Abstract Number: Esoc2026a1156 Isolated Cortical Venous Infarction Mimicking Transient Neurological Symptoms in a Patient With Multiple Comorbidities

Abstract Background and aims Isolated-Cortical-Vein-Thrombosis-(ICVT) is a rare and frequently underdiagnosed cause of stroke, representing approximately 1% of all stroke cases and 6% to 8.7% of Cerebral-Venous-Thrombosis-(CVT). Unlike major sinus thrombosis, ICVT presents with highly variable clinical features and often yields unremarkable results on standard venous imaging, such as CT-Venography. Methods A woman in her early 40s with type 2 diabetes, polycystic ovarian syndrome (PCOS), and functional neurological disease (FND) presented with a two-week history of severe intermittent thunderclap headaches and transient visual loss. Neurological examination revealed a 4/5 power deficit in the left-sided limbs (NIHSS score of 0). Initial CT and MRI imaging identified right frontal lobe hypodensity and restricted diffusion. However, CT intracranial angiography and venography were normal. Due to the atypical presentation, she was initially discharged on dual antiplatelet therapy (DAPT). Results Following multidisciplinary team (MDT) review, the parenchymal findings were identified as being consistent with isolated cortical venous infarction. Comprehensive screening for thrombophilia, connective tissue disorders, and malignancy (CT abdomen/pelvis) was negative. The patient was transitioned from antiplatelets to therapeutic enoxaparin followed by lifelong direct oral anticoagulant (DOAC) therapy. A follow-up MRI at three weeks confirmed partial resolution of the infarct. Conclusions This case highlights the diagnostic complexity of ICVT, which can easily be masked by co-existing functional disorders or misleadingly normal vascular imaging. A high index of suspicion and MDT neuroradiological review are essential when parenchymal lesions do not follow arterial territories. Accurate identification is critical for shifting management from antiplatelet therapy to anticoagulation to prevent further morbidity. Conflict of interest Nothing to Disclose