Reversible diencephalic dysfunction as presentation of deep cerebral venous thrombosis due to hyperhomocysteinemia and protein S deficiency: Documentation of a case

A 45-year-old man presented with global headache, vomiting and abnormal behavior after cross-country run at high altitude. There was no seizure, loss of consciousness, fever or head injury. He was conscious, abulic and uncooperative with normal vitals. There was no focal neurological deficit. Non contrast computed tomography scan of head was normal. Magnetic resonance imaging of brain showed venous infarct in bilateral thalami, left basal ganglia and periventricular white matter. Magnetic resonance venography revealed thrombosis involving internal cerebral veins, septal veins, thalamostriate veins, vein of Galen and proximal portion of straight sinus. His condition steadily improved on low molecular weight heparin bridged with oral anticoagulation for one year. At two months, serum homocysteine was 31.51 μmol/l (5.46-16.2 μmol/l) and protein S was 49.00% (77-143.00%). He received methylcobalamin, pyridoxine and folic acid. After 16 months, he was asymptomatic with partially recanalized deep cerebral veins and serum homocysteine falling to 16.50 μmol/l (5.46-16.2 μmol/l).