Presentation
Right neck pain.
Patient Data
A large region of wedge-shaped hypodensity blurring the grey-white matter differentiation in the right temporoparietal region contains a moderate volume of parenchymal hemorrhage, which measures 5.8 x 3.7 x 2.7 cm. The right transverse sinus is hyperdense and shows thrombus in the venogram study. There is moderate mass effect, with effacement of the occipital horn of the right lateral ventricle, effacement of right-sided sulci and subfalcine herniation to the left of up to 5 mm at the septum pellucidum. No other regions of hemorrhage or loss of grey-white matter association. No hydrocephalus.
Filling defect in the right transverse sinus, extending to the sigmoid sinus, jugular bulb and upper right internal jugular vein. The superior sagittal sinus, straight sinus and left transverse sinus opacifies normally. The deep cerebral veins also opacified normally.
No skull fracture. The paranasal sinuses and mastoid air cells are clear.
Conclusion: Deep venous sinus thrombosis involving the right transverse and sigmoid sinuses, extending to the jugular bulb and a right internal jugular vein. Associated venous infarct and hemorrhage.
CT arterial angiogram was also performed and was normal (not shown).
A large ( 3.1 x 6.5 cm ) right temporal intraparenchymal hematoma with surrounding edema is again demonstrated. Absence of flow in the right transverse, sigmoid and imaged superior internal jugular vein is again demonstrated in keeping with venous sinus thrombosis. Interpretation of the diffusion restriction images is limited by the hematoma however the area of infarction does not appear to extend beyond the hematoma.
Conclusion:
Right transverse and sigmoid venous sinus thrombosis with associated venous infarct and hemorrhage again demonstrated.
Case Discussion
Venous sinus thrombosis is usually identified on non contrast CT, which is the first imaging investigation given the common nonspecific clinical presentation. It is challenging when not associated with venous hemorrhage or infarction as you must rely on the identification of an hyperdensity sinus, which could be trick sometimes. Things are easier in cases like the present one, where a typical venous hemorrhagic and infarction is present.
As a result of the arterial supply to the infarcted tissue not being compromised, hemorrhagic transformation is common, and is typically heterogenous and gyriform
With contrast administration, especially with a CT venogram, then a filling defect in a sinus is sought. Multiplayer reformatted CT venography has been reported with a sensitivity of 95% for this diagnosis.
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