Presentation
Sudden onset left sided body weakness, power 4/5. 12 hours later, she developed generalized tonic clonic seizure.
Patient Data
3 hours from onset of symptom
Cerebral sulci effacement of the right cerebral hemisphere with an apparent loss of insular ribbon sign. No dense right MCA sign. Subtle subarachnoid hemorrhage in the right superior frontal sulcus. Dense vein sign of superior sagittal sinus and adjacent cortical veins at right high frontal region.
Dense vein sign of superior sagittal sinus and adjacent cortical veins at right high frontal region were more apparent 12 hours later.
Case Discussion
On the initial CT Brain (3 hours from onset of symptom), the dense vein sign was subtle and was not appreciated (due to the location). The loss of right insular ribbon sign was misleading. Furthermore, power of left-sided body weakness was not documented in the request form.
Hence, the case was mistakenly reported as a hyperacute infarct, possibly right MCA vascular territory. The degree of swelling so early would be unusual in an ischemic stroke and could have been a clue to the diagnosis.
12 hours later, the patient developed a generalized tonic-clonic seizure. The dense vein sign was more conspicuous in subsequent plain CT Brain allowing a final diagnosis of superior sagittal sinus thrombosis with involvement of adjacent right cortical veins to be made.
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