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Cortical venous sinus thrombosis after LP and high dose steroid in a case clinically isolated syndrome.

UNLABELLED: Role of lumbar puncture and high dose steroids have been implicated previously in causing cerebral venous sinus thrombosis in multiple sclerosis. We report a case of clinically isolated syndrome who developed cerebral venous sinus thrombosis after Lumbar puncture and high dose steroids. Forty two years old gentleman presented with right hand numbness and weakness over 1 week. MRI brain and spine showed periventricular and cerebellar white matter lesions suggestive of multiple sclerosis. ANA, ANCA, APLA, B12 and NMO antibody were negative. VEP was normal. CSF showed oligoclonal bands. Post lumbar puncture he received pulse dose of 1gm Methylprednisoplone for 5 days. He developed occipital headache on the 6th day especially on sitting up which improves on lying down. On the 9th day the headache became frontal and continuous with no relief on lying down. He developed generalized tonic clonic seizures on the 12th day and MRI brain done revealed sagittal sinus thrombosis with bilateral sulcal subarachnoid hemorrhage. He was started on low molecular heparin followed by Warfarin. Headache resolved. His thrombophilia screen revealed Protein C and S deficiency with heterozygous MTHFR gene mutation whether Lumbar puncture which caused the low pressure headache along with high dose steroids provoked cerebral venous thrombosis in this predisposed patient who had Protein C and S deficiency can be debated. There have been many cases reported of similarly of CVT in MS after LP and steroids. It can be debated that LP and steroids are routinely given simultaneously in MS patients and questionably this can be avoided.

CONCLUSION: This is a case of CIS who developed cerebral venous sinus thrombosis post lumbar puncture and mega steroids pulse therapy, initially he presented with symptoms similar to headache of intracranial hypotension followed by seizure. High index of suspicion of CVT post LP and steroids therapy should be considered.

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