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Editors:
William Hu, Mark Hudon
Superior
Sagittal Sinus Thrombosis
Submitted
by: Jean-Wen Chan, William Hu, David Patry and Mark Hudon
A
30-year-old female suffered minor head and neck trauma while
tubing on a lake. Three days later she experienced an episode
of transient expressive dysphasia later followed by a generalized
seizure. Medications include oral contraceptives.
Computed
tomography revealed no significant abnormalities. Magnetic resonance
imaging (MRI) demonstrated subtle hyperintense cortical signal
in the lateral anterior right frontal lobe on FLAIR images (Figure
1) which was much more obvious on diffusion-weighted imaging
(DWI) with associated decreased apparent diffusion coefficient
(ADC) (Figures 2a and 2b).
Hyperintense T1 signal thrombus is seen in the location of the
superior sagittal sinus (SSS) (Figure
3). MR venography (Figure
4) showed reduced flow in the anterior two thirds of the
superior sagittal sinus which was confirmed with catheter angiography
(Figure 5a and 5b).
Follow-up MRI at about one month revealed resolution of the
previous abnormalities (Figures
6a-d).
Dural
sinus thrombosis is a rare condition that presents with nonspecific,
highly variable clinical findings. At least four typical syndromes
of presentation have been described: i) pseudotumor cerebri,
ii) headache and focal neurologic deficit, iii) focal seizure
and headache, and iv) headache, nausea, long-tract symptoms,
and progressive decline in level of consciousness.1
Imaging is mandatory with CT, MRI with MRV and/or cerebral angiography
to provide the diagnosis. Distinct stages of parenchymal changes
may be seen depending on the severity of venous congestion.
Subtle early changes may be best detected with DWI but unlike
arterial ischemia, DWI changes suggesting cytotoxic edema can
be reversible and do not predict subsequent venous infarction.2,3,4
There
is potential for full recovery with early treatment. An extensive
etiologic search is needed as there are numerous causes or predisposing
factors (infectious, hematological, connective tissue disorders,
metabolic, trauma, pregnancy, neoplastic and medication related).
The mainstay of therapy is to treat the cause and symptoms as
well as anticoagulation with intravenous heparin. Local thrombolysis
can be performed if there is clot extension or clinical worsening
despite treatment.5
References
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1.
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Villringer
A, Einhaupl KM. Dural sinus and cerebral venous thrombosis.
New Horiz 1997; 5(4): 332-341.
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2.
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Tsai
FY, Wang AM, Matovich VB, et al. MR staging of acute dural
sinus thrombosis: correlation with venous pressure measurements
and implications for treatment and prognosis. AJNR 1995;
16(5): 1021-1029.
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3.
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Ducreux
D, Oppenheim C, Vandamme X, et al. Diffusion-weighted
imaging patterns of brain damage associated with cerebral
venous thrombosis. AJNR Am J Neuro Radiol 2001; 22(2):
261-268.
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4.
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Keller
E, Flacke S, Urbach H, Schild HH. Diffusion- and perfusion-weighted
magnetic resonance imaging in deep cerebral venous thrombosis.
Stroke 1999; 30(5): 1144-1146.
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5.
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Bousser
MG. Cerebral venous thrombosis: diagnosis and management.
J Neurol 2000; 246(4): 252-258
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From the Dept of Radiology (J-WC, WH, MH), Dept of Neurology
(DP), Foothills Hospital, Calgary AB, Canada.
Received September 6, 2001. Accepted in final form September
27, 2001.
Reprint requests to: Jean-Wen Chan, Dept of Radiology,
Foothills Hospital, 1403 - 29th Street NW, Calgary AB
T2N 2T9, Canada
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Can.
J. Neurol. Sci. 2001; 28: 346-348
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