Emerg Radiol (2014) 21:83–84 DOI 10.1007/s10140-013-1189-6
CASE REPORT
Core curriculum illustration: cerebral venous thrombosis Sadaf Fatima Zaidi & David Nickels & Ken F Linnau
Received: 17 December 2013 / Accepted: 18 December 2013 / Published online: 9 January 2014 # Am Soc Emergency Radiol 2014
This is the fifth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www. aseronline.org/curriculum/toc.htm .
History A 27-year-old woman with history of sinus headaches developed severe headache and nausea 2 days prior to presentation. The headache was sharp, frontal in location, and radiating to the nose and eyes. Initially, she attributed the headache to her sinus disease, but after there was no improvement over 2 days, she presented to the emergency department. She has a past medical history of polycystic ovarian syndrome for which she takes oral contraceptive pills (OCPs).
Findings An initial non-contrast head CT shows high attenuation areas in the region of the superior sagittal sinus (Fig. 1) and left basal vein of Rosenthal (Fig. 2). Cerebral venous sinus S. F. Zaidi : K. F. Linnau (*) Emergency Radiology, UW Medicine, Harborview Medical Center, 325 Ninth Ave, Box 359728, Seattle, WA 98117, USA e-mail: [email protected] D. Nickels Department of Radiology, University of Kentucky, 800 Rose Street, Room HX 313E, Lexington, KY 40356-0293, USA e-mail: [email protected]
thrombosis was suspected which was subsequently confirmed on a CT cerebral venogram. CT venogram of the cerebral vessels confirms extensive filling defects throughout the superior sagittal and straight sinuses (Fig. 3). Thrombosis was also seen in the right transverse sinus (not shown). There was no evidence of venous infarction concordant with the patient’s neurological exam, which was unremarkable. Anticoagulation therapy was started, and the patient did well. The cause of venous sinus thrombosis was initially attributed to OCPs; however, a complete hypercoagulability workup later revealed a prothrombin gene mutation for which the patient was kept on lifelong low molecular weight heparin.
Discussion Cerebral venous thrombosis (CVT) is a potentially lifethreatening, yet easily treatable, condition, if diagnosed in a timely manner. The biggest dilemma in diagnosing this condition is the fact that clinical presentation is nonspecific [1]. Clinical presentation may range from headache, focal neurologic deficits, seizures, and altered consciousness [1] to obscuration of vision, nausea, vomiting, papilledema, cranial nerve palsies, and even coma [2]. The etiology of CVT is multifactorial [1]. It may result from local alterations in cerebral venous blood flow due to skull trauma or intracranial/head and neck infections that may promote thrombosis. CVT can also occur due to systemic causes including hypercoagulable states and diseases [3]. Angiography remains the gold standard for imaging this condition [4] but may not be routinely available at many institutions. MRI and MRV are considered as the modality of choice for detecting CVT [5]. Non-contrast head CT remains
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Fig. 1 Axial non-contrast head CT image shows a triangular high attenuation area also known as “delta sign” (arrow) that is in the region of the superior sagittal sinus, consistent with acute sinus thrombosis
the first-line imaging modality for patients presenting to the ED with neurological symptoms [4]. This case demonstrates the findings of cerebral venous thrombosis on non-contrast head CT. Thrombus is visible on non-enhanced CT as a high-attenuation lesion in the venous sinus, producing a dense triangle/delta sign representing the intravascular acute blood clot [2]. Our patient subsequently had a CT venogram (CTV) since the combination of CT and
Emerg Radiol (2014) 21:83–84
Fig. 3 Sagittal image from the CT venogram in same patient shows thrombus seen as non-opacification of the superior sagittal sinus (small arrows). Notice the abrupt cutoff in contrast in the straight sinus (long arrow). Vein of Galen is patent (arrow head)
CTV is a rapid screening modality for an early diagnosis of CVT in the emergency setting [6]. CTV with multi-planar reformats has a reported sensitivity of 95 % when compared with conventional angiography [2]. Detection of this disease on a non-contrast CT is very important for emergency radiologists in order to facilitate further imaging evaluation with a venogram to confirm the diagnosis. In our case, prompt diagnosis lead to early treatment, saving the patient from fatal complications like venous hemorrhagic infarction which may have resulted in permanent neurological damage. Conflict of Interest The authors declare that they have no conflict of interest.
References
Fig. 2 Axial CT image at the level of the interpeduncular fossa shows hyper-attenuation extending in the left basal vein of Rosenthal (short arrow). Long arrow points to the superior sagittal sinus
1. Poon CS, Chang JK, Swarnkar A et al (2007) Radiologic diagnosis of cerebral venous thrombosis: pictorial review. Am J Radiol 189:S64– S75 2. Rodallec MH, Krainik A, Feydy A et al (2006) Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics 26:S5–S18 3. Leach JL, Fortuna RB, Jones BV et al (2006) Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 26:S19–S43 4. Karthikeyan D, Vijay S, Kumar T et al (2004) Cerebral venous thrombosis-spectrum of CT findings. Neuroradiology 14:129–137 5. Biousse V, Bousser MG (1999) Cerebral venous thrombosis. Neurologist 5:236–249 6. Aliasgar V, Moiyadi MC, Indira Devi B (2006) Posttraumatic nonsinus cerebral venous thrombosis. Indian J of Neurotrauma 3:143–146
CASE REPORT
Core curriculum illustration: cerebral venous thrombosis Sadaf Fatima Zaidi & David Nickels & Ken F Linnau
Received: 17 December 2013 / Accepted: 18 December 2013 / Published online: 9 January 2014 # Am Soc Emergency Radiol 2014
This is the fifth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www. aseronline.org/curriculum/toc.htm .
History A 27-year-old woman with history of sinus headaches developed severe headache and nausea 2 days prior to presentation. The headache was sharp, frontal in location, and radiating to the nose and eyes. Initially, she attributed the headache to her sinus disease, but after there was no improvement over 2 days, she presented to the emergency department. She has a past medical history of polycystic ovarian syndrome for which she takes oral contraceptive pills (OCPs).
Findings An initial non-contrast head CT shows high attenuation areas in the region of the superior sagittal sinus (Fig. 1) and left basal vein of Rosenthal (Fig. 2). Cerebral venous sinus S. F. Zaidi : K. F. Linnau (*) Emergency Radiology, UW Medicine, Harborview Medical Center, 325 Ninth Ave, Box 359728, Seattle, WA 98117, USA e-mail: [email protected] D. Nickels Department of Radiology, University of Kentucky, 800 Rose Street, Room HX 313E, Lexington, KY 40356-0293, USA e-mail: [email protected]
thrombosis was suspected which was subsequently confirmed on a CT cerebral venogram. CT venogram of the cerebral vessels confirms extensive filling defects throughout the superior sagittal and straight sinuses (Fig. 3). Thrombosis was also seen in the right transverse sinus (not shown). There was no evidence of venous infarction concordant with the patient’s neurological exam, which was unremarkable. Anticoagulation therapy was started, and the patient did well. The cause of venous sinus thrombosis was initially attributed to OCPs; however, a complete hypercoagulability workup later revealed a prothrombin gene mutation for which the patient was kept on lifelong low molecular weight heparin.
Discussion Cerebral venous thrombosis (CVT) is a potentially lifethreatening, yet easily treatable, condition, if diagnosed in a timely manner. The biggest dilemma in diagnosing this condition is the fact that clinical presentation is nonspecific [1]. Clinical presentation may range from headache, focal neurologic deficits, seizures, and altered consciousness [1] to obscuration of vision, nausea, vomiting, papilledema, cranial nerve palsies, and even coma [2]. The etiology of CVT is multifactorial [1]. It may result from local alterations in cerebral venous blood flow due to skull trauma or intracranial/head and neck infections that may promote thrombosis. CVT can also occur due to systemic causes including hypercoagulable states and diseases [3]. Angiography remains the gold standard for imaging this condition [4] but may not be routinely available at many institutions. MRI and MRV are considered as the modality of choice for detecting CVT [5]. Non-contrast head CT remains
84
Fig. 1 Axial non-contrast head CT image shows a triangular high attenuation area also known as “delta sign” (arrow) that is in the region of the superior sagittal sinus, consistent with acute sinus thrombosis
the first-line imaging modality for patients presenting to the ED with neurological symptoms [4]. This case demonstrates the findings of cerebral venous thrombosis on non-contrast head CT. Thrombus is visible on non-enhanced CT as a high-attenuation lesion in the venous sinus, producing a dense triangle/delta sign representing the intravascular acute blood clot [2]. Our patient subsequently had a CT venogram (CTV) since the combination of CT and
Emerg Radiol (2014) 21:83–84
Fig. 3 Sagittal image from the CT venogram in same patient shows thrombus seen as non-opacification of the superior sagittal sinus (small arrows). Notice the abrupt cutoff in contrast in the straight sinus (long arrow). Vein of Galen is patent (arrow head)
CTV is a rapid screening modality for an early diagnosis of CVT in the emergency setting [6]. CTV with multi-planar reformats has a reported sensitivity of 95 % when compared with conventional angiography [2]. Detection of this disease on a non-contrast CT is very important for emergency radiologists in order to facilitate further imaging evaluation with a venogram to confirm the diagnosis. In our case, prompt diagnosis lead to early treatment, saving the patient from fatal complications like venous hemorrhagic infarction which may have resulted in permanent neurological damage. Conflict of Interest The authors declare that they have no conflict of interest.
References
Fig. 2 Axial CT image at the level of the interpeduncular fossa shows hyper-attenuation extending in the left basal vein of Rosenthal (short arrow). Long arrow points to the superior sagittal sinus
1. Poon CS, Chang JK, Swarnkar A et al (2007) Radiologic diagnosis of cerebral venous thrombosis: pictorial review. Am J Radiol 189:S64– S75 2. Rodallec MH, Krainik A, Feydy A et al (2006) Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics 26:S5–S18 3. Leach JL, Fortuna RB, Jones BV et al (2006) Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 26:S19–S43 4. Karthikeyan D, Vijay S, Kumar T et al (2004) Cerebral venous thrombosis-spectrum of CT findings. Neuroradiology 14:129–137 5. Biousse V, Bousser MG (1999) Cerebral venous thrombosis. Neurologist 5:236–249 6. Aliasgar V, Moiyadi MC, Indira Devi B (2006) Posttraumatic nonsinus cerebral venous thrombosis. Indian J of Neurotrauma 3:143–146
