Superior sagittal sinus thrombosis with subarachnoid and intraparencyhmal hemorrhage
Presentation
First-episode generalized tonic-clonic seizures in a young male.
Patient Data
CT Brain
Multiple areas of intra-axial hemorrhage in both frontal lobes at the convexity. A small subarachnoid hemorrhage is seen along the interhemispheric fissure.
The superior sagittal sinus anteriorly and in its mid portion to approximately 10cm above torcula is hyperdense on non-enhanced imaging and shows no enhancement post-contrast in the venogram phase supporting a large acute thrombosis.
Some cortical veins are also hyperenhancing suggesting early thrombosis.
Conclusion: Large acute thrombosis of the superior sagittal sinus with associated intraparenchymal and subarachnoid hemorrhage.
Case Discussion
This young patient presented with status epilepticus. He was intubated and ventilated on arrival and commenced on anti-convulsants. Initial non-contrast CT showed dural venous sinus thrombosis with associated subarachnoid hemorrhage and intracranial hemorrhage. He was commenced on intravenous heparin. Thrombophilia screen identified factor V Leiden mutation.
The primary sign of acute dural venous sinus thrombosis on a non-contrast CT is hyper-density of a cortical vein or dural sinus. An ischemic infarction, sometimes with a hemorrhagic component, may be observed. Subarachnoid hemorrhage (SAH) and intraparenchymal venous hemorrhage are infrequently seen. SAH, when present, is localized in the convexity as opposed to around the area of circle of Willis, which is usually observed in patients with aneurysmal rupture.
Contrast-enhanced CT may show enhancement of the dural lining of the sinus with a filling defect within the vein or sinus. Contrast-enhanced CT may show the classic “empty delta” sign, in which a central hypointensity due to very slow or absent flow within the sinus is surrounded by contrast enhancement in the surrounding triangular shape in the posterior aspect of the superior sagittal sinus.