Severe cerebral venous thrombosis initially presenting as puerperium psychiatric and behavioral symptoms: one case report

doi:10.3969/j.issn.1672-6731.2025.06.009

Abstract

Abstract:

Objective: To report a case of severe cerebral venous thrombosis (CVT) with an initial presentation of puerperium psychiatric and behavioral abnormalities, and to summarize and analyze its clinical manifestations and imaging changes, to enhance clinicians' awareness of this condition. Methods and Results: A 34 - year - old female patient developed psychiatric and behavioral abnormalities one month postpartum. She was initially presumed by her family to have "postpartum depression", and subsequently diagnosed at an external hospital as "psychiatric disorder of undetermined etiology". Following treatment with antipsychotic medications, the patient's psychiatric and behavioral abnormalities progressively aggravated. Upon the patient's development of right - sided limb weakness, a definitive diagnosis of severe CVT was ultimately established, corroborated by imaging findings. After a therapeutic regimen comprising fluid repletion, anticoagulation, reduction of fibrinogen level, corticosteroid anti - inflammatory therapy, and antipsychotic medications, the patient's psychiatric and behavioral abnormalities and right - sided limb weakness ameliorated, with a good prognosis. Conclusions: CVT manifesting with psychiatric and behavioral abnormalities is relatively uncommon. Its clinical presentation overlaps with that of various psychiatric disorders. Particularly in puerperium patients exhibiting psychiatric and behavioral abnormalities, a misdiagnosis of "postpartum depression" is frequent. Consequently, when such patients demonstrate an inadequate response to antipsychotic medications, the potential for CVT should be vigilantly considered, and comprehensive multimodal imaging should be pursued promptly to prevent misdiagnosis and inappropriate treatment.

Key words: Venous thrombosis, Cerebral veins, Magnetic resonance imaging, Postpartum period, Mental disorders

摘要：

目的: 报道1例以产褥期精神行为异常发病的重症脑静脉血栓形成病例，总结其临床表现及影像学变化，以提高临床医师对此类疾病的认识。方法与结果: 女性患者，34岁，分娩后1个月以精神行为异常发病，被家属误以为“产后抑郁”，外院诊断为“精神障碍原因待查”，经抗精神病药物治疗后精神行为异常仍进一步加重，直至出现右侧肢体力弱后，结合影像学检查，最终明确诊断为重症脑静脉血栓形成，经补液、抗凝、降低纤维蛋白原、激素抗炎症、抗精神病药物等治疗后，精神行为异常和右侧肢体力弱症状缓解，预后良好。结论: 以精神行为异常发病的脑静脉血栓形成较为罕见，其临床表现与多种精神疾病存在重叠，尤其对于产褥期出现精神行为异常的患者，常误诊为“产后抑郁”，故此类患者出现抗精神病药物治疗效果欠佳时，应警惕脑静脉血栓形成的可能，尽早完善多模态影像学检查，以免误诊、误治。

关键词: 静脉血栓形成, 脑静脉, 磁共振成像, 产后期, 精神障碍

Hou-lin LAI, Jing-kai LI, Na TANG, Jian-gang DUAN. Severe cerebral venous thrombosis initially presenting as puerperium psychiatric and behavioral symptoms: one case report[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 509-516.

赖厚霖, 李京凯, 唐娜, 段建钢. 以产褥期精神行为异常发病的重症脑静脉血栓形成一例[J]. 中国现代神经疾病杂志, 2025, 25(6): 509-516.

/ / Recommend / Download Citations

URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2025.06.009

https://journal11.magtechjournal.com/cjcnn/EN/Y2025/V25/I6/509

Figures/Tables 5

Figure 1 Pre-admission (September 13, 2024) head imaging findings MRV showed non-visualization of the anterior third of the superior sagittal sinus, straight sinus, left transverse sinus, and sigmoid sinus (arrows indicate; Panel 1a, 1b). Axial FLAIR showed patchy hyperintensity with central hypointensity in the left cerebellar hemisphere and left fronto-temporo-parietal lobe (arrows indicate; Panel 1c, 1d). Axial CT showed increased density in the left transverse sinus, and patchy low density in the left cerebellum and fronto-temporo-parietal lobe with surrounding gyrus swelling (arrows indicate; Panel 1e, 1f). Figure 2 Imaging findings on day 2 post-admission (September 17, 2024) Contrast-enhanced MRV showed discontinuous visualization of the superior sagittal sinus, alongside non-visualization of the straight sinus, left transverse sinus, and sigmoid sinus (arrows indicate; Panel 2a, 2b). Sagittal MRBTI showed thrombosis within the middle third of the superior sagittal sinus, straight sinus, left transverse sinus, and sigmoid sinus (thick arrows indicate), as well as hyperintensity in some cortical superficial vein in the right frontal lobe and left fronto-parietal lobe (thin arrows indicate; Panel 2c-2f).

Figure 3 Imaging findings on day 7 post-admission (September 22, 2024) Contrast-enhanced MRV showed discontinuous visualization within the lumen of the anterior and middle thirds of the superior sagittal sinus, and improved visualization of the straight sinus, left transverse sinus, and sigmoid sinus compared to previous findings (arrow indicates, Panel 3a). Sagittal MRBTI showed reduced hyperintensity within the superior sagittal sinus, straight sinus, left transverse sinus, and sigmoid sinus compared to previous findings (thick arrows indicate); persistent hyperintensity was noted in some cortical superficial vein in the right frontal lobe and left fronto-parietal lobe (thin arrows indicate; Panel 3b-3e). Figure 4 Imaging findings on day 22 post-admission (October 7, 2024) Axial CT showed previously noted abnormal low density in the left cerebellar hemisphere and left fronto-temporo-parietal lobe were reduced in extent (arrows indicate; Panel 4a, 4b). Axial FLAIR showed multiple patchy lesions of mixed hyper- and hypointensity, or predominantly hypointensity in the left cerebellar hemisphere and left fronto-temporo-parietal lobe, which were reduced in extent compared to previous findings (arrows indicate; Panel 4c, 4d). Contrast-enhanced MRV showed continuous visualization of the superior sagittal sinus and straight sinus, and further improved visualization of the left transverse sinus and sigmoid sinus compared to previous findings (arrows indicate, Panel 4e). Sagittal MRBTI showed a further reduction in hyperintensity within the left transverse sinus and sigmoid sinus compared to previous findings (thick arrow indicates); persistent hyperintensity was noted in some cortical superficial vein in the right frontal lobe and left fronto-parietal lobe (thin arrows indicate; Panel 4f, 4g).

Figure 5 Fundus photography on day 24 post-admission (October 9, 2024) showed bilateral blurred optic disc margins and retina hyperemia. Right eye (Panel 5a). Left eye (Panel 5b). Figure 6 Fundus photography 4 months post-discharge (February 19, 2025) showed bilateral optic disc margins were clearer compared to previous findings. Right eye (Panel 6a). Left eye (Panel 6b).

Figure 7 Imaging findings 4 months post-discharge (February 19, 2025) Axial FLAIR showed lesions of mixed hyper- and hypointensity in the left cerebellar hemisphere and left fronto-parietal lobe, with resolution of swelling (arrows indicate; Panel 7a, 7b). Contrast-enhanced MRV revealed an attenuated appearance of the left transverse and sigmoid sinuses, with further reduction in filling defects compared to previous findings (arrows indicate, Panel 7c). Sagittal MRBTI showed reduced hyperintensity within the left transverse and sigmoid sinuses compared to previous findings (thick arrow indicates); persistent hyperintensity was noted in some cortical superficial vein in the left fronto-parietal lobe (thin arrows indicate, Panel 7d).

Table 1. Optic nerve sheath ultrasound examination (mm)

日期	视盘凸起		神经鞘直径
日期	左侧	右侧	左侧	右侧
2024年9月17日	1.20	1.00	4.80	4.40
2024年9月23日	1.20	1.10	4.35	4.30
2024年10月8日	0.80	0.80	3.85	3.70
2024年10月21日	0.90	0.70	4.20	4.05
2025年2月19日	0.00	0.00	2.90	1.90

References 21

1	Safeguarding maternal mental health in the perinatal period[J]. EClinicalMedicine, 2024, 71: 102663.
2	Saposnik G , Bushnell C , Coutinho JM , Field TS , Furie KL , Galadanci N , Kam W , Kirkham FC , McNair ND , Singhal AB , Thijs V , Yang VXD . American Heart Association Stroke Council; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Hypertension. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke, 2024, 55: e77- e90.
3	Bousser MG , Ferro JM . Cerebral venous thrombosis: an update. Lancet Neurol, 2007, 6: 162- 170. doi: 10.1016/S1474-4422(07)70029-7
4	Silvis SM , de Sousa DA , Ferro JM , Coutinho JM . Cerebral venous thrombosis. Nat Rev Neurol, 2017, 13: 555- 565. doi: 10.1038/nrneurol.2017.104
5	Brockington IF . Cerebral vascular disease as a cause of postpartum psychosis. Arch Womens Ment Health, 2007, 10: 177- 178. doi: 10.1007/s00737-007-0187-7
6	Gao MX , Fu HB , Chen F , Luo KY , Zhao HD . Progress in the diagnosis and treatment of postpartum depression. Zhuan Hua Yi Xue Za Zhi, 2024, 13: 136- 140.
	高明秀, 付华斌, 陈峰, 罗克勇, 赵会懂. 产后抑郁的诊疗进展. 转化医学杂志, 2024, 13: 136- 140.
7	Stam J . Thrombosis of the cerebral veins and sinuses. N Engl J Med, 2005, 352: 1791- 1798. doi: 10.1056/NEJMra042354
8	Kashkoush AI , Ma H , Agarwal N , Panczykowski D , Tonetti D , Weiner GM , Ares W , Kenmuir C , Jadhav A , Jovin T , Jankowitz BT , Gross BA . Cerebral venous sinus thrombosis in pregnancy and puerperium: a pooled, systematic review. J Clin Neurosci, 2017, 39: 9- 15. doi: 10.1016/j.jocn.2017.02.046
9	Khan M , Arauz A , Uluduz D , Barboza MA , Duman T , Cano - Nigenda V , Awan S , Wasay M , Venost Study Group . Predictors of mortality and functional outcome in pregnancy and puerperium-related cerebral venous thrombosis. Cerebrovasc Dis, 2023, 52: 393- 400. doi: 10.1159/000527155
10	Saposnik G , Barinagarrementeria F , Brown RD Jr , Bushnell CD , Cucchiara B , Cushman M , deVeber G , Ferro JM , Tsai FY . American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2011, 42: 1158- 1192. doi: 10.1161/STR.0b013e31820a8364
11	Ropper AH , Klein JP . Cerebral venous thrombosis. N Engl J Med, 2021, 385: 59- 64. doi: 10.1056/NEJMra2106545
12	Saposnik G , Bushnell C , Coutinho JM , Field TS , Furie KL , Galadanci N , Kam W , Kirkham FC , McNair ND , Singhal AB , Thijs V , Yang VXD . American Heart Association Stroke Council; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Hypertension. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke, 2024, 55: e77- e90.
13	Shabo E , Wach J , Hamed M , Güresir Á , Weinhold L , Vatter H , Güresir E . Asymptomatic postoperative cerebral venous sinus thrombosis after posterior fossa tumor surgery: incidence, risk factors, and therapeutic options. Neurosurgery, 2023, 92: 1171- 1176. doi: 10.1227/neu.0000000000002340
14	Uzun G , Zlamal J , Althaus K , Bevot A , Hennersdorf F , Wolska N , Jock A , Kern J , Icheva V , Poli S , Ernemann U , Neu A , Bakchoul T . Cerebral venous sinus thrombosis and thrombocytopenia due to heparin - independent anti - PF4 antibodies after adenovirus infection. Haematologica, 2024, 109: 2010- 2015.
15	James AH . Pregnancy and thrombotic risk. Crit Care Med, 2010, 38 (2 Suppl): S57- S63.
16	Silvis SM , Lindgren E , Hiltunen S , Devasagayam S , Scheres LJ , Jood K , Zuurbier SM , Kleinig TJ , Silver FL , Mandell DM , Middeldorp S , Putaala J , Cannegieter SC , Tatlisumak T , Coutinho JM . Postpartum period is a risk factor for cerebral venous thrombosis. Stroke, 2019, 50: 501- 503. doi: 10.1161/STROKEAHA.118.023017
17	Algahtani H , Bazaid A , Shirah B , Bouges RN . Cerebral venous sinus thrombosis in pregnancy and puerperium: a comprehensive review. Brain Circ, 2022, 8: 180- 187. doi: 10.4103/bc.bc_50_22
18	Hu S , Lee H , Zhao H , Ding Y , Duan J . Inflammation and severe cerebral venous thrombosis. Front Neurol, 2022, 13: 873802. doi: 10.3389/fneur.2022.873802
19	Baldini T , Asioli GM , Romoli M , Carvalho Dias M , Schulte EC , Hauer L , Aguiar De Sousa D , Sellner J , Zini A . Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: a systematic review and meta - analysis. Eur J Neurol, 2021, 28: 3478- 3490. doi: 10.1111/ene.14727
20	Hu SY , Zhang KY , Gu YQ , Li JK , Zhou C , Ji XM , Duan JG . Exploration of glucocorticoid combined with anticoagulation in acute/subacute severe cerebral venous thrombosis. Shou Du Yi Ke Da Xue Xue Bao, 2023, 44: 280- 288. doi: 10.3969/j.issn.1006-7795.2023.02.015
	胡舒缘, 张开元, 谷亚钦, 李京凯, 周陈, 吉训明, 段建钢. 糖皮质激素联合抗凝在急性/亚急性重症颅内静脉血栓治疗中的探索. 首都医科大学学报, 2023, 44: 280- 288. doi: 10.3969/j.issn.1006-7795.2023.02.015
21	Hu S, Gu Y, Zhao T, Zhang K, Li J, Zhou C, Song H, Liu Z, Ji X, Duan J. Steroids combined with anticoagulant in acute/subacute severe cerebral venous thrombosis[J]. Chin Med J (Engl), 2025. [Epub ahead of print]

[1]	Jian-gang DUAN, Bao-ying SONG. Progress and prospect of glucocorticoids therapy for severe cerebral venous thrombosis [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 459-463.
[2]	Jia-hao ZHANG, Lei GENG, Zhi-tao XIAO, Xing CHEN, Xiang-yu CAO. Advances in the study methods of cerebral venous sinus hemodynamics [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 464-469.
[3]	Yu-shuang RUAN, Zi-kang DONG, Zhi FANG, Yuan-peng XIA. Inflammatory mechanisms and therapeutic targets in cerebral venous system diseases [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 470-476.
[4]	Ye LANG, Meng-fei ZHONG, Zong-en GAO. Progress on anticoagulation therapy and mechanical thrombectomy for cerebral venous thrombosis [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 477-482.
[5]	Hong-yan DING, Ya-nan XIE, Qiang DONG. Analysis of influencing factors of increased intracranial pressure in patients with cerebral venous thrombosis [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 483-488.
[6]	Qiu-ju LIAO, Xiao-yi YANG, Yi ZHAO, Li SU. Clinical characteristics of cerebral venous thrombosis in patients with systemic lupus erythematosus [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 503-508.
[7]	YU Xuan-yue, LIU Ke-xin, FAN Tie-ping, LI Shu-min, LIANG Xin-tian, LIU Yi. Compound heterozygous mutation in MTHFR gene lead to chronic cerebral venous thrombosis: one case report [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 517-522.
[8]	HUANG Zhan, ZHU Ming-fang, MENG Qi, TAN Lei-lei, ZHANG Jie-wen, HUANG Yue. Protein C and protein S deficiency associated cerebral venous thrombosis: one case report [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 523-529.
[9]	DING Le, SHI Miao, XUE Xiu-yun, ZHANG Quan, LIU Zhi-qin. Anemia-induced recurrent cerebral venous thrombosis: one case report and literature review [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 530-537.
[10]	Jun-shan WANG, Wei-wei ZHAO, Ma ZHUO, Yu-xiu CHEN, Yu-hua ZHAO, Jing YUAN. Imaging characteristics of cerebral small vessel disease in high-altitude plateau [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(5): 390-395.
[11]	Peng-fei ZHAO, Jia-liang WANG, Yan WANG, Cheng-yuan SUN, Hai-peng LIU. Pituitary adenoma apoplexy for ischemic infarction: three cases report and literature review [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(4): 296-302.
[12]	Zhen LI, Peng-fei SONG, Rui-ze ZHU, Shan JIANG, Shi-wen CAO, Jin-hua YU, Zhi-feng SHI. Prediction of genetic status and grading in glioma based on fusion of macro - and micro-imaging features [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(3): 165-174.
[13]	Xing CHENG, Zhi-chao WANG, Hua-ning LI, Xie-feng WANG, Yong-ping YOU. Noninvasive prediction of meningioma brain invasion via multiparametric MRI-based brain-tumor interface radiomics [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(3): 175-186.
[14]	Jing-tao JU, Xin CHEN, Jia-bin LIU, Yong-sheng HU, Lei-ming WANG, Nan CHEN. Clinical characteristics analysis of focal cortical dysplasia with negative MRI [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(3): 259-264.
[15]	Yu-feng ZANG. Research and clinical application prospects of precision transcranial magnetic stimulation in neuromodulation guided by brain imaging [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(2): 152-154.

Please choose a citation manager

Content to export