Venous sinus thrombosis and intraparechymal haemorrhage

Case contributed by Prof Peter Mitchell

Presentation

Sudden onset of severe headache. CT request "rule out SAH"

Patient Data

Age: 41
Gender: Female

Non-contrast axial images through the brain have been obtained. No previous CT is available for comparison.

Intraparenchymal haemorrhage in the posterior left temporal lobe with surrounding subarachnoid blood and blood layering on the tentorium cerebelli.

The left transverse sinus is hyperdense. Hypodense region surrounding the haemorrhage in keeping with oedema. Mild effacement of the left ambient cistern. No midline shift.

Grey-white matter differentiation is preserved with no evidence of acute ischaemia. Old let lacunar infarct.

No calvarial fracture or suspicious bony abnormality seen. Imaged paranasal sinuses and mastoid air cells are clear.

Conclusion:

Left temporal lobe haemorrhage with surrounding oedema, in association with hyperdense left transverse sinus. Subarachnoid blood also demonstrated.

The findings are most in keeping with an infarct secondary to venous sinus thrombosis. Associated subarachnoid blood. CT Venogram is recommended.

CT Venogram

Modality: CT

Venogram reveals absence of opacification of the torcula, left transverse and sigmoid sinuses extending to the jugular bulb. The visualised upper left internal jugular vein contains contrast with central hypodensity consistent with thrombus.There is relative hypodensity of the entire left internal jugular vein when compared with the right side on the CTA study.

The remainder of the venous sinuses opacify normally.

Conclusion

Left transverse and sigmoid sinus thrombus extending into the left internal jugular vein. The straight sinus drains to the right TS, the deep veins are patent and normal, there is a narrow channel from the SSS connecting through the torcular to the right TS.

Whilst a dedicated venogram of the neck vessels has not been performed, the thrombus extends into the jugular bulb and IJV just below this is patent.

Stable appearance of the left temporal hemorrhage (likely hemorrhage into a venous infarct in this setting). Layering of subarachnoid blood vs thin tentorial subdural.

 

The previously demonstrated left inferior temporal gyrus intraparenchymal haematoma, and blood along the tentorium is undergoing expected evolution, with no convincing features to suggest an new haemorrhage. Abnormal signal continues to be seen extending from the torcula, through the left transverse sinus and sigmoid sinus consistent with venous sinus thrombosis, which does not appear to have extended since prior vascular imaging. Some fluid opacifies the left mastoid air cells, without florid enhancement or adjacent dural enhancement to suggest acute otomastoiditis.

Ventricular size is unaltered when compared to previous imaging with no evidence of hydrocephalus, and no effacement of the ventricles or sulci or basal cisterns to suggest intracranial hypertension. There is however some prominence of the optic nerve sheaths, with slight restricted diffusion is seen at the optic disc, suggesting papilloedema. The pituitary fossa remains mostly empty, unaltered when compared to the earlier CT venogram.

No asymmetry of the cavernous sinuses, and no orbital abnormality. The superior ophthalmic veins do not appear enlarged.

Conclusion:

1. Expected evolution of intracranial haemorrhage, with persistent venous sinus thrombosis, involving the torcula and dominant left transverse/sigmoid sinus.

2. Suggestion of papilloedema presumably due to venous hypertension, with no other features to suggest raised intracranial pressure. Clinical correlation recommended.

 

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Case Information

rID: 33886
Case created: 28th Jan 2015
Last edited: 19th Feb 2016
Inclusion in quiz mode: Included

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