Objective:

To highlight the importance of cranial venous outflow insufficiency in assessing the etiology of strokes and headaches. This condition is commonly overlooked, and further workup with diagnostic imaging is often deferred as radiology reports do not usually comment on possible cerebral venous abnormalities. This is a unique case of a young stroke patient who required Tenecteplase (TNK) additionally presenting with chronic headaches, which subsided after venous angioplasty. To the author’s knowledge, there are no other cases reported with this specific presentation.

Background:

44-year-old male with a history of possible transient ischemic attack presenting several months later to the emergency department (ED) with sudden-onset expressive aphasia, perioral numbness, bilateral upper and left lower extremity numbness. In the ED, blood pressure was 164/117, glucose 92, and NIH Stroke Scale 2. Computed Tomography (CT) Angiography revealed a distal left M2 branch occlusion of the middle cerebral artery, not amenable to thrombectomy. CT Perfusion revealed a 42cc mismatch penumbra in the left parietotemporal region. Additional multifocal vascular stenoses and occlusions were deemed likely noncontributory. The patient received TNK given his debilitating symptoms, aborting his ischemic stroke. He later developed a severe headache with left periorbital eye pain, consistent with prior intermittent headaches. Diagnostic cerebral angiogram revealed that the superior sagittal and straight sinuses drained predominantly to the right sinus, with high pressure in the left transverse, sigmoid, and internal jugular vein (IJV). Venoplasty of the left IJV restored normal pressure from 24 to 8 cm H2O.

Design/Methods:

NA

Results:

The patient’s expressive aphasia and paresthesias resolved after the administration of TNK. Venoplasty normalized venous pressures, leading to resolution of his chronic headaches and left eye pain.

Conclusions:

Cranial venous outflow insufficiency may represent an underrecognized contributor to strokes and/or headaches. Consideration of this diagnosis with interventions such as venoplasty may improve patient outcomes.