Paradoxical presentation of orthostatic headache associated with increased intracranial pressure in patients with cerebral venous thrombosis
A previously healthy 29-year-old man visited the hospital complaining of headache for the past day. The headache was localized to the bifrontal–temporal area with moderate to severe intensity (VAS 7–8/10), and was squeezing in nature. The symptoms developed only when the patient stood up, and were partially relieved when lying down (VAS 2-3/10). We performed CSF tapping and checked intracranial pressure under suspicion of SIH. However, the CSF opening pressure was 36 cmH2O (normal range: 8-18 cmH2O). MRI of the brain showed no definite parenchymal lesion, but gadolinium-enhanced T1-weighted images revealed the empty delta sign with enhancement of the collateral veins in the SSS walls surrounding a non-enhanced thrombus in the sinus. Also, there were no findings suggesting SIH. MRV revealed a voiding defect in the SSS, right transverse sinus and right sigmoid sinus. Diagnosis of CVT according to the clinical presentation and imaging findings was made. The patient's headache near completely subsided after intravenous anticoagulation treatment. He remained asymptomatic after 13 months of follow-up.