Cerebral venous thrombosis presenting as multiple lower cranial nerve palsies
A 34-year-old pregnant lady in last trimester presented with headache of two months duration and difficulty in speaking, swallowing, and tinnitus of two weeks duration. Headache was mainly in the occipital region radiating to the retroauricular region and the back of the neck. It was initially associated with vomiting. Six weeks after the onset of headache, she developed slurring of speech, hoarseness, nasal twang of voice and difficulty in swallowing with nasal regurgitation. She had also difficulty in moving the tongue side-to-side and hearing with right ear.\nOn examination, the lady was pale, and her speech was dysarthric. The first seven cranial nerves were normal. Fundi were bilaterally normal. Sensorinural deafness was present on the right side. There was arching of the palate to the left side, and palatal movements were decreased on right side. Gag reflex was absent on the right side. The trapezius and the sternocleidomastoid muscles had normal strength. There was weakness of the tongue with deviation to the right side. Rest of the neurological examination was normal. ENT examination did not reveal any focus of infection.\nHer routine blood examinations showed hemoglobin of 10 gms, total count of 7000 cells/cumm, and an ESR of 76 mm/hr. Her routine urine examination, liver, and renal function tests were normal. Anti-nuclear antibody and anti-phospholipid antibodies were negative. Serum homocystine and C-reactive protein values were normal. Coagulation profile including prothrombin time, activated partial thromboplastin time was normal. Her blood culture and sensitivity were negative. Pure tone audiometry showed moderate sensorineural deafness of right ear. Magnetic Resonance Imaging (MRI) of brain with Magnetic Resonance Venogram was done and showed a thrombus in the right internal jugular vein and sigmoid sinus [Figures and ]. The thrombus was extending to right transverse sinus and confluence of sinuses []. The patient was treated with heparin in the hospital for a total of 4 week and subsequently switched over to oral anticoagulants. She had an uneventful twin delivery. Her neurologic signs and symptoms slowly improved over one week. At the time of discharge, she had residual sensorineural deafness.