The Lancet 2007; 370:1188

Case Report

4-week headache after 60 pints of beer

Dr Zia I Carrim MRCOphth  a ,   Jane MacPhillimy MB a   and   Ravi
Jampana FRCR b

References

In October, 2006, a 37-year-old man self-presented to our emergency
department, with blurred vision and a persistent dull occipital
headache, both of which had been present for 4 weeks. He had no other
symptoms; there was no history of head injury or loss of
consciousness; his past medical history was unremarkable, and he was
taking no regular medications. The patient was fully alert, had no
fever, and his blood pressure was normal. Systemic examination,
including a neurological examination, revealed nothing abnormal-except
for fundoscopy, which was thought to show retinal haemorrhages.

An ophthalmological opinion was requested. The patient described the
"blurring" of his vision as consisting of episodes in which objects
looked "wavy". On examination, visual acuity was preserved at 6/5 in
both eyes, and there was no relative afferent pupillary defect. The
visual fields had generalised constriction, and greatly enlarged blind
spots. Repeat fundoscopy showed swollen optic discs with nerve fibre
layer haemorrhages ("flame haemorrhages"), consistent with
papilloedema (figure)-signifying raised intracranial pressure (ICP).
In the absence of any features of other syndromes that cause raised
ICP, we suspected idiopathic intracranial hypertension (IIH). We
sought a more detailed history. The patient revealed that, after a
domestic crisis, he had consumed about 60 pints of beer in 4 days. His
symptoms had begun immediately after the binge. He had also
experienced severe headache and vomiting for a day after the binge,
but had attributed these to a bad hangover. The apparent onset of
raised ICP, at a time of dehydrating alcohol consumption,1 indicated
the possibility of cerebral venous sinus thrombosis (CVST). We did
urgent CT of the brain, with and without venography. Plain CT showed
no abnormality; but venography showed extensive thrombosis, extending
from the sagittal sinus to the jugular bulb. A lumbar puncture
confirmed raised ICP; blood tests showed a raised concentration of
lupus anticoagulant, indicating probable antiphospholipid syndrome.
All other blood tests gave normal results, except for a slightly
increased activated partial thromboplastin time ratio of 1·3 (upper
limit of normal range 1·2). We offered the patient long-term
anticoagulation, which he accepted. When last seen, in July, 2007, the
patient had no headache or blurred vision, although slight
papilloedema remained; his visual fields had mild generalised
constriction, with normal blind spots.

Click to enlarge imageFigure. Cerebral venous sinus thrombosis
(A) Papilloedema: the outer circle shows the extent of swelling, and
the inner circle indicates the typical margins of a healthy optic
disc. (B) CT with venography, showing a filling defect in the sigmoid
and right transverse sinuses.

The estimated annual incidence of CVST is 3-4 cases per million; CVST
mainly occurs in children and young adults. About 75% of adult
patients are women.2 CVST causes venous infarction and intracranial
hypertension. Venous infarction, and the resulting localised oedema,
can cause seizures, impaired consciousness, and focal neurological
impairment. Intracranial hypertension can cause headache, vomiting,
and loss of vision-which can be caused by reduced visual acuity, or
constriction of the visual fields. In 20-40% of cases, CVST has no
features of venous infarction, and is particularly likely to be
mistaken for IIH3-which, like CVST, is particularly common in young
women.4 Plain CT has a false-negative rate of 25-30% for CVST;3,4
however, venography increases the sensitivity of CT to 95%.3 As shown
by this case, however, a detailed history is also crucial. The
management of CVST differs radically from that of IIH, with CVST
requiring urgent anticoagulation.2-4

References
1. Gill GV, Baylis PH, Flear CT, Skillen AW, Diggle PH. Acute
biochemical responses to moderate beer drinking. BMJ 1982; 285:
1770-1773. MEDLINE

2. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med
2005; 352: 1791-1798. CrossRef

3. Masuhr F, Mehraein S, Einhaupl K. Cerebral venous and sinus
thrombosis. J Neurol 2004; 251: 11-23. MEDLINE | CrossRef

4. Renowden S. Cerebral venous sinus thrombosis. Eur Radiol 2004; 14:
215-226. MEDLINE | CrossRef

Affiliations

a. Department of Ophthalmology, Southern General Hospital, Glasgow, UK
b. Department of Neuroradiology, Institute of Neurological Sciences,
Glasgow, UK

Correspondence to: Dr Zia I Carrim, Department of Ophthalmology,
Southern General Hospital,1345 Govan Road, Glasgow G51 4TF, UK

*   *   *

"A detailed history is also crucial," in that you must ask the patient
whether he had a fight with his wife and consumed 60 beers over a
period of four days . . .

Marilyn