Presentation
Headache, Right sided weakness.
Patient Data
The CT scan of the brain shows a hypodense lesion in the left parietal lobe, measuring approximately 30x44 mm. The lesion exhibits heterogeneity and has indistinct margin borders. Additionally, there is evidence of hyperdensity in the cortical vein of Trolard, which may indicate thrombosis of the vein (dense vein sign) (arrow).
The MRI scan reveals a lesion in the left parietal lobe, consistent with the findings from the CT scan. The lesion demonstrates hypointensity on T2-weighted imaging, intermediate intensity on T1-weighted imaging (with subtle peripheral hyperintensity), and blooming on susceptibility-weighted imaging. These characteristics suggest the presence of an acute-subacute stage of intracranial hemorrhage. Edema is observed surrounding the lesion, indicative of tissue swelling in response to the pathology.
Furthermore, on susceptibility-weighted imaging, both the superior sagittal sinus and the cortical vein of Trolard exhibit prominent dark and blooming signals (arrow). Additionally, contrast-enhanced T1-weighted imaging with Gadolinium reveals a lack of enhancement within these veins and sinus (arrow), indicating a defect in their vascular perfusion.
Following a three-month course of treatment, the post-treatment MRI reveals the presence of residual hemosiderin deposition in the periphery of the lesion, manifesting as a hypointense area on susceptibility-weighted imaging sequences. Additionally, the contrast-enhanced T1-weighted imaging demonstrates perfusion within the superior sagittal sinus, with the exception of a minor band within its lumen. These bands are suggestive of prior cerebral venous thrombosis.
Case Discussion
Cerebral venous thrombosis (CVT), which involves thrombosis of the cerebral veins and the dural sinuses, is a rare disorder that can lead to significant morbidity and mortality. Due to the diverse range of risk factors and the variability in presentation, delays in diagnosing the disease are common.
In this case, the initial imaging modality used is a CT scan. Fortunately, the observation of cortical vein hyperdensity on the CT scan may indicate the presence of venous thrombosis, thereby facilitating a relatively straightforward diagnosis. If the CT scan does not reveal any signs of hyperdensity, acquiring MRI images becomes necessary.
And on the MRI images, we identified this hemorrhage in a young individual, which is not a common occurrence. Therefore, we have to consider venous thrombosis. By utilizing techniques such as TOF 2D and MRI with contrast enhancement, the confirmation of the diagnosis can be significantly more straightforward.
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