Another hyperemesis gravidarum? Probably not.: A Case Report on Cerebral Venous Sinus Thrombosis in Early Pregnancy

Abstract

IntroductionPregnant ladies in early stages of pregnancy frequent the emergency department with nausea and vomiting. They are usually diagnosed as hyperemesis gravidarum, which has a prevalence of 10%. Cerebral venous sinus thrombosis during pregnancy is an uncommon diagnosis. It can present with a range of symptoms, and often left undiagnosed. Case reportA 37-year-old (gravida 5, para 4) with 8 weeks of pregnancy presented with nausea and vomiting for 2 weeks. She was treated as hyperemesis gravidarum in her previous visit. Further history revealed left-sided headache over the past 2 weeks, which was described as “the worst headache in her life” a night before presentation. She was well, with uneventful previous pregnancies; and she was not on oral contraceptives. On arrival, she had a pain score of 10/10 with normal vitals and no neurological deficit. An hour later, headache persisted despite being given opioids, and she got drowsy. There was an episode of raised blood pressure-169/113mmHg. Re-examination noted generalised reduction of power to 3/5, but no meningeal signs. Her routine laboratory investigations were unremarkable, while urinalysis showed ketone 2+ but no protein. Computer tomography (CT) of the brain revealed a large left temporal acute intraparenchymal haemorrhage. MRI brain showed left transverse and sigmoid sinus thrombosis causing left temporal intraparenchymal haemorrhage. Neurosurgical team planned for conservative management and started her on Levetiracetam and subcutaneous Enoxaparin. ConclusionCerebral venous sinus thrombosis is uncommon and has variable clinical presentations. Hyperemesis gravidarum is common in early pregnancy, but it can mask other acute cerebral disorders. Clinicians should remain thoughtful and consider other differential diagnoses, especially with the presence of neurological deficit. Most clinicians hesitate to perform CT brain in pregnancy due to the myth of fetal radiation. However, benefits outweigh the risk due to the low radiation dose of <0.5mGy.