Unilateral Papilledema in Cerebral Venous Sinus Thrombosis

Abstract

In the majority of patients with raised intracranial pressure, the papilledema is bilateral. Unilateral papilledema is rare in conditions causing intracranial hypertension, and it has been described in Foster-Kennedy syndrome and in some cases of idiopathic intracranial hypertension. It has never been reported in cerebral venous thrombosis. We report a young lady presenting with features of subacute onset of headache with seizures, on evaluation she had superior sagittal and bilateral lateral sinus thrombosis. The risk factors found on evaluation were Vitamin B12 deficiency and hyperhomocysteinemia. On optic fundus examination, she had swollen optic disc on the right side with normal fundus on the left side, confirmed with the orbital ultrasound B-scan and optic coherence tomography. Her magnetic resonance imaging showed features of raised intracranial pressure with thrombosis of the superior sagittal and bilateral lateral sinus thrombosis. She was treated with anticoagulation (heparin followed by oral anticoagulants), antiedema measures, and vitamin supplementation for hyperhomocysteinemia. She improved over time and was asymptomatic during follow-up. We discuss the possible mechanisms described in the literature for unilateral papilledema. This report highlights the need for carefully performing bilateral fundus examination so as not to miss the vision or life-threatening causes of a headache.

Keywords: Cerebral venous sinus thrombosis; intracranial pressure; optic fundus; papilledema.

Figure 1

Fundal pictures of both the eyes showing the right eye with swollen optic disc (a), left eye disc being normal (b). Optic coherence tomography of the right (c) and left (d) eye including a graphical representation of retinal nerve fiber thickness (e) in each quadrant of each optic nerve confirming the increased nerve fiber thickness and swelling due to edema on the right side

Figure 2

Postcontrast computerized tomographic scan of the brain showing (a) (superior sagittal), (e) (bilateral lateral sinus) thrombosis in the form of filling defects (arrows). Magnetic resonance imaging T2 Sagittal scan (b) showing thrombosis of superior sagittal sinus and partial empty sella (arrows). Magnetic resonance venogram showing nonvisualization of superior sagittal and bilateral lateral sinuses (c). Magnetic resonance imaging brain sagittal (d and h) showing prominent and tortuous right optic sheath (arrow) more pronounce on coronal T2 magnetic resonance imaging image (g) (arrow). Magnetic resonance imaging T2 axial (f) shows right temporal parenchymal lesion (arrow)