Introduction: Pseudotumor cerebri is a condition of raised intracranial pressure in the absence of a mass lesion. It is associated with headaches and visual deterioration that may culminate in blindness. When medical therapies fail, surgical options can be considered including lumboperitoneal (LP) or ventriculoperitoneal shunting and optic nerve fenestration.
Methods: This 24 year old female with a two year history of worsening headaches and visual obscuration presented for neurosurgical evaluation after being diagnosed with pseudotumor cerebri by her neurologist. A thorough evaluation ruled out sinovenous thrombosis (SVT) as a cause for intracranial hypertension. She was managed with acetazolmide and serial lumbar punctures. Despite medical management she developed worsening bilateral papilledema and progressive visual loss.
Results: The patient underwent LP shunt insertion which was complicated by symptomatic overdrainage requiring a distal revision on post-operative day two. Two days later, the patient developed a severe headache that was no longer postural in nature. Imaging studies demonstrated an acute superior sagittal sinus thrombus. The patient was transferred to the intensive care unit and therapeutic intravenous heparin was initiated. A hypercoagulable workup was negative. The patient remained neurologically stable throughout the hospital stay and was discharged home feeling well on warfarin.
Conclusions: Dural sinus thrombosis and venous hypertension are known causes of pseudotumor cerebri as a result of venous outflow obstruction. To our knowledge, this is the first report of cerebral SVT occurring in the post-operative course of a patient undergoing LP shunt with a negative hypercoagulable profile. A review of the literature, however, has revealed an association between other conditions causing intracranial hypotension and cerebral SVT and we postulate a similar pathophysiology in our patient.
Patient Care: Help raise awareness of a potential complication of LP shunting in this condition
Learning Objectives: By the conclusion of this session, participants should be able to 1) Discuss the clinical presentation of pseudotumor cerebri 2) Describe the clinical correlation between pseudotumor cerebri and sinovenous thrombosis and 3) Understand potential physiological mechanisms in which shunting patients with this condition could contribute to the development of a cerebral sinus thrombosis