Presentation
Acute severe headache, nausea, vomiting and fever. To exclude meningitis.
Patient Data
Non-contrast CT brain demonstrates a hyperdense torcula, left transverse sinus, sigmoid sinus and left internal jugular vein. There are hyperdense left cerebellar veins. There is a hyperdense superior sagittal sinus with numerous hyperdense high vertex cortical veins.
The internal cerebral veins, vein of Galen and anterior portion of the straight sinus appear normal.
There is bilateral maxillary antral mucosal thickening, the rest of the paranasal sinuses are clear.
The mastoids are normal and clear.
CT brain is otherwise normal.
Case assistance: Dr K.Kobo
Extensive acute cerebral venous thrombosis involving the dural venous sinuses and cortical veins. This involves the superior sagittal sinus, left transverse and sigmoid sinus, left internal jugular vein, left cerebellar/ tentorial veins, and bilateral high vertex cortical veins. The acute clot is typically isointense on T1, and hypointense on T2 with well-identified filling defects noted on contrast administration and the 'empty delta sign'.
There is no cerebral venous infarction.
There is maxillary antral and ethmoid mucosal thickening.
There are no mastoid effusions or acute mastoiditis.
Case assistance: Dr IA. Nagdee
Case Discussion
A case of extensive acute cerebral venous thrombosis. The child subsequently developed seizures on anticoagulation therapy. Excepting for the uncomplicated maxillary antral and ethmoid appearance, no other source of thrombosis could be found. The lumbar puncture confirmed the absence of any meningitis or encephalitis, and the prothrombotic workup was negative. All other possibilities were excluded and eventually, idiopathic cerebral venous thrombosis was considered as the most likely cause.
The dural venous sinuses and left cerebellar including cortical veins are markedly hyperdense and one can be fooled into thinking of acute subarachnoid hemorrhage and/or contrast administration based on the CT brain appearance. The trauma history is negative, and the CT brain study is a non-contrast study noted by the absence of any contrast within the intracerebral arteries and additionally the absence of any paranasal sinus 'enhancement'.
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