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We describe the successful treatment of a 5-year-old girl with rapidly evolving left hemispheric hemorrhagic infarcts resulting from left transverse and sigmoid sinus thrombosis using combined endovascular dural sinus angioplasty and local low-dose thrombolytic therapy.
An 84-year-old Japanese woman had cavernous sinus thrombosis (CST) due to abdominal wall abscess. The diagnosis was delayed because abdominal wall abscess is an unfamiliar cause of CST, but a definite diagnosis was reached with the use of magnetic resonance imaging. We started intravenous antibiotic therapy against gram-positive and gram-negative organisms and the patient responded well, although the diagnosis was delayed.
The aim of this study was to examine the reliability of single-slice phase-contrast angiography (SSPCA) as a rapid technique for the investigation of suspected dural venous sinus occlusion. Images were obtained on 25 normal volunteers to document the accuracy of SSPCA in the demonstration of slow flow states. Normal volunteers were imaged using sagittal and coronal SSPCA (slice thickness 13 cm, matrix 256 x 256, TR 14 ms, TE 7 ms, flip angle 20 degrees, peak velocity encoding rate 30 cm/s). Sinus patency and flow rate were confirmed by measurement of flow in the superior sagittal and transverse sinuses using quantified single-slice phase difference images. Imaging was performed in 50 patients undergoing routine brain scans in order to determine the optimal slice orientation for clinical use. Twenty-one patients with suspected dural venous sinus thrombosis were also investigated with SSPCA and the diagnosis confirmed by one or more alternative imaging techniques. Imaging time was 29 s per acquisition and image quality was good in all cases. Variations in dural sinus patency and flow in normal volunteers were accurately predicted by SSPCA (kappa = 0.92). Use of a single angulated slice (130 mm thick, para-sagittal image angled 30 degrees towards coronal and 30 degrees towards transverse) provided sufficient separation of right- and left-sided venous structures to allow use of a single projection. The presence and extent of sinus occlusions in 14 patients and the absence of thrombosis in 7 were accurately identified by SSPCA. Sensitivity and specificity in this limited study were both 100%. The SSPCA technique takes less than 30 s and provides a reliable and rapid technique for the diagnosis of dural venous sinus thrombosis.
The history of a patient with lateral (sigmoid) sinus thrombosis is described. The diagnosis was confirmed by contrast-enhanced computed cranial tomography demonstrating the empty delta sign as characteristic manifestation of cerebral sinovenous thrombosis. Specific and nonspecific abnormalities on computed cranial tomography in cerebral sinovenous occlusive disease are discussed.
The use of high-resolution computed tomography (CT) is described in four patients with septic cavernous sinus thrombosis. In all patients CT findings included multiple irregular filling defects in the enhancing cavernous sinus. Unilateral or bilateral inflammatory changes in the orbital soft tissues were also present. Enlargement of the superior ophthalmic vein due to extension of thrombophlebitis was noted in three patients.
A rare case of straight sinus thrombosis in a 36-year-old female with sudden onset of status migrainosus is presented. This condition was demonstrated by a linear density in the midline on a noncontrast computed tomography scan, as a filling defect at the location of straight sinus on magnetic resonance imaging, and by the inability to visualize blood flow in the straight sinus on magnetic resonance venography, with a similar demonstration on a 4-vessel digital subtraction angiography.
OBJECTIVE: To assess the risk of recurrence of cerebral venous and sinus thrombosis (CVST) during subsequent pregnancy and puerperium in women with previous cerebral venous occlusive disease. METHODS: The authors retrospectively studied the relapse rate of CVST and the incidence of extracerebral venous thrombosis during subsequent pregnancies in 39 women (from 125 patients with CVST) who suffered a CVST at childbearing age. RESULTS: Mean follow up was 10.25 years (range 1 to 20). Twenty two pregnancies and 19 births were observed in 14 women without evidence of either recurrence of CVST or extracerebral venous thrombosis. One pregnancy occurred during oral anticoagulation and was interrupted and two pregnancies ended with spontaneous abortions. Low dose heparin had been given during five pregnancies. CONCLUSIONS: The risk of recurrence for CVST during pregnancy seems to be low and these data do not justify a negative advice on pregnancy in women with previous CVST. Further studies are needed to evaluate the need for a prophylactic anticoagulation during pregnancy and puerperium.
BACKGROUND AND PURPOSE: The clinical features and prognosis of cerebral vein and dural sinus thrombosis (CVT) in elderly patients have not been previously described. METHODS: In a multicenter prospective observational study, we compared clinical and imaging features, risk factors, and outcome of adult patients aged <65 (young and middle-aged patients) and > or =65 years (elderly patients). RESULTS: A total of 624 adult patients with CVT were registered and followed-up for a median of 16 months. Fifty-one (8.2%) were aged > or =65 years. Presentation as an isolated intracranial hypertension syndrome was less frequent in elderly patients (4/51 versus 139/573, P=0.008), whereas depressed consciousness (17 versus 97, P=0.005), and mental status changes (22 versus 115, P=0.001) were more frequent in the elderly. The prognosis of elderly patients was considerably worse than that of younger patients, as only 49% of elderly patients made a complete recovery (versus 82% in younger patients), whereas 27% died and 22% were dependent at the end of follow-up (versus 7 and 2% respectively in younger patients). Carcinoma (5 cases) was more frequent as a risk factor for CVT in elderly patients (P=0.017). During follow-up, elderly patients were more likely to experience thrombotic events (HR=4.8, 95% CI=1.9 to 11.9) and were less likely to experience severe headaches (HR=0.2, 95% CI=0.02, 0.97). CONCLUSIONS: Elderly patients with CVT have a distinctive clinical presentation: isolated intracranial hypertension is uncommon, whereas mental status and alertness disturbances are common. The prognosis of CVT is worse in elderly patients.
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A case of superior sagittal sinus thrombosis which was complicated with ulcerative colitis is reported. A 16-year-old male patient had a 2-year history of ulcerative colitis. He was admitted to our hospital complaining of abdominal pain, bloody bowel discharge and appetite loss, and was then treated conservatively. Two days after admission, he demonstrated generalized convulsions which were followed by right hemiplegia. MRI showed a low intensity lesion on T1 and an irregular high intensity in the subcortical area of the left frontal lobe on T2 and T2 FLAIR-weighted images. The MRI findings resembled either invasive brain tumor or local inflammation. Cerebral angiography appeared to demonstrate complete obstruction of the superior sagittal sinus with congestion of venous flow in the cortical veins. Ulcerative colitis has been reported to show hypercoagulation, leading to deep vein thrombosis within the body which sometimes causes pulmonary infarction; however, occurrence of venous thrombosis in the intracranial veins and sinus is rare. This report underscores the fact that cerebral venous thrombosis should be suspected in the case of patients with ulceritive colitis who suffer sudden onset of neurological deficits.
Cerebrospinal fluid hydrodynamics were investigated with a constant pressure infusion method in patients with superior sagittal sinus thrombosis. Ten patients were studied with serial examinations up to 15 years after the onset of the disease. A total of 70 CSF hydrodynamic examinations were performed. A clear increase in intracranial pressure due to raised pressure in the major dural sinus was seen in all patients. A striking feature was the persistent intracranial pressure increase that declined only gradually. This had no obvious clinical impact. Change in CSF resorption facility played only a minor role in the intracranial pressure elevation. None of the patients developed hydrocephalus.
BACKGROUND AND PURPOSE: The common entity cerebral venous sinus thrombosis is associated with the poorly characterized imaging finding of parenchymal abnormalities; diffusion-weighted imaging has offered some insight into these manifestations. We assessed the relationship between the diffusion constant from apparent diffusion coefficient (ADC) maps in patients with cerebral venous thrombosis (CVT) with follow-up imaging findings and clinical outcome. METHODS: We evaluated the medical records and T2-weighted MR images of 13 patients with CVT complicated by intraparenchymal abnormality. Diffusion-weighted (DW) images and ADC maps were evaluated for increased, decreased, or unchanged signal intensity and were compared with signal intensity of contralateral, normal-appearing brain. In addition, ADCs were obtained in nine pixel regions of interest in abnormal regions in eight of the 13 patients. RESULTS: Eight patients had superficial CVT, and five had superficial and deep CVT. CVT of deep veins was associated with deep gray nucleus and deep white matter abnormalities, whereas superficial CVT was associated with cortical and subcortical abnormalities. Twenty-four nonhemorrhagic lesions were identified in 10 of 13 patients on the basis of follow-up imaging findings. Four patients without seizures had lesions with decreased diffusion that appeared hyperintense on follow-up T2-weighted images, three patients with seizures had lesions with decreased diffusion that resolved, and seven patients had lesions with increased diffusion that resolved. Three of 10 patients had more than one lesion type. No difference was noted in mean ADCs for lesions with decreased diffusion that resolved compared with lesions with decreased diffusion that persisted. CONCLUSION: DW imaging in these patients disclosed three lesion types: lesions with elevated diffusion that resolved, consistent with vasogenic edema; lesions with low diffusion that persisted, consistent with cytotoxic edema in patients without seizure activity; and lesions with low diffusion that resolved in patients with seizure activity. This information may be important in prospectively determining severity of irreversible injury and in patient treatment.
OBJECTIVE: To present our experience with the diagnosis and treatment of lateral sinus thrombosis (LST) secondary to otogenic disease. PATIENTS AND METHODS: We have retrospectively reviewed all the cases of LST caused by chronic otitis media in ten years. RESULTS: In our series of five patients, four patients were successfully treated by surgery without opening the sigmoid sinus. On the other hand, one of our patients developed hydrocephalus and ataxia during preoperative antibiotic treatment. CONCLUSION: Most patients with thrombotic/nonabscessed sinuses will have successful outcomes with this approach, but careful observation is needed, given the possibility of advancing disease.
A 19-year-old man with severe active ulcerative colitis was admitted to our hospital where he was prescribed 80 mg prednisolone and underwent leukocytapheresis (LCAP). Two weeks after initiating therapy, his symptoms had not recovered. We administered cyclosporin via continuous intravenous infusion for 12 days. Although his clinical symptoms improved, he complained of severe headache. Immediate plain computed tomography (CT) and magnetic resonance imaging angiography (MRA) revealed extensive thrombosis in the superior sagittal sinus and right transverse sinus. We treated this condition with the anticoagulant agent, heparin, which prevents and can treat venous thrombosis. We report an occurrence of cerebral sinus thrombosis accompanying ulcerative colitis, where active anticoagulant therapy was useful.
A case was reported in which the patient, whose leukemic cells were not found in the peripheral blood, died several days after the onset of cerebral sinus thrombosis, and after the autopsy acute leukemia was diagnosed. The patient, a 68-year-old female, was admitted with clouding of the consciousness. In the initial examination, she was semicomatose, pendulum-like movement was seen in the eyeballs, and hemorrhagic maculae on the trunk and extremities. Among the laboratory findings, WBC was 8, 100 (B 1, St 6, S 77, L 14, Mon 2), RBC 375 x 10(4), Hb 12.5, Ht 37, PLT 3.5 x 10(4), PT 15.6, PTT 68, Fib 158, FDP 10 and AT-III 75. In contrast enhanced CT, an empty triangular sign was observed. On the third hospital day, the patient died of a cerebral hernia. On autopsy, thrombosis was found in the bilateral sigmoid sinus. In the cerebral tissue, congestion was throughout the brain, and many leukemic cells were seen in the dilated blood vessels, but there was no infiltration into the parenchyma. The bone marrow, hypercellular, showed many intermediate type and blastic myeloid cells. The main neurological complications of leukemia are leukemic infiltration and intracranial hemorrhages. Capillary obstructions associated with the disseminated intravascular coagulation (DIC) syndrome are rarely experienced, but obstructions of thick arteries or thick veins such as venous sinuses are seldom seen in general, and most reports of such cases were those resulting from chemotherapy after making a diagnosis of acute leukemia. In the literature, there have been only two reports in our literature.(ABSTRACT TRUNCATED AT 250 WORDS)
Coronary sinus thrombosis was found at necropsy in a girl with spina bifida who underwent ventriculoatrial shunt revision. There was secondary myocardial infarction, close to the conducting system within the interventricular septum. We suggest that this led to cardiac arrest and sudden death.
A 30-year-old man presented with sagittal sinus thrombosis. He had a history of multiple thrombotic events since adolescence, and his father had had a similar history. Laboratory studies revealed the complete absence of free protein S in his plasma. Protein S deficiency, an autosomal dominant disorder, is an identifiable cause of cerebral thrombosis. The literature and our experience with this case suggest that long-term anticoagulant therapy may prevent thrombotic episodes in patients with this disorder.
Two cases of coronary sinus thrombosis with myocardial changes suggestive of "haemorrhagic infarsation" as the cause of death of cardiac transplantant recipients are presented. The discussion points to the macroscopical and histologic findings completely different from those seen in myocardial infarction induced by coronary artery occlusion.