Grave's disease with transverse and sigmoid sinus thrombosis needing surgical intervention
A 42-year-old female, a diagnosed case of Graves disease, was on treatment for thyrotoxicosis. Her thyroid profile was as mentioned in . She was on Tab. Neomercazole 10 mg tds and Tab. Propranolol 10 mg tds. Serum Anti Microsomal Antibody (AMA) and Anti Nuclear Antibodies (ANA) levels were negative. Ultrasound (USG) thyroid showed increased size of both lobes of thyroid suggestive of goiter. Radio isotope thyroid uptake study showed a 33.6% thyroid uptake of 99mTcO4 (Normal 1-4%) suggestive of multinodular goiter with increased trapping function. Her thyroid hormone levels were controlled on anti thyroid medications.\nShe presented to us with headache, drowsiness, and decreased ability to move the left side of her body since three days. Computed Tomography (CT) of the brain showed a large right sided parietoccipital hypodense region with areas of hyperdensity suggestive of venous infarct with hemorrhagic transformation []. A right temporo-parietal craniotomy was performed. On opening the dura the brain was seen to be tense. A lax duroplasty was perfomed. Post-operatively, she was ventilated electively for 48 hours and then extubated. There were no added neurological deficits. She was given intravenous Mannitol 100 cc 8 hourly (for 3 days), Phenytoin Sodium 100 mg 8 hourly, along with other pre operative medicines. Three days (72 hours) after the surgery, she was started on injection Enoxaparin 0.6 mg subcutaneously 12 hourly for 6 days followed by Tab. Asprin 150 mg once a day for 6 months.\nPost operative CT scan performed after five days showed an organized infarct in the right parieto occipital region with no midline shift []. Magnetic Resonance Imaging (MRI) performed three weeks after the surgery showed well defined areas of altered signal intensity involving grey and white matter in right parieto occipital region with gyriform and adjacent dural enhancement []. Magnetic Resonance Venography (MRV) showed absent signals in right transverse and sigmoid sinus suggestive of thrombosis of these sinuses.\nShe gradually improved in her power in left sided limbs. At three months follow-up, the power in all four limbs was grade 5/5. Delayed (6 months post operative) MRV showed partial recanalization of the right transverse and sigmoid sinuses with evidence of collaterals []. These sinuses were opacified on post contrast images as well.\nHer thrombophilia profile which was sent on admission indicated low levels of Protein S and Antithrombin (AT) III. Other parameters were normal [].