Further investigations taken to find the etiology of multiple sites of thrombosis. Results as followings:

• lupus anticoagulant positive (two samples taken in 4 months apart)
• ANA negative
• C3/C4 normal
• anti-cardiolipin negative
• cANCA and pANCA negative

According to revised Sapporo criteria¹, this patient fulfills the clinical and the laboratory criteria for the diagnosis of antiphospholipid syndrome. The patient has been put on life-long anticoagulation. 

Follow-up chest radiograph showed resolution of the pulmonary artery enlargement and resolution of cerebral venous sinuses thrombosis in CT venogram of the brain.

This is a great radiology case for demonstrating important radiological signs to identify cerebral venous sinuses thrombosis and massive pulmonary embolism.

The patient initially presented with sudden onset of central nervous system symptoms (headache, photophobia and altered behavior), where plain CT brain performed showed multiple sites of acute infarctions which are not confined to one particular arterial vascular territory, ie: left thalamus and right temporal-parietal lobes. The presence of abnormally high attenuation of the dural venous sinuses (cord sign) should raise the suspicion of venous thrombosis and lead to performing urgent CT venogram by radiologists/physicians.

Fleischner sign is one of the signs of pulmonary embolus on chest radiographs , which is closely related to massive pulmonary embolism. It has a low sensitivity but high specificity.