Cerebral venous thrombosis

Case contributed by Dr Bruno Di Muzio

Presentation

First seizure.

Patient Data

Age: 40 years
Gender: Male
CT

CT Brain + CTA and CT Venogram

There is a small volume of left frontal subarachnoid blood. The overlying left frontal superficial cortical veins and anterior superior sagittal sinus appear hyperdense. No definite intra-axial haemorrhage (possible small petechial component). Grey-white matter differentiation is preserved. No midline shift. No hydrocephalus. No skull fracture or subgaleal haematoma.

Conclusion: Left frontal subarachnoid haemorrhage with findings suggestive of left frontal cortical vein thrombosis with involvement of the frontal aspect of the sagittal sinus.

Whilst this may be an isolated finding an underlying dural AVF warrants exclusion. Emergent evaluation with CTV/CTA COW recommended in the first instance.

CT Venogram

There is a filling defect within the anterior superior sagittal sinus and hypoenhancement and additional filling defects in the left frontal superficial cortical veins. The posterior superior sagittal sinus and remainder of the venous sinuses opacify normally.

CTA COW (not shown)

The aortic arch has not been imaged. The right vertebral artery is dominant; the left arises from the arch. The left PCA has a fetal origin. The extracranial vessels, circle of Willis and vertebrobasilar system opacify normally. No evidence of an aneurysm, vascular malformation, dissection or significant stenosis.

Conclusion: Findings are consistent with anterior superior sagittal sinus/left frontal superficial cortical vein thrombosis. No underlying dural AVF identified. 

MRI

MRI Brain / MRV (follow-up 6 months later)

Technique: Multiplanar, multisequence imaging has been obtained through the brain including post contrast images and MRV.

Findings: No intra or extra-axial abnormality, mass, or collection. Ventricles and basal cisterns are normal in appearance. No abnormal enhancement. Cerebral venous sinuses, deep and superficial cerebral veins appear normal, with no signs of new venous thrombosis, although the calibre of the anterior two thirds of the superior sagittal sinus remains reduced. Flow is demonstrated in this region on phase contrast MRV. Within the left frontal lobe are numerous prominent transmedullary veins which drain into the internal cerebral veins on the left. These presumably represent enlarged collateral drainage pathways, and no abnormal arteries are demonstrated in the region (middle cerebral, middle meningeal or superficial temporal arteries) to suggest the presence of a dural arteriovenous venous fistula, however continued followup is recommended. On future imaging a MR angiogram would be of benefit.

Case Discussion

Cortical vein thrombosis is a subset of cerebral venous thrombosis involving the superficial cerebral veins besides the dural sinus, often coexisting with deep cerebral vein thrombosis or dural venous sinus thrombosis

This case illustrates left frontal cortical veins and superior sagittal sinus thrombosis managed clinically with no signs of chronic thrombosis on the MRA follow-up. However, some prominent transmedullary veins on the left caught our attention on this exam. They probably represent an anatomical variation, although follow-up with MRA was recommended as surveillance for possible fistula complication. 

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Case information

rID: 38392
Case created: 17th Jul 2015
Last edited: 8th Jan 2017
Tag: rmh
Inclusion in quiz mode: Included

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