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Yesterday, upon hearing the news that HRC is now hospitalized and receiving anticoagulation therapy for a "clot" related to her recent concussion, I wrote a diary extemporaneously out of concern for this very admirable human being.

Without complete information, I speculated on what was reported and it turns out that my hunch was is now reported that she suffers from a dural venous sinus thrombosis - specifically a right transverse sinus thrombosis.

This is a serious complication related to her recent concussion and thankfully, HRC is now receiving proper care for this.  I am so glad that she did not reportedly have any further neurological deficits from this, as other complications related to dural venous sinus thrombosis are surprisingly common.

Below is a brief explanation of what this diagnosis is, how it can develop and what is done to treat it.

Any dural venous sinus thrombosis is concerning since a thrombus can grow rapidly and eventually occlude blood flow in the vessel that it obstructs.

This can be dangerous if left untreated without anticoagulation.  Dural venous thromboses can occur in settings of hypercoaguable states and after head trauma - which seems to be the case regarding HRC.  The risk of dural venous sinus thrombosis can also occur during pregnancy and so a golden rule is that pregnant women who have persisting headaches without a history of headaches warrant immediate workup.

If the clot grows large enough, the flow of blood through the sinus in question becomes impaired creating a backlog of blood - that tends to pool without adequate outflow.  This leads to poor perfusion around the areas that are normally drained by the sinus in question and puts people at risk for ischemic strokes - a so called venous infarction.

Headaches are quite common with venous sinus thromboses.  Elevated intracranial pressure that may show up as papilledema on a fundoscopic exam as well as certain cranial nerve abnormalities may hint at the diagnosis (I once diagnosed a transverse venous sinus thrombosis in a pregnant female with left sided facial weakness - facial nerve palsy and a headache).

Even in the setting of a hemorrhage - anticoagulation is absolutely necessary which is quite counterintuitive from a medical standpoint. Without anticoagulation being initiated, there is a much higher risk that the clot will grow, propagate and create an even bigger problem.

Seizures can often be a presenting sign heralding workup that may reveal a dural venous sinus thrombosis - thankfully, HRC is not reported to have had a seizure associated with this diagnosis.  She just had a persisting headache - the most common heralding symptom that can clue a neurologist as to what might be the problem.

Based on the standard of care - HRC will need to be on anticoagulation (most commonly - coumadin/warfarin) with therapeutic blood levels (INR needs to be between 2-3) for at least 3-6 months.

After a few months, her physicians will likely repeat an MRV of the head (MRI that specifically is protocoled to look at the veins of the head via the use of a contrast dye that "lights up" the blood vessels on a scan) to see if the clot still remains.  If there is no further clot evident on imaging, she is free to discontinue coumadin.  If a clot remains - she needs to be on coumadin for longer.

There are newer anticoagulants on the market that do not require as frequent monitoring of blood levels and may be more convenient for HRC to use - such as Pradaxa - however these newer anticoagulants haven't been used for long compared to something like coumadin.

The reason why HRC needs to be in the hospital is because as she starts coumadin - it doesn't have an immediate effect.  It has a long half life and takes several days to build up in the blood stream.  She concurrently will need to be on heparin until her coumadin levels are therapeutic.

As long as treatment is initiated promptly and there are no further complications, there should be no long term sequelae regarding this matter.  I.E - should HRC decide to run for president again in 2016 - a past history of dural venous sinus thrombosis should not preclude her from running.  If the GOP tries to use this medical history against her, it will fail.

I wish her well and a safe recovery. She is an amazing woman!

Wishing you all a very safe and happy new year.  Have a wonderful night tonight.

4:59 PM PT: Please see this excellently detailed diary written by Fight the Untruth, another neurologist on dKos, that further explains what a dural venous sinus thrombosis is.

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