Presentation
Sudden onset of headache
Patient Data
Intraparenchymal hemorrhage in the posterior left temporal lobe with surrounding subarachnoid blood and blood layering on the tentorium cerebelli. The left transverse sinus is hyperdense. Hypodense region surrounding the hemorrhage in keeping with edema.
Mild effacement of the left ambient cistern. No midline shift. Grey-white matter differentiation is preserved with no evidence of acute ischemia. Old left lacunar infarct. No calvarial fracture or suspicious bony abnormality seen. Imaged paranasal sinuses and mastoid air cells are clear.
Conclusion:
Left temporal lobe hemorrhage with surrounding edema, in association with hyperdense left transverse sinus. The findings are most in keeping with a venous infarct secondary to venous sinus thrombosis.
Venogram reveals absence of opacification of the torcula, left transverse and sigmoid sinuses extending to the jugular bulb. The visualized upper left internal jugular vein contains contrast with central hypodensity consistent with thrombus.
Conclusion:
Left transverse and sigmoid sinus thrombus extending into the left internal jugular vein.
Case Discussion
A parenchymal hemorrhage, particularly in a younger patient, should trigger a careful scrutiny of relevant dural venous sinuses and cortical and deep veins for hyperdensity indicating thrombus, keeping in mind that acute thrombus only gradually becomes hyperdense.
The location of this hemorrhage (inferior temporal lobe) is a classic location for a transverse / sigmoid sinus thrombosis, often secondary to mastoiditis (not present in this case).
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