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Findings: An axial noncontrasted CT image through the brain demonstrates cerebral edema within the left frontal lobe and deep gray matter. In addition, there is hyperattenuation within the region of the straight sinus. Petechial hemorrhage as well as edema is seen within the left frontal lobe.
An angiogram demonstrates occlusion of the anterior one half of the superior sagittal sinus as well as occlusion of the deep venous system bilaterally.
Diagnosis: Dural sinus and deep venous thrombosis.
Discussion: Dural sinus and deep venous thrombosis can be a clinically devastating event. There are multiple etiologies including dehydration, sepsis, trauma and lead encephalopathy. In addition, hypercoagulable states such as sickle cell disease, leukemia and pregnancy are also predisposing factors.
Evaluation usually includes an initial CT scan followed by an MRV or angiogram. A non-contrasted CT oftentimes demonstrates a hyperdense thrombus within the dural sinuses or draining cortical veins. A contrast-enhanced CT may demonstrate low- attenuation thrombus surrounded by contrast material. This is known as the empty delta sign. Angiographic findings include delayed venous emptying as well as occluded or absent dural sinuses.
The most common dural sinus involved is the superior sagittal sinus followed by the transverse, sigmoid and cavernous sinus respectively.
Deep venous thrombosis which includes thrombosis of the internal cerebral vein as well as vein of Galen are much less common but are often catastrophic events.
It should be noted that a distinction must be made between thrombosis and a dural mass displacing the dural sinuses. Example of these include meningiomas as well as an epidural hematoma.
Sadly, multiple attempts to lyse this patient's clot via direct Urokinase infusion were made without success.
References:
Osborn AG. Introduction to Cerebral Angiography. Lippincott, Philadelphia; 1997:352.
Osborn AG. Diagnostic Neuroradiology. Mosby, St. Louis; 1994:385-394.
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