Isolated Psychiatric Presentation of Cerebral Venous Thrombosis in a Patient Without Risk Factors: A Diagnostic Challenge.

BACKGROUND Cerebral venous thrombosis (CVT) is an uncommon form of stroke with highly variable clinical manifestations. Although headache and focal neurological deficits are typical presenting features, isolated psychiatric symptoms as an initial manifestation are exceptionally rare and may substantially delay diagnosis. CVT most commonly affects young adults and women with identifiable prothrombotic risk factors. CASE REPORT We report the case of a 37-year-old previously healthy woman with no identifiable thrombotic risk factors who presented with acute behavioral disturbances characterized by insomnia, agitation, emotional lability, and aggressive behavior. There was no history of prior psychiatric illness. Initial investigations, including brain magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and infectious workup, were unremarkable, with no evidence of structural abnormalities on early neuroimaging. She was admitted with a working diagnosis of acute polymorphic psychotic disorder and started on psychiatric treatment. Six days later, she developed sudden loss of consciousness followed by generalized tonic-clonic seizures, prompting urgent neuroimaging. Imaging revealed a right high-parietal intracerebral hemorrhage, and subsequent venous imaging confirmed CVT involving the superficial superior cerebral vein. The patient was treated with antiepileptic therapy and anticoagulation, leading to gradual neurological and psychiatric improvement. CONCLUSIONS This case highlights an unusual presentation of CVT with isolated psychiatric manifestations, absence of classical risk factors, and initially normal neuroimaging findings, all of which contributed to delayed diagnosis. Abrupt neurological deterioration can occur despite non-specific early investigations. Early consideration of cerebral venous imaging may be warranted in atypical acute psychiatric presentations to avoid delayed diagnosis and potentially life-threatening complications.