Presentation
Severe headache, nausea, and left side weakness. No past medical or surgical history.
Patient Data
Loss of normal signal void is seen involving the right transverse and sigmoid sinuses extending to the proximal ipsilateral internal jugular vein with signal appearances as hyperintense on T1w and FLAIR images representing a subacute blood clot.
A moderately well-defined intra-axial cortical and subcortical heterogeneous lesion is seen in the right occipitotemporal region, hyperintense on T1w and T2w sequences with surrounding vasogenic and cortical edema. Blooming artifact is also noted within the lesion. Appearances are in keeping with intra-axial late subacute hemorrhage measuring about 17 x 10 mm.
Cortical restricted diffusion is seen involving the posterior aspect of the insular cortex representing cortical ischemia.
Subarachnoid hyperintensity is seen on T1w and FLAIR images involving the right temporal lobe anteriorly highly suggestive of associated subarachnoid hemorrhage.
Few small scattered white matter hyperintensities without edema, mass-effect, or restricted diffusion representing small vessel disease.
The CSF spaces are of normal size. Grey-white matter differentiation is normal. No shift of midline. No arterial territory infarction. The other major vascular voids appear unremarkable. The sella showed no gross pathology.
Conclusion:
Features are in keeping with dural venous sinus thrombosis involving the right transverse and sigmoid sinuses extending to the proximal internal jugular vein with associated hemorrhagic infarction right occipitotemporal region and right temporal subarachnoid hemorrhage.
Case Discussion
CT scan of this patient shows an intracranial hemorrhage, MRI was requested for better assessment and to assess for any underlying pathology.
Features that suggest venous infarction include bilateral, peripheral/cortical, hemorrhagic, and non-arterial territory infarct. The infarct and hemorrhage in this case make it a type 4 in severity.
Pitfalls for diagnoses include arachnoid granulations which are usually characterized by focal rounded filling defects rather than linear filling defects taking the shape of the sinus. Also, granulations follow CSF signal on all MRI sequences, while thrombus does not.
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