits. Systemic examinations were within normal limits.
The hemogram, baseline coagulation profile were normal, however, D-dimer (2.16 ug/ml), ESR (50 mm/hour), and CRP (25 mg/dl) were raised. The coagulation parameters including factor level, homocysteine, and antithrombin III levels could not be measured due to financial constraints. Her cardiac enzymes, renal function test, liver function test, lipid profile, and thyroid function tests were within normal limits. The nasopharyngeal swab Polymerase Chain reaction (PCR) for the SARS CoV-2 virus was negative. With the suspicion of CVT, plain and contrast-enhanced Magnetic Resonance Imaging (MRI) of the brain with Magnetic Resonance Venography (MRV) was sent. Infarction involving the bilateral thalamus (Right > Left) was seen in ADC MAP (figure 1) and 2.3 x 2.6 x 1.5 cm hematoma in the left parieto-occipital region with thin extension to the adjacent area of the left temporal lobe and perilesional edema with some mass effect (figure 2). Thrombosis of the dural venous sinus thrombosis involving sigmoid dural venous sinus (figure 3A), left transverse sinus (figure 3B) as well as the straight sinus (figure 3C) was evident.
She was admitted to the Neurology ward with the diagnosis of bilateral thalamic infarction with dural venous thrombosis due to a hypercoagulable state secondary to UC. She was treated with subcutaneous Heparin 40 U and monitored with APTT, intravenous Leveraticetem, intravenous Dexamethasone, intravenous Mannitol, and intravenous pantoprazole. Regular Azathioprine and steroids were continued for UC. Once her condition stabilized, regular physiotherapy and acupuncture therapy was done. Her hospital stay was uneventful. At discharge, the patient was stable with an NIHSS score of 2 and a score mRS score of 1; a motor power of 5/5 in the right upper/lower limbs and left upper limb whereas it was 4/5 in the left lower limb. She was sent home on oral Dabigatran and oral leveraticetem. All her regular medications were continued at this time. A week following discharge, she developed nausea, vomiting, and multiple episodes of diarrhea and was advised to visit her gastroenterologist. Colonoscopic examination with biopsy revealed severely active pancolitis. She underwent laparoscopic total proctocolectomy with ileal pouch anal anastomosis with diverting ileostomy. She was recovering well during follow-up.