A 66 year-old woman presented to the emergency department complaining of a headache for the past 6 weeks. She described it as a throbbing pain in the frontal region and behind her eyes. She had no neurologic complaints, no vision changes, no scalp pain or jaw claudication.
Her past history was significant for hyperparathyroidism, migraines, GERD, and factor XI deficiency.
Her medications included a triptan and a PPI
Her vital signs were normal except for an elevated BP of 180/112. Her examination including a full neurologic exam was unremarkable. Her fundi were difficult to visualize clearly, therefore we proceeded with an ocular point-of-care ultrasound.
The clips above demonstrate signs of papilledema in both eyes. The optic nerve is seen to protrude into the vitreous body. This is often called the ‘crescent sign’ or ‘mushroom sign’.
The patient was sent for a non-contrast head CT:
This scan was reported as being completely normal. What would you do next?
Based on the finding of bilateral papilledema with a normal head CT, we were concerned about the possibility of venous sinus thrombosis. We sent the patient for a CT venogram:
The CT venogram demonstrated a thrombus in the left sigmoid sinus extending into the left internal jugular vein.
The patient was sent for an MR venogram which confirmed this finding, as well as discovering a thrombus in the right transverse sinus.
The patient was admitted and started on anticoagulation as well as acetazolamide to reduce CSF production. She was discharged home 2 days later in good condition.
- Consider ocular ultrasound for patients with undifferentiated headaches and red flags
- Raised intracranial pressure can manifest as dilation of the optic nerve sheath diameter or protrusion of the optic nerve into the vitreous body (crescent sign)
- Consider venous sinus thrombosis in patients with evidence of raised intracranial pressure with normal CT head scans