Presentation
Metastatic carcinoma breast with severe suboccipital headache
Patient Data
Thrombosed left sigmoid sinus and internal jugular vein. A 3.4 x 2.5 x 1.8 cm (TR x AP x CC) enhancing lytic expansile soft tissue lesion is seen involving left occipital condyle with anterolateral cortical break and perivertebral soft tissue component.
Moderate mucosal thickening with air fluid levels seen in bilateral maxillary, ethmoidal and right sphenoidal air cells.
Conclusion
left occipital condyle lytic expansile neoplasm causing left sigmoid and jugular venous thrombosis
no brain scondaries
moderate bilateral maxillary, ethmoidal and right sphenoidal sinusitis
Case Discussion
Always look for dural venous sinuses when relatively normal brain is seen in a patient with severe headache. The high signal intensity in pulse sequences alerted me first. The diffusion restriction raised the suspicion of intra-luminal thrombus. I went ahead and did a venogram to identify the absence of filling. Reviewing axial T1 weighted image enabled me to pick up the obvious asymmetry in the skull base which is one of the hidden areas of a brain study. I alerted the MR technician to do a i.v. gadolinium contrast study and a contrast enhanced venogram to reaffirm the findings.
The malignant left occipital condyle lytic neoplasm has resulted in the venous thrombosis. The sluggish flow in the hypoplastic left transverse sinus is responsible for the high signal intensity in all pulse sequences.
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