VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

24 Central Venous Thrombosis in the Postpartum Patient

Holly Howard, DO; Carlos Pottinger, MD Corresponding author: holly.howard@lpnt.net

SOVAH Health Family Medicine Residency Program

improved and she was discharged on anticoagulation with outpatient follow-up. Treatment: Patient was initially admitted and started on magnesium drip. Blood pressure was controlled with nifedipine. At an external facility, nifedipine was increased to 60 mg daily as she continued to be hypertensive. MRI demonstrated cortical venous thrombosis with bilateral small subarachnoid hemorrhage. Lovenox initiated as bridge to Coumadin with goal INR of 2-3. Diagnosis: Initial CT head without contrast demonstrated no gross intracranial abnormalities. Initial MRI showed vague curvilinear cortical restricted diffusion involving the posterior left parietal and occipital lobes. CTA and CTV of the brain were also negative. Repeat MRI demonstrated left cortical vein thrombosis and small bilateral subarachnoid hemorrhage. Comment: Patient was initially treated for postpartum eclampsia given symptoms of hypertension, persistent headache and seizure-like activity. She was started on a magnesium drip and nifedipine for blood pressure control. Initial CT head was negative. After discontinuation of the magnesium

drip, the patient experienced clumsiness prompting neurology consult. MRI showed nonspecific findings over restricted diffusion involving posterior left parietal and occipital lobes. Symptoms thought to be due to posterior reversible encephalopathy syndrome. Her headache and blood pressure improved with nifedipine. Headaches returned and she presented to outside facility where imaging showed central venous thrombosis with small bilateral subarachnoid hemorrhage. Anticoagulation was initiated. Conclusion: Central venous thrombosis, while a less common cause of stroke, is more frequently seen during pregnancy and the puerperium and should be considered as a differential especially in a patient who remains symptomatic after proper treatment for pre-eclampsia/eclampsia. Repeat imaging is useful in aiding in proper diagnosis of patients as initial imaging can be unremarkable.

Context: Central Venous thrombosis is a type of cerebrovascular accident that occurs less frequently and is more challenging to diagnose due to its varying causes and presentation. There are several acquired risk factors with the most common being pregnancy and the puerperium, all contraceptive use, malignancy, and obesity. Case report: A 32-year-old African American female G1 P1001 with a past medical history of morbid obesity, hemoglobin C trait, provoked DVT while on OCPs, anxiety and depression presented at 1 week postpartum after a C-section due to persistent headache and weakness seizure-like activity lasting approximately 3 minutes. Vital Signs: BP 151/86, HR 74, RR 18, Pulse Ox 99% RA. She was admitted and treated for eclampsia. MRI demonstrated posterior cortical abnormalities consistent with posterior reversible encephalopathy syndrome. Her symptoms improved and she was discharged home on hypertension medication. Her headaches continued to worsen and blood pressure remained elevated despite nifedipine. Repeat MRI demonstrated central vein thrombosis with small bilateral subarachnoid hemorrhage. She was started on Lovenox and bridged to Coumadin. Her symptoms

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