Paediatric stroke and cerebral sinovenous thrombosis: Case

This girl has a cerebral sinovenous thrombosis until proven otherwise. The progressive headache and vomiting, the papilloedema, the new seizure, and the recent otitis media together form the classic presentation of a dural sinus thrombosis that has spread from the middle ear to the adjacent transverse and sigmoid sinuses. The right hemiparesis suggests a venous infarct in the left hemisphere, which may be haemorrhagic given the venous origin. The priority is to confirm the thrombosis with venous imaging and to initiate anticoagulation. ^[9][1]

Clinical findings and assessment

The key findings are the progressive headache with papilloedema, the seizure, the fever, and the mild right hemiparesis. The papilloedema is the sign that separates a venous sinus thrombosis from a routine postictal headache, because it reflects the raised intracranial pressure from the obstructed venous outflow. The recent otitis media, despite antibiotics, raises the possibility of a complicated ear infection with spread to the mastoid and the adjacent dural sinus, which is the classic local cause of cerebral sinovenous thrombosis in children. ^[9]

The bedside assessment confirms that the airway is patent, the glucose is normal, and the child is cardiovascularly stable, which allows the team to proceed to imaging without delay. The differential of headache, papilloedema, and seizures in a febrile child includes a cerebral sinovenous thrombosis, a brain abscess from the ear infection, and a bacterial meningitis, and the imaging and the lumbar puncture, once safe, will separate them. The working diagnosis is cerebral sinovenous thrombosis, which directs the imaging to include the MRV and the treatment to include anticoagulation. ^[3]