Unilateral internal cerebral vein thrombosis: Review of literature and case illustration at 3T

Isolated unilateral thalamic venous infarct in a toddler

Isolated deep cerebral venous thrombosis (CVT), especially involving only the right thalamus, is one of the rarest forms of intracranial venous thrombosis in a child. The anatomy and flow patterns of the deep cerebral venous system are complex and usually, the thrombosis of the internal cerebral veins (ICV) results in thalamic infarction bilaterally. The focal infections, thalamic tumours and vascular malformations may have overlapping clinicoradiological patterns. The treating team should be able to recognise the atypical phenotypes of the deep CVT at the earliest, which can facilitate apt treatment and obviate the need for unnecessary investigations and interventions. We present a rare case of an isolated right thalamic acute venous infarct secondary to bilateral ICV thrombosis in a toddler who was successfully managed by timely diagnosis and with only conservative therapy.

Postoperative Unilateral Internal Cerebral Vein Thrombosis with Venous Watershed Infarcts: Case Report and Review of the Literature

BACKGROUND

Cerebral venous complications related to neurosurgical interventions are only rarely reported in the literature. Internal cerebral veins (ICVs) are vulnerable to injury during neurosurgical approaches to the pineal and thalamic regions. The occurrence of unilateral postoperative ICV thrombosis in children is extremely rare, with only 2 such cases reported thus far.

CASE DESCRIPTION

A 15-year-old child presented to the emergency department with headache, persistent vomiting, and pronounced lethargy for 3 days. Magnetic resonance imaging of the brain was performed and showed a large solid-cystic mass at the pineal region, resulting in upstream hydrocephalus. Serum beta-human chorionic gonadotropin was elevated, and a diagnosis of germ cell tumor was made. Patient was started on neoadjuvant chemotherapy, with partial response on repeat imaging after 3 courses of chemotherapy. Decision was made to proceed with surgical resection of the residual tumor. Magnetic resonance imaging of the brain performed on postoperative day 1 showed multiple foci of restricted diffusion in the right cerebral deep white matter, giving rise to a "string of pearls" appearance. There is also absence of enhancement of the right ICV, suspicious for deep cerebral venous thrombosis. This was confirmed on subsequent computed tomography venogram.

CONCLUSIONS

Our reported case adds to the limited literature on postoperative ICV thrombosis in children and describes a unique imaging phenotype of venous watershed infarcts. Neurosurgeons and neuroradiologists should be aware of this unique imaging phenotype and have a high index of suspicion for deep cerebral venous thrombosis, especially in patients with prior neurosurgical intervention in the pineal or thalamic regions.

Letter to the editor. Unilateral thalamic infarction in vein of galen and straight sinus thrombosis

Deep cerebral venous thrombosis is an uncommon event. It usually involves the halami and adjacent areas on both sides. Unilateral thalamic infarction is extremely rare subsequent to deep cerebral venous thrombosis. Imaging findings of a female in the postpartum period with unilateral thalamic infarction and basal ganglia edema are presented.