Cerebral Venous Thrombosis as an Initial Presentation of Streptococcal Parameningeal Infection: A Diagnostic Conundrum (P5-5.003).

Objective: Early recognition of Bacterial sinusitis as a rare presentation of cerebral venous sinus thrombosis (CVST) in pediatric patients with intractable headaches.

Background: CVT is caused by thrombotic obstruction of the venous sinuses leading to increased ICP with neurological deficits. It can present as a complication of rhinosinusitis, streptococcus anginosus () being the most notorious in pediatric age groups.

Design/methods: A 14-year-old male with no medical history presented twice to the ER within a span of two days with a two-week history of headache, photophobia, emesis & URI symptoms. Initial CT head showed paranasal sinusitis; hence he was discharged on nasal decongestants with return precautions. One week later, he presented again to the ER as a stroke code with acute onset left hemiplegia, dysarthria, and left facial droop (NIHSS 15). CT showed a right frontal lobe infarct, superior sagittal sinus venous thrombosis, and a right subdural empyema, later confirmed by MRI Brain and MRV. He was admitted to the pediatric intensive care unit and initially started on heparin and broad-spectrum antibiotics. One day later, he underwent a craniotomy to remove the subdural empyema, course complicated by status epilepticus requiring intubation and antiseizure medications(ASM). Cultures grew Streptococcus constellatus. Patient had reemergence of subdural empyema and restricted diffusion within the left maxillary sinus on repeat MRI Brain. He then underwent repeat craniotomy and an endoscopic sinus surgery which grew Staph aureus. Patient recovered and was discharged home after 4 weeks of hospitalization.

Results: Patient gained full neurologic recovery, was maintained on low-molecular-weight heparin, ASM with Physical and occupational therapy, currently off medications.

Conclusions: This case highlights the need for high suspicion and treatment of CSVT given the worst prognosis with Streptococcus Anginosus group. This is the first case report of superior sagittal sinus thrombosis with Ischemic stroke secondary to Streptococcus constellatus sinusitis in a pediatric patient. Dr. Raja has received personal compensation in the range of $500-$4,999 for serving as a Resident Scholarship recipient with American Headache Society Resident Education Program . Dr. Reznikov has nothing to disclose.