Dural Sinus Thrombosis with Nonsymptomatic Persistent Falcine Sinus: A Case Report

A 24-year-old woman was admitted to our hospital after convulsive status epilepticus. A cerebral magnetic resonance venography revealed a persistent fetal falcine sinus. Additionally, the posterior third of the superior sagittal sinus was hypoplastic and the abnormal deep venous drainage was accompanied. These abnormalities had already been detected by magnetic resonance imaging several years ago. In the present scan, we discovered a sinus thrombosis in the hypoplastic superior sagittal sinus. In the cerebral angiography, we observed delayed venous return in the left parieto-occipital lobe and hypothesized that cerebral venous stasis due to the thrombus caused the convulsive status epilepticus. The patient was treated with intravenous administration of heparin along with an antiepileptic drug, and she recovered with no neurological defects. In the present case, the falcine sinus and the anomalous venous return were likely congenital while the status epilepticus was derived from thrombosis in the hypoplastic superior sagittal sinus. Although the falcine sinus functioned as an alternative pathway for the superior sagittal sinus, the hypoplastic superior sagittal sinus itself may also play an important role as a venous drainage channel.

Dynamic morphological changes of thrombosed lateral sinus pericranii revealed by serial magnetic resonance images

BACKGROUND

Sinus pericranii (SP) is a rare venous anomaly involving an abnormal connection of the intracranial dural sinuses with the extracranial veins. Magnetic resonance (MR) imaging (MRI) with MR venography can detect the typically congested intra- and extracranial venous components of SP.

CLINICAL PRESENTATION

We report a rare case of lateral SP associated with the superior sagittal sinus, which might had already developed almost total thrombosis of the SP at the first MRI. As this patient had not presented with classical manifestations of SP on clinical or neuroradiological findings, the initial diagnosis of SP was difficult. Repeated MRI revealed dynamic morphological changes associated with reperfusion of the thrombosed SP via the cortical vein.

CONCLUSION

MR venography combined with gadolinium enhancement was useful for diagnosis of the SP with an extremely slow flow status.

[Cerebral venous thrombosis misinterpreted as migraine]

A 23-year-old woman with known tension-type headache and in treatment with oral contraceptives was hospitalized with headache, nausea and vomiting during two weeks. Prior to hospitalization the symptoms had been interpreted as migraine. Blood samples including D-dimer were normal. A computed tomography showed cerebral venous thrombosis (CVT), so the patient was treated with anticoagulation drugs and her symptoms remitted slowly. CVT is a dangerous condition, and the symptoms can have a fluctuating course which can mask the diagnosis. D-dimer cannot be used to exclude CVT, and attention should be paid to the risk factors.

Cerebrovascular complications in patients with inflammatory bowel disease

Cerebrovascular complications in 9 patients with inflammatory bowel disease (IBD) are presented, 6 with Crohn's disease (CD) and 3 with ulcerative colitis (UC), 7 men and 2 women, mean age 36.5 +/- 3.5 years, 4 of them during acute disease. Cerebrovascular complications were: cerebral venous thrombosis (CVT)--7 cases (5 CD and 2 UC) and ischemic stroke--2 cases (1 CD and 1 UC). Out of 7 cases with CVT 5 were superior sagittal sinus thrombosis (SSS), 2 SSS and transverse and sigmoid sinus thrombosis. Both ischemic strokes were infarctions in the middle cerebral artery area. No correlation between high doses of corticosteroids or their lowering, IBD activity, duration of the disease, and the appearance of cerebrovascular complications was observed. Tendency to hypercoagulation even in the inactive stage of the IBD was revealed. Investigations for thrombophilia were negative. Significantly high levels of homocysteine were observed in all patients.

CONCLUSION

Neurovascular complications may be observed in IBD, both of venous and arterial type. Pathogenic mechanisms of these vascular complications are complex, low serum folate levels, of vitamin B6 and B12 being associated with elevation of homocysteine levels, high activation of platelets and microvascular endothelial dysfunction. A guide for the orientation of prophylaxis of cerebrovascular complications in IBD patients is necessary.

[Local thrombolysis of sinus thrombosis]

A 16-year-old girl was diagnosed with widely distributed dural sinus thrombosis (DST) and a haemorrhagic infarct in the left parietal lobe. Despite of heparin treatment, pronounced aggravation of symptoms was observed. Through a femoral vein approach a micro-catheter was advanced into the superior sagittal sinus and rt-PA was infused slowly, directly into the thrombus over 24 hours. A follow up angiogram showed recanalisation of sinus. The patient recovered almost completely, with only few remaining cognitive symptoms. This treatment remains experimental, but should be kept in mind for DST-patients unresponsive to heparin treatment.

Pulmonary embolism and cerebral venous thrombosis after thoracoscopic surgery for benign pulmonary disease

A-76-year-old woman consulted for open biopsy for a pulmonary mass. Thoracoscopic wedge resection was performed. The lesion was histologically diagnosed as nonspecific inflammation. On the first postoperative day (POD1), the patient lost consciousness transiently. Eleven hours after the first stroke, the patient experienced a second stroke together with hypoxia. Pulmonary perfusion scan on POD2 showed multiple perfusion defects, and the patient was diagnosed with pulmonary embolism (PE). Thrombolitic therapy was started. Neurological symptoms didn't improve, and cerebral angiography on POD3 showed delayed perfusion in superficial veins. The patient was diagnosed with cerebral venous thrombosis (CVT). Thrombolytic and anticoagulant therapy had been continued, and the patient was found to have hemorrhagic cerebral infarction on POD11. After persistent therapy, the patient was discharged on POD120. Although both PE and CVT are rare complications after thoracic surgery, we must consider these complications in patients undergoing thoracic operations including thoracoscopic surgery.

Superior sagittal sinus thrombosis: subtle signs on neuroimaging

INTRODUCTION

The aim of this study was to review the clinical, computed tomography (CT) and magnetic resonance imaging (MRI) diagnosis and the frequency of positive neuroimaging findings in patients with cerebral venous thrombosis (CVT) involving the superior sagittal sinus.

MATERIALS AND METHODS

A clinical and radiological database of patients with final diagnosis of CVT was compiled from the inpatient hospital information service of a tertiary neurological hospital over 5 years. CT and MRI studies in 22 patients were retrospectively examined for direct signs of venous sinus thrombosis and for complications of CVT. The diagnosis of CVT before and after CT and MRI was reviewed.

RESULTS

Clinical diagnosis of possible CVT was suspected in only 1 patient. When the diagnosis was not suspected, CT diagnosis was difficult and there was a high false negative rate of 52.6%. MRI fared better, but the false negative rate was still 11%. Directs signs of venous sinus thrombosis such as the triangle sign, empty delta sign on CT and loss of the normal flow voids on MRI, could be retrospectively detected in 57.9%, 100% and 100% of patients respectively. Although 4 patients presented with subarachnoid haemorrhage, these direct signs were present in 3 patients.

CONCLUSION

Clinical diagnosis of CVT is rarely suspected before CT and MRI, and although subtle positive signs are often present, these may not be appreciated unless there is a high index of suspicion or image review at multidisciplinary team meetings.

Marked saggital sinus dilatation and thrombi without thrombosis in a patient with systemic lupus erythematosus

Superior saggital sinus thrombosis (SSST), which has a strong causal link with antiphospholipid syndrome, rarely occurs in patients with systemic lupus erythematosus (SLE). We describe a 34-year-old woman with SLE whose clinical problem was mild headache. Her serology indicated negative antiphospholipid, anticardiolipin antibodies and lupus anticoagulants. However, marked dilatation of the entire saggital sinus with scattered thrombi was observed in enhanced-, surface- and three-dimensional reconstructed CTs (3D-CTs) without abnormal intra-axial signal in brain MRI. The enhanced-, surface- and 3D-CTs are useful to detect silent dural sinus dilatation with scattered thrombi in a patient with SLE without any symptoms of SSST.

Gyral abnormalities in the early stage of superior sagittal sinus thrombosis

We report computed tomography (CT) features in a case of segmental thrombosis of the superior sagittal sinus. On the initial cranial CT scan, both frontal cortices showed focal areas of slightly increased attenuation. The lesions were isointense on magnetic resonance (MR) images no matter what pulse sequence was used, except on fluid-attenuated inversion recovery images, which showed curvilinear sulcal hyperintensity. On postcontrast T1-weighted images, curvilinearly enhancing structures were apparent in both frontal cortical sulci. No lesion appeared on follow-up CT or in MR images. We speculated that the areas of slightly increased attenuation in the cortices represented blood congestion in the cortical veins, venules and capillaries without serum leakage. Cranial CT images should be carefully interpreted to avoid overlooking subtle lesions.

A case of cerebral sinus thrombosis developed during a high-altitude expedition to Gasherbrum I

We report a case of cerebral sinus thrombosis, which is a rare but serious complication that may develop during high-altitude climbing. A climber who reached the summit of Gasherbrum I (8068 m) suffered from motor weakness and gait disturbance as he descended from the peak. Within a few days, the symptoms progressed until he could not walk. Following a difficult and week-long rescue mission by his colleagues, he was hospitalized and diagnosed with thrombosis at the superior sagittal and right transverse sinuses. Climbers and rescuers should know the risk factors of this complication, such as hemoconcentration, procoagulability, and dehydration.

Adult pial arteriovenous fistula and superior sagittal sinus stenosis: angiographic evidence for high-flow venopathy at an atypical location. Case report

The authors present the case of a 69-year-old man who suffered from bilateral cortical venous hypertension due to a brain pial arteriovenous malformation (AVM) with a high-flow fistula. The AVM became complicated by the development of a high-grade stenosis of the posterior superior sagittal sinus (SSS). A comparison of cerebral angiograms obtained at different times revealed that the severe SSS stenosis had developed within a 5-year period and was located distal to the nidus of the left parietal AVM nidus, away from the entrance of the dominant superior superficial cortical draining vein into the SSS. The high-flow fistula was occluded with detachable coils and the AVM nidus was further embolized with acrylic. The SSS stenosis was mechanically dilated by means of balloon angioplasty and stent placement. This case provides angiographic evidence to support the hypothesis that a pial arteriovenous fistula in an adult can cause high-flow occlusive venopathy in a major sinus within a relatively short time and that this acquired high-flow occlusive venopathy can develop at an atypical location distant from the nidus of the AVM.

[Diagnostic image (54). Sinus thrombosis and hemorrhagic infarction in puerperium ]

A 28-year-old woman developed puerperal sinus sagittalis superior thrombosis that caused hemorrhagic cerebral infarction and death by cerebral herniation.

Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis

BACKGROUND AND PURPOSE

Cerebral venous thrombosis is a rare entity that can be difficult to manage. Intrasinus thrombolysis is an increasingly applied intervention, but this modality carries an increased risk of hemorrhage. We describe for the first time an option with a potentially lower incidence of intracranial bleeding, the combination of the AngioJet rheolytic thrombectomy catheter with intra-arterial thrombolysis, in 2 patients with extensive dural sinus thromboses, preexisting intracranial hemorrhage, and severe progressive neurological deficits despite heparin therapy.

METHODS

Four procedures were performed in 2 patients with thromboses in the superior sagittal and transverse sinuses (right in 1 patient and bilateral in 1 patient) and cortical veins. Rheolytic thrombectomy was performed in the sigmoid, transverse, straight, and superior sagittal sinuses; this technique involves the use of the Bernoulli effect to create a vacuum that fragments and aspirates thrombus. For associated persistent cortical vein thromboses, low-dose intra-arterial thrombolysis was used.

RESULTS

Both patients had excellent angiographic results with sinus reopening after rheolytic thrombectomy and cortical vein reopening after intra-arterial thrombolysis. Follow-up CT showed no change in 1 patient and increased preexisting intracranial hemorrhage in the other. One patient had a negative hypercoagulable workup, and the other patient had probable anti-phospholipid antibody syndrome. At 6 months, both patients had excellent clinical outcome with no neurological deficits except mild short-term memory loss in 1 patient.

CONCLUSIONS

The combination of rheolytic thrombectomy with intra-arterial thrombolysis is a treatment modality that allows accelerated recanalization of occluded dural sinuses and cerebral veins with lower doses of thrombolytic agents.

Dural sinus thrombosis in a patient with protein S deficiency--case report

A 23-year-old female presented with dural sinus thrombosis caused by protein S deficiency. She suffered superior sagittal sinus thrombosis 6 days after delivering her first child. Past history showed deep vein thrombosis at the age of 20. While conservative management was initiated because of the potential risk of increasing intracranial hemorrhage, several hours later she deteriorated rapidly because of severe brain swelling with massive hemorrhage. The patient died despite surgical decompression. Autopsy disclosed organized thrombus in the superior sagittal and transverse sinuses. Although the total concentration of protein S was normal, the free protein S concentration and protein S activity were decreased. Protein S deficiency is a rare cause of dural sinus thrombosis, but is associated with a high mortality rate, so accurate diagnosis and urgent intervention are required.

Cerebral venous sinus thrombosis associated with hepatic cirrhosis

Cerebral venous sinus thrombosis is not a recognized complication of end-stage liver disease. A case of sagittal sinus thrombosis in a 44-year-old male with end-stage hepatic cirrhosis is described. Recurrent seizures were the only manifestation. Work-up revealed severe deficiency of protein C, protein S, and antithrombin III. He was treated with low molecular weight heparin and underwent an orthotopic liver transplant after three months. Follow-up helical CT venogram showed resolution of the sinus thrombosis.

Superior sagittal sinus thrombosis: a rare complication of nephrotic syndrome

A two and half year-old-male child, known case of steroid responsive nephrotic syndrome presented with fever and vomiting of acute onset. He was diagnosed to have superior sagittal sinus thrombosis on a contrast computerised tomographic scan of brain. Recovery was complete without anticoagulant therapy. Superior sagittal sinus thrombosis is an extremely rare complication of nephrotic syndrome.

[Ultrasonographic imaging of superior sagittal thrombosis]

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.