Dados do Trabalho

Título

STROKE ASSOCIATION WITH EXTENSIVE CENTRAL VENOUS TROMBOSIS IN THE CONTEXT OF NEUROINFECTION

RESUMO

A 48 old female patient was admitted to the emergency department due to several episodes of seizures without recovery of consciousness lasting more than 5 minutes. There was no record of previous diseases besides one hospitalization due to status epilepticus four months earlier, from which she was discharged with valproate 500 mg once a day. Nonetheless, the patient was known to live in precarious situation and to be a frequent user of alcohol, tabaco, crack and cocaine.
At the admission, the patient presented comatose, however without vital signs alterations. She was stabilized after pharmacological measures and was performed intubation for clinical support. Physical examination revealed left hemiparesis, worse at the upper limb and right eye mydriasis. The Neurological Team was required due to symptoms being presented within time for thrombolytic use in case of acute stroke.
A head computed tomography (CT) scan revealed intense cerebral oedema and hyperdensity of the cerebellar tentorium. At CT angiography it was observed absent flow in inferior sagittal sinus, straight sinus and bilateral transverse sinus. Patient was conducted as a case of Central Venous Thrombosis and transferred to the intensive care unit.
Patient recovered partially with persistence of right eye mydriasis and after waking up, presented right ptosis. Further investigation revealed on Magnetic Resonance Restricted diffusion within the right lateral portion of the pons and midbrain, identifying compatible ischemia with clinical findings and pachymeningeal enhancement on cerebellar tentorium too. It was also performed an angiography that observed absent flow in sinuses and diffuse small venous engorgement leading to the hypothesis of ischemia associated with low venous flow.
Fluid analysis showed discrete rise of cellular count (06 cells with 70% lymphocyte) hyper proteinorachie (66 mg/mL) and hypoglycorrhachia (CSF to serum glucose ratio 0,45).
Granulomatous disease such as tuberculosis was raised as a suspicion. On CT scan, the patient had a typical diffuse “tree-in-bud” pattern, consolidations and cavitations.
This report intention is to contribute to the differential diagnosis and relevance of neuroinfection causing CVT which can also be responsible for arterial ischemia. Association of epidemiological features with unusual differential diagnosis were vital to deliver the right treatment for the patient and could be used as an example of a good clinical practice.