CT Case 082

Non-contrast CT: there is increased density of the superior sagittal, right transverse and sigmoid dural venous sinus.

CT venogram: there is no enhancement of these vessels.

The left cortical veins demonstrate a similar appearance. This observation may be difficult to appreciate, and is perhaps easier on the pre-contrast CT, where it is hyperdense.

The hyperdensity of the vessel is due to acute thrombus. If a post contrast study is not available to confirm absence of enhancement, comparing the density with the major arteries may be helpful.

This patient’s case is complicated by acute parenchymal haemorrhage.

This is a case of cerebral venous sinus thrombosis (CVST), unlike in CT case 071, this patient’s case illustrates the complication of intraparenchymal haemorrhage, which occurs as a result of venous obstruction and venous hypertension. Isolated SAH may also occur, although it is very rare.

Intraparenchymal haemorrhage complicates 30-40% of all cases of CVST and is associated with a poorer prognosis.

CVST represents 0.5-1% of all strokes and there is a higher incidence in females with a female to male ratio of 3:1.

Mortality is approximately 10-30% in all cases and is as a consequence of intracranial hypertension, cerebral oedema, venous infarction or intracerebral haemorrhage.

Anticoagulation is the standard therapy for CVST, even in the presence of intracranial haemorrhage, and management for this patient involved heparin infusion, and blood pressure control.

However, when anticoagulation is contra-indicated due to the size of the bleed or worsening neurological symptoms, other therapeutic options may include mechanical thrombectomy or intra-sinus thrombolysis.

This patient’s haematoma was relatively small and he made a good recovery.

He was discharged on warfarin therapy and had further investigation as an outpatient for the underlying cause. His thrombophilia screen was negative and his CT chest/abdo/pelvis excluded malignancy.

Of note, he returned five months later following a seizure, which is a known complication of CVST occurring in 40%.

• Davidson J. CT case 071. LITFL
• Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M, deVeber G, Ferro JM, Tsai FY; American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Apr;42(4):1158-92.
• Guo XB, Liu S, Guan S. The clinical analysis and treatment strategy of endovascular treatment for cerebral venous sinus thrombosis combined with intracerebral hemorrhage. Sci Rep. 2020 Dec 18;10(1):22300
• Ulivi L, Squitieri M, Cohen H, Cowley P, Werring DJ. Cerebral venous thrombosis: a practical guide. Pract Neurol. 2020 Oct;20(5):356-367.
• Neuroimaging Cases 002 • LITFL • CMC Radiology
• Nickson C. Cerebral Venous Thrombosis. LITFL