Dural venous sinus thrombosis

Case contributed by A.Prof Frank Gaillard

Presentation

Left arm weakness and incoordination since 5pm today, nil past history. ? Stroke.

Patient Data

Age: 65
Gender: Male
CT

 

Prominence of the ventricles and cerebral cortical sulci reflects age-related involution. No haemorrhage, collection or mass. Grey-white differentiation satisfactory. No hyperdense vessel sign. The cerebellum and brainstem appear normal.

Note is made of marked hyperdensity of the posterior sagittal sinus on the unenhanced studies and this correlates with a filling defect on the CTV study and indicates the presence of a sagittal sinus thrombus. Several superficial cortical veins over the vertex of the skull also appear hyperdense (cord sign).

The orbital contents are of satisfactory appearance. The mastoid air cells are normally aerated. There is mucosal thickening throughout the paranasal sinuses, to bony defect or adjacent extra-axial intracranial collection is identified. No significant bony finding.

CT Venogram:

There is extensive dural venous sinus thrombosis within the sagittal sinus, particularly posteriorly next to the torcular and extending throughout the right transverse and sigmoid sinus. The left transverse is patent. Given the hyperdense appearance of several superficial cortical veins on the unenhanced study, I suspect these are also thrombosed - at least two large frontal cortical veins and two smaller veins parallel to the more posterior sagittal sinus have this appearance.

The straight sinus, internal cerebral veins and basal veins of Rosenthal remain patent.

MRI

Heterogeneous high FLAIR and T2 signal in the posterior superior sagittal sinus and right transverse and sigmoid sinuses extending into the jugular bulb is consistent with thrombosis, confirmed on MRV. Normal signal is demonstrated in the left transverse and sigmoid sinuses. No restricted diffusion. Bilateral pachymeningeal thickening and enhancement. No abnormal parenchymal enhancement. Cortical and subcortical FLAIR/T2 hyperintensity in the right posterior frontal and parietal lobes adjacent to the prominent and likely thrombosed cortical vein. Mo hydrocephalus. Widespread paranasal sinusitis.

Conclusion:

Extensive dural venous sinus thrombosis involving the posterior superior sagittal sinus and right transverse and sigmoid sinuses extending into the jugular bulb is again demonstrated and stable in extent compared to the recent CT. No evidence of infarction or haemorrhage. Right frontoparietal FLAIR/T2 hyperintensity likely represents oedema.

Case Discussion

This case demonstrates extensive dural venous sinus thrombosis and its appearance on CT and MRI. Note that even in such an 'obvious' example there are pitfalls: CTV must be windowed correctly and adequate venous opacification obtained to distinguish hyperdense clot form contrast. Familiarity with normal appearance of slow flow / thrombus on various sequences is required; knowledge of the venous anatomy is needed to interpret phase contrast MRV. 

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Case information

rID: 38773
Case created: 3rd Aug 2015
Last edited: 30th Oct 2015
Inclusion in quiz mode: Included

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