Communicating hydrocephalus due to cerebral venous sinus thrombosis treated with ventriculoperitoneal shunt
A 40-year-old gentleman presented with history of insidious onset headache for 6 months and diminution of vision for 2 months. The headache was holocranial, continuous and of mild to moderate intensity. It was not associated with nausea, vomiting, photo or phonophobia. Since 2 months, he noticed progressive diminution of vision in both eyes. He did not have seizures, altered sensorium or any focal deficit. There was no history of fever. He was previously healthy and was not on any medications. On examination, blood pressure was 120/80 mmHg, general and systemic examination was normal. On neurologic examination, there was optic atrophy in both eyes. Visual acuity in the right eye was 6/60 and there was absent perception of light in the left eye. Rest of the neurologic examination was normal. There were no signs of meningism. A diagnosis of raised intracranial pressure with post-papilloedema optic atrophy was made. A differential diagnosis of chronic meningitis, idiopathic intracranial hypertension and chronic venous sinus thrombosis was made. A computed tomogram (CT) scan of the brain [] with contrast showed mild communicating hydrocephalus. There was no mass lesion, cerebral edema or meningial enhancement. Magnetic resonance venogram (MRV) showed near-complete thrombosis of the right transverse sinus and partial thrombosis of the left transverse and the sigmoid sinus []. Cerebrospinal fluid (CSF) manometry demonstrated opening pressure of 30 cm of CSF in the lateral decubitus position. Twenty of CSF was drained and the pressure reduced to 15 cm. The CSF did not show any cells, while proteins were 5 mg/dL and sugar was 99 mg/dL (blood sugar of 130 mg/dL). India ink preparation and cryptococcal antigen were negative. Post CSF drainage, the headache promptly decreased in intensity. Two days later, the headache recurred. CSF manometry was repeated, where the opening pressure was 27 cm. CSF was drained and pressure was reduced to 15 cm of H2O. There was relief of headache for the next 2 days. Two days later, the headache recurred and CSF manometry (pressure of 30 cm) with drainage of CSF was repeated for the third time, which resulted in prompt relief of headache. In view of persistently elevated CSF pressure and presentation similar to IIH, a thecoperitoneal (TP) shunt was performed. The patient had relief of headache following TP shunt. Post TP shunt, he was started on low-molecular heparin followed by warfarin for venous sinus thrombosis. He did not have headache for the next 4 weeks but there was no improvement in vision. After 4 weeks, the headache recurred and was severe in intensity. CT scan of the brain did not show any significant change. In view of failure of TP shunt to relieve headache and persistence of hydrocephalus, a ventriculoperitonial (VP) shunt was placed. Post VP shunt, there was relief of headache and reduction in ventricular size but no improvement in vision. Six months later, he is free of headache although there is no improvement in vision. He is on oral anticoagulation for chronic venous sinus thrombosis.