Objective:

To present an unusual clinical pattern of a young patient presenting with audio-visual hallucinations who was found, on imaging, to exhibit cortical venous infarction (CVI). 

Background:

Cortical venous infarction (CVI) is a rare type of stroke with variable presentation. Without prompt diagnosis, its subacute presentation can delay treatment.  

Design/Methods:

A 26-year-old man with no past neurological nor psychological history presented with audio-visual hallucinations, transient uncontrolled movements of his left upper extremities, and right-sided headache. His auditory hallucinations were described as hearing repetitive sentences. His visual hallucinations consisted of facial and typed word distortions while also observing moving stars, lights, and insects in bilateral temporal visual fields. Physical exam was nonfocal and he demonstrated complete awareness, orientation, and motor function. Computed tomography (CT) imaging was negative for any acute findings. Electroencephalogram was negative for any active focus but noted right hemispheric temporal slowing. Malignancy workup was negative. The patient was admitted to the primary neurological service for further workup.  

Results:

CT angiography and magnetic resonance (MR) imaging were initially suggestive of a dural arteriovenous fistula. The patient underwent digital subtraction angiography which demonstrated several right posterior temporal cortical veins with nonocclusive thrombi. There was also nonocclusive thrombus in the right sigmoid sinus. Neither intracranial aneurysm, arteriovenous malformation, nor arteriovenous shunting were found. The patient was started on antiseizure medication as treatment for ongoing hallucinations. After several days of intravenous heparin, the patient was transitioned to oral anticoagulant. Hypercoagulable panel was acquired prior to discharge.    

Conclusions:

Cerebral venous thrombosis is a rare cerebrovascular disease that accounts for 0.5% of all strokes. The diagnosis is usually seen in young adults and, typically, with pre-existing hypercoagulable risk factors or positive family history. With symptoms such as those mentioned above, a high degree of suspicion is needed to mitigate delay in diagnosis and therapy.