Cerebral venous thrombosis secondary to an occult maxillary sinusitis in a young male from sub-Saharan Africa

Background: Cerebral venous thrombosis (CVT), is a cerebrovascular disease characterized by an infarction of a cerebral vein. Only few cases have been reported. We report a rare case secondary to an occult maxillary sinusitis in a young male of Sub-sahar an Africa origin. Case presentation: We report a case of a 36-year-old Cameroonian male who was admitted to hospital for left side hemiparesia associated with repetitive focal left-size tonicoclonic seizures and, frontal headache. The physical examination reveals normal vital signs, left cortical-type pyramidal syndrome, tactile hypoesthesia on the left side, normal ear nose throat examination. Cerebral magnetic resonance imaging (MRI) show a cerebral venous thrombosis and, a sinus radiograph revealed a right maxillary sinusitis, probably the etiology of the CVT.The patient was successfully managed by anticoagulant, antibiotics,maxillary sinusdrainage and supportive measures. Conclusion: CVT is a common cause of stroke in children and young adults. In sub-Saharan Africa, an infectious etiology should be considered and rollout before any other consideration.


Introduction
Cerebral venous thrombosis (CVT) also termed cerebral venous sinus thrombosis (CVST), is a special type of cerebrovascular disease characterized by cerebral venous infarction [1].As from 1825 when the first case was described by Ribes [2], epidemiological descriptions are still restricted to case reports and small retrospective cross-sectional studies yielding low butincreasing incidence: <10 cases per million per year in 1995 to about 13.2 cases per million per year in 2012.CVT mainly occurs in women of child bearing age, probably owing to the use of oral contraceptive pills, and mostly has an acute or subacute course [1].It can be categorized as primary/idiopathicand secondary.Secondary CVT can further be classified into infective (mainly due to or fungal infections) and non-infective CVT; the latterbeing due tocoagulation disorders, neoplasms, procoagulant hemodynamic states, vascularitis,homocystinuria, or head trauma [3].With the advent of antibiotics, the epidemiology of CVT has shifted from predominant infective CVT to predominant non-infective CVT, leading to increased risk of misdiagnosis and delayed treatment [3].We report occult purulent maxillary sinusitisrelated CVT in a male Cameroonian patient who presented with headaches, seizures and acute stroke syndrome.The aim of this paper is to reiterate CVT as the main cause of acute stroke syndrome in young adults irrespective of ethnic origin and sex, and suggest systematic screening of infections in those patients, especially in regions with high rates of infections likesub-Saharan Africa.We describe this case with regard to CARE guidelines.

Case presentation
A 36-yearold male patient with no contributive past history was admittedin a hospital for a rapidly progressive onset of left side deficit associated with repetitive focal left-size tonico clonic seizures lasting for 3 minutes and moderate intermittent frontal headache.These symptoms progressed since 24 hours before admission without fever or any other signs of intracranial hypertension.
Upon admission, physical examination revealed:normal vital parameters, left corticaltype pyramidal syndrome with brachio-facial predominance (muscular strength of 3/5 in the upper limb and 4/5 in lower limb), tactile hypoesthesia in the left side, normal ENT examination.
Based on this examination, we discussed a diagnosis of space occupying lesion or stroke.Cerebral CT-scan revealed a right frontoparietal hypodensity which did not respect any vascular topography and this lesion was not enhanced with contrast (Figure 1).Subsequent cerebral magnetic resonance imaging (MRI) confirmed a cerebral venous thrombosis (Figure 2).On etiological work up, sinus radiograph revealed a right maxillary sinusitis (Figure3).Biological exams showned a slight elevated white blood cells of 10 800 per mm 3  with neutrophiles predominance at 81% , Prothrombin level=96.6%(international normalize ratio [INR] 1.3), Kaolin clotting time=27.5 s (witness time: 35 s), negative HIV serology, D-dimers=3886.61 ug per liter, C protein=117% and Sprotein=67%.Finally, our working diagnosis was cerebral venous thrombosis secondary to a maxillary sinusitis.The patient was managed symptomatically by physiotherapy, analgesics paracetamol 3g per day, anticonvulsants diazepam: 20 mg per day.For the etiology drainage of maxillary sinus was done and the patient received 3g of amoxicilline and clavulanic acid per day.Acenocoumarol was used for anticoagulation at initial dose of 1mg per 24 hours, secondary adapted for International Normalized Ratio (INR) with a goal of 2-3, this goal was reached after 6 weeks of follow up (INR=2.17)with a daily dose of 5mg.The variation of INR through follow-up period can be observed in figure 4.

Discussion
This case describes a male patient with cerebral venous thrombosis (CVT) due to an inexpressive maxillary sinusitis.CVT is an acute or subacute disease of the central nervous system that often affects women of childbearing age, and children [1].Its incidence varying between 1.32-1.57per 100,000 person-years [4,5].The disease is known more prevalent in women than men because of the high rate of contraceptive use that create a procoagulant status in this population [1].Others risk factors Page: 11 www.raftpubs.cominclude coagulation disorders, neoplasms, vascularitis,homocystinuria, head trauma and infections [3].In developed countries,this last condition becomes less frequent with the advent and adequate use of antibiotics [3].
Sinusitis is define as infection of sinus; it's a common cause of infection related CVT [3].The pathophysiology is directly by causing septic thrombosis or indirectly by precipitating thrombosis in people who have a prothrombotic condition; this is explain by cytokines inducing endothelial lesion.It's well known that the dural sinuses and the cerebral and emissary veins have no valves, which allow blood to flow in either direction according to pressure gradients in the vascular system.This makes these venous systems vulnerable to septic thrombosis resulting from spreading of infection from adjacent locations [3].Maxillary sinusitis is rarely involved in CVT than sphenoidal and ethmoidal sinuses and clinical presentation associate facial pain, rhinorheaand tenderness of the maxillary sinus [3,6].Our patient was asymptomatic and it was difficult to clinically evoke this etiology.In the other hand the current diagnostic guidelines do not mention the systematic screening of CVT etiology by doing sinus radiography [7].In the lack of evidence our approach was guided by the biological exam showing slightly elevated neutrophiles which suggesting the bacterial etiology.
To the best of our knowledge, the association of occult sinusitis and CVT was not describe in the literature, making this case an original one.
In Subsaharan African context with high burden of infection it may be necessary to systematically investigate sinusitis when any apparent cause of CVT is found.

Conclusion
CVT is a common cause of stroke in children and young adults.In sub-Saharan Africa, and infectious etiology should be considered and rollout before any other consideration.