Presentation
Altered mental status and not herself for the past one week.
Patient Data
A large area of wedge-shaped hypodensities blurring grey-white matter differentiation in the left parieto-temporo-occipital lobes, which contained a large volume of acute intraparenchymal hemorrhage. The acute hemorrhage has a characteristic gyriform configuration and is heterogenous.
Hyperdensities seen within the adjacent left transverse and sigmoid sinuses, raise suspicion of thrombi.
Subfalcine herniation/midline shift (measured at the level of the foramen of Monro) to the right side by 0.5cm.
Partial effacement of left lateral ventricle and left uncal herniation.
Basal cisterns are partially effaced.
CT Venogram showed filling defects (long tubular shape) within the anterior and posterior parts of the superior sagittal sinus, bilateral transverse, and sigmoid sinuses.
Empty delta sign for the superior sagittal sinus thrombosis.
Annotated images showed the cerebral venous sinuses thrombi,
Case Discussion
Imaging features are consistent with cerebral venous hemorrhagic infarction.
Patient has background medical history of cyanotic heart disease (tricuspid atresia) with high haemotocrit level (67) on admission. This has predisposed patient to be prothrombotic state.
Patient was treated with venesection and anticoagulation.
Venous thrombosis should be considered in the assessment of acute lobar hemorrhage in atypical areas which involve multiple arterial territories or infarcts with cortical sparing