Case of the Month, March 2018

Submitted by  Peyman Kangavari, MD and Thomas Learch, MD.

Presentation

72-year-old female who presents to the emergency department with right-sided headache which started approximately 3 days ago. Patient states that the pain was initially in the right frontal region; however, today it has started radiate to the left frontal region. Severity of pain has been 8/10. Onset of headaches was gradual and worsening over the past 3 days. Patient reports photophobia, phonophobia, and nausea, but denies any vomiting.

Patient denies any dizziness, blurred vision, loss of vision, chest pain, shortness of breath, diaphoresis, neck pain, neck stiffness, back pain or loss consciousness.

Non-contrast CT of the brain was ordered.
What is the abnormality demonstrated on the CT? What’s the next step in management?

Imaging 

CT Findings

Hyperdensity in the right transverse sinus and confluence of the sinuses, which can be seen with dural venous sinus thrombosis. Further evaluation with CT or MR venogram is recommended.

No evidence of acute infarction.

 

 

Patient underwent MR venogram demonstrating occlusion of the right transverse and sigmoid sinus.

MR Venogram

Cine MIP images of MR Venogram

Patient was discharged and treated with anticoagulation with resolution of symptoms. Follow up CT of the brain performed 4 months later demonstrated normal appearance of the transverse sinus.

Final Diagnosis

Dural Sinus Thrombosis

Discussion

Clinical Presentation:

Presentation is variable but most commonly presents with headache. Other symptoms may include nausea, and vomiting with and without neurological symptoms.

Imaging Features:

Commonly clinical and imaging features are subtle and therefore may cases can be undiagnosed or underdiagnosed.

  • “Hyperdensedural venous sinus”: Clot in the dural sinus is hyperdense and often this is the only diagnostic clue on initial non-contrast brain CT.
  • “Cord Sign” refers to hyeprdense cord-like appearance of clot within the cortical veins
  • “Empty Delta Sign” is the finding seen on contrast enhanced CT or MR venogram. The sign consists of a triangular area of enhancement with a relatively low-attenuating center, which is the thrombosed sinus.
  • Absence of normal flow void on MR

Complications:

Untreated dural venous thrombosis can result in venous infractions. Up to 50% of cases can lead to infarction, which can be fatal due to severe brain swelling and herniation.

Treatment::

Most patients can be treated with anticoagulation. In more severe cases, endovascular mechanical thrombectomy needs to be performed. 

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