The role of lumbar puncture and pressure-lowering therapy for transverse dural sinus thrombosis
An 11-year-old girl with no significant past medical history presented to the ED complaining of 2 days of worsening headache, vomiting, and double vision. Approximately 2 weeks earlier, the patient was seen by her primary care physician (PCP) for evaluation of flu-like symptoms, headache, and left-sided neck pain. Examination at that time revealed an erythematous right tympanic membrane. The patient was diagnosed with AOM and started on oral amoxicillin/clavulanate. The patient continued to complain of worsening headache for 7 days following PCP evaluation, at which point she developed diplopia, nausea, and vomiting. She was subsequently taken to the ED for evaluation.\nNon-contrast CT revealed an asymmetrically hyperdense right transverse sinus []. Brain MRI demonstrated a thrombus in the right transverse sinus as well as fluid within the right mastoid air cells consistent with mastoiditis [Figures -]. A filling void in the right transverse sinus, consistent with a right transverse sinus thrombosis, was found on MRV [].\nNeurology evaluation did not reveal any focal abnormalities but ophthalmic examination was incomplete; LP was not recommended. The patient was admitted to the pediatric intensive care unit where heparin drip and intravenous antibiotics were started. Hypercoagulablity studies were negative. Ophthalmology consultation found a small right esotropia in primary gaze; optic disc edema bilaterally; and nerve fiber layer hemorrhages more pronounced in the right fundus than left. The patient was diagnosed with papilledema and palsy of the right cranial nerve VI, secondary to increased ICP.\nThe patient was discharged on oral cefdinir without performing an LP or ICP-lowering therapy. Outpatient ophthalmology follow-up 2 weeks later found worsening headache, persistent papilledema, and esotropia in primary and right-gaze. Formal visual field testing revealed enlarged blind spots bilaterally. The patient was referred to the ED for LP which revealed an opening pressure of 310 mm H2O (upper limit of normal 210 mm); the patient was started on oral acetazolamide. CSF studies were otherwise unremarkable. Follow-up examination 2 weeks later revealed improvement in headache and complete resolution of diplopia and esotropia.