Norethisterone enanthate-induced cerebral venous sinus thrombosis (CVST)

Abstract

A 23-year-old East Indian woman with no significant medical history, except a depot-norethisterone enanthate injection taken 3 weeks prior to admission, presented with a gradually worsening headache for the past 5 days. She had no fever, vomiting, neck stiffness, focal weakness or rash, and examination was unremarkable with no focal neurological deficits. Vasculitic, thrombophilia and sepsis screens were normal. A brain CT scan showed a left parietal lobe venous infarct, secondary to a venous dural sinus thrombosis, with MRI and Magnetic Resonance Venogram (MRV) confirming a signal void. She was diagnosed to have multiple cerebral venous sinus thrombosis due to norethisterone enanthate. She made a complete recovery following treatment with mannitol, dexamethasone and anticoagulants. A follow-up brain MRI done at 6 months was normal.

Keywords: drugs and medicines; neurology (drugs and medicines).

Figure 1

Brain CT findings on admission. The first red arrow shows a left parasagittal parietal lobe high convexity gyral hypodensity (1.8×0.9 cm) region is seen. Appearances may be caused by a venous infarct. The second red arrow shows an abnormal superior sagittal and left sigmoid sinus hyperdensity suspicious for venous sinus thrombosis (empty delta sign). Relative hypodensity in the left internal capsule. No other areas of abnormal attenuation. Otherwise normal appearances of the brain parenchyma, ventricles, cisterns and nuclei. No extra-axial collections. No intraparenchymal haemorrhage detected. Impression: left parietal lobe venous infarct. Venous dural sinus thrombosis.

Figure 2

Brain MRI and MRV findings on admission. The red arrows show a signal void seen in the posterior 2/3 of the superior sagittal sinus, as well as within the right transverse and sigmoid sinuses. Correlation with CT suggests venous sinus thrombosis.

Figures 3

(A and B) Follow-up brain MRI and MRV after 6 months. Normal MRI and MRV of the brain with no defects in the superior sagittal, right transverse and sigmoid sinuses, and no acute intracranial haemorrhages.