Medroxyprogesterone
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Extensive cerebral venous sinus thrombosis: case report A 28-year-old woman developed extensive cerebral venous sinus thrombosis (CVST) during treatment with medroxyprogesterone for contraception [dosages and routes not stated]. The woman presented with a 4 day history of bilateral and decreased, "tunnel vision", accompanied by tinnitus, headache and pulsatile "whooshing" in both ears. Her medical history was significant for bipolar disorder, and medroxyprogesterone [medroxyprogesterone acetate; Depo-Provera] injections every 3 months for contraception. She was using this contraception, for at least 1 year prior to presentation. Her baseline visual acuity was 20/100 in the right eye (OD) and 20/200 in the left eye (OS). Her pupils were minimally reactive. Confrontation visual fields were markedly diminished, associated with small central islands in both eyes (OU). Colour vision was markedly decreased OU. Dilated fundus examination (DFE) showed florid 5+ disc oedema along with profound vessel tortuosity OU. An orbital ultrasound demonstrated increased optic nerve sheath diameters. A non-contrast head CT scan revealed hyperdense, dilated superior sagittal, transverse, and straight sinuses suggestive of extensive CVST. Subsequent head MRI and magnetic resonance venography (MRV) confirmed extensive CVST [duration of treatment to reaction onset not stated]. The woman was admitted to the neuro-intensive care unit (N-ICU) and was initiated on a heparin drip (anticoagulation therapy) and IV acetazolamide. Afterwards, medroxyprogesterone and her bipolar medication, lithium, were stopped, considering as possible contributors to high intracranial pressure (ICP). A full hypercoagulation panel was found negative. Due to constricted visual fields, severe disc oedema, and highly elevated ICP, an optic nerve sheath fenestration (ONSF) OD was performed on day 2 of admission. Initially, her visual acuity improved post-procedure, but subsequently decreased to 20/200 OU on post-operative day 1. On post-operative day 2, visual acuity was no light perception (NLP) OU (vision loss). IV methylprednisolone-sodium-succinate [solumedrol] infusion for 3 days led to a small visual improvement. On post-operative day 3, her vision OS declined again. Therefore, ONSF was performed in the left eye, leading to visual improvement to 20/70 OD and 20/200 OS. Anti-coagulation therapy was continued the same day post-procedure. For approximately 3 weeks, she remained stable on anti-coagulation and acetazolamide. Then, her vision OS declined again. Afterwards, a lumbar drain was placed, recording an opening pressure of 30mm Hg. Consequently, her visual field constriction improved slightly over the following week. Following consultation with neurosurgery, a ventriculoperitoneal (VP) shunt was placed. Within days of VP shunt placement, her visual acuity improved to 20/20 OD, while the vision in OS remained unchanged. Eventually, the shunt clotted, probably due to holding of anti-coagulation perioperatively. Restart of anticoagulation (heparin) resulted
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