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Left transverse sinus thrombosis developed in a 27-year-old male with ulcerative colitis. The diagnosis was based on cerebral angiography and magnetic resonance (MR) imaging, the latter of which clearly delineated the intraluminal thrombus. Serial MR images demonstrated thrombus organization. The use of this method in the diagnosis of cerebral sinus thrombosis might reduce the need for cerebral angiography.
Cerebral venous thrombosis in various clinical conditions, such as congenital heart disease (CHD) and hypercoagulable states, have been recognized previously. However, dural sinus thrombosis in a pediatric patient with Antiphospholipid Syndrome (APLS) after the repair of a ventricular septal defect (VSD) has not been reported yet. A child who underwent an operation for the surgical repair of VSD under cardiopulmonary bypass (CPB) developed a stroke after the procedure. A cranial computer tomography (CT) scan of the patient showed dural sinus thrombosis and severe cerebral edema. APLS and CPB were thought to be the only risk factors of dural sinus thrombosis. This observation warrants attention and screening should be taken into consideration in patients with APLS who carry a higher risk for dural sinus thrombosis after CPB.
Coronary sinus thrombosis is an unusual but potentially serious complication of the use of central venous devices. We report a fatal case of coronary sinus thrombosis in relation to a malpositioned central venous catheter. The death occurred very soon following the beginning of symptoms and the cause could not be suspected. Direct trauma of the catheter on the coronary sinus endothelium seems the most probable cause of the thrombosis.
We report a case of transverse sinus thrombosis accompanied by colon and rectal double cancers. A 48-year-old male transferred to our department from the division of surgery due to deterioration manifested by headache after colectomy and low anterior resection of the rectum. There was bilateral papilledema and right upper homonymous hemianopsia. On admission all the laboratory data were within normal range. CT showed a left temporal mass lesion of heterogeneous density, which was suspected as being intratumorous hematoma in a metastasis. MRI revealed a left transverse sinus thrombosis. The left transverse and sigmoid sinuses were not opacified, but angiography showed that the occipital and marginal sinuses seemed to be markedly developed. Evacuation of the subcortical hematoma was carried out. Histologically, it was a mixed hematoma in acute and chronic stages without any carcinoma component or vascular malformation. Postoperative course was uneventful, and the patient was returned to the division of surgery in order to follow up the cancer 2 weeks after operation. Angiography 4 months after operation showed almost no recanalization in the left transverse sinus. Further, development of the collateral flow and the double occipital sinus was opacified. Because the coagulation system is often activated by the presence of cancer, it is important to distinguish intracerebral hemorrhage due to sinus thrombosis from intratumorous hemorrhage within a metastatic tumor.
PURPOSE: To evaluate the efficacy, safety, and results of direct thrombolytic therapy in intracranial dural sinus thrombosis by infusion of alteplase (recombinant tissue plasminogen activator). METHODS: Nine patients were treated during a 2-year period for intracranial dural sinus thrombosis. A microcatheter was placed directly into the thrombus in the dural sinus via the transfemoral route. Thrombolysis was initiated with a rapid injection of 10 mg of alteplase over 10 minutes, followed in 3 hours by a continuous infusion of 50 mg, then a continuous infusion at 5 mg per hour until complete thrombolysis or a total dose of 100 mg per day had been reached. Repeat thrombolysis was tried the following day if complete recanalization did not occur at 100 mg per day. RESULTS: Successful recanalization with improvement of symptoms was achieved in all cases. Time required for complete thrombolysis was between 8 and 43 hours. The total dose of alteplase ranged from 50 to 300 mg. Complications of a small intrapelvic hemorrhage and oozing at a femoral puncture site occurred in separate cases, but were not related to the amount of infused alteplase. MR venograms obtained 1 to 4 weeks after the procedure showed no evidence of reocclusion of the dural sinuses. CONCLUSION: Direct fibrinolytic therapy with alteplase is safe, fast, and effective in treating dural sinus thrombosis. However, to prevent hemorrhagic complications, further studies are required to determine its optimal dose and proper rate of administration.
A 36-year-old female was admitted with leptomeningeal melanoma associated with straight sinus thrombosis manifesting as headache and vomiting. Computed tomography and magnetic resonance imaging showed the subarachnoid space was diffusely enhanced. Her consciousness rapidly deteriorated to a coma. Angiography demonstrated straight sinus thrombosis. Thrombolysis by superselective catheterization and infusion of urokinase was successfully performed. She recovered consciousness, but developed paraparesis 2 weeks later. Malignant melanoma with meningeal dissemination was diagnosed by an open biopsy of the lumbar lesion. Angiitis induced by the infiltration of tumor cells and activation of the blood coagulation cascade was probably the causative mechanism of the sinus thrombosis.
For 150 years, the variable clinical appearance of dural sinus thrombosis has plagued clinicians. Computed tomography (CT) has alleviated much of the difficulty in making this diagnosis. A high density lesion in the involved sinus on precontrast scans and a filling defect in the sinus on postcontrast scans were the most frequently observed CT abnormalities in 12 patients with sinus thrombosis. Other findings include the "cord" sign and diffuse cerebral edema. Thrombosis of the superior sagittal sinus, transverse sinus, or sigmoid sinus can occur as an isolated event or in association with other disease entities and may cause no neurologic impairment.
Dural sinus thrombosis has protean clinical and radiological manifestations ranging from minimal effacement of sulci with no symptoms to severe haemorrhagic infarcts associated with focal deficits, coma and even death. An uncommon form of presentation is characterized by unilateral lobar haemorrhage associated with extensive oedema and parenchymal distortion. In an acute presentation, this might resemble haemorrhage into a tumour. In delayed presentations, the haematoma, being iso- or hypodense and showing peripheral ring-like enhancement, can mimic aggressive tumours or infective processes. As this is an uncommon condition, misdiagnosis is common with the potential for mismanagement and adverse outcomes. We present five such consecutive cases that were initially misdiagnosed as other entities. Each of these cases on closer inspection show features observed on CT and MRI that should have suggested a diagnosis of dural venous sinus thrombosis. One of these cases progressed to not only extensively involve the superficial sinuses but also the deep veins, with a significant adverse outcome. The imaging features of this interesting variant of dural sinus thrombosis are reviewed. The haemodynamic basis for haemorrhage and anatomical basis for the lateralization of the lesions are discussed.
Pulmonary emboli as a fatal complication of superior sagittal sinus thrombosis was once well recognized in the literature but appears to have been forgotten. The sagittal sinus appeared to be the source of pulmonary emboli in previously reported cases. Even in patients with no evidence of systemic thrombosis, but who have sagittal sinus thrombosis, the possibility of dislodging pulmonary emboli should be strongly considered. We report a case of nontraumatic sagittal sinus thrombosis complicated by multiple pulmonary emboli and a fatal saddle embolism, likely originating from the thrombosed sinus. Our review of the literature between 1942 and 1990 yielded 203 cases of intracranial venous thrombosis. The overall mortality rate was 49.3%. In 23 cases (11.3%), the venous sinus thrombosis was associated with pulmonary emboli and in these the overall mortality rate was 95.6%. In the 203 cases in our review, those patients who received anticoagulation therapy also had a statistically significant better outcome. Therefore, the presence of pulmonary emboli in association with sagittal sinus thrombosis mandates a sober assessment of the need of anticoagulation therapy in the absence of obvious contraindication.
Forty-five cases of lateral sinus thrombosis were recorded in King Edward VIII Hospital from 1978 to 1984. Eighty-two per cent of the patients were under the age of 15 years. Associated complications recorded were: 9 patients with meningitis, 4 with posterior-fossa abscess, 1 patient suffering from posterior fossa empyema; 4 presented with facial palsy and 1 with tuberculous mastoiditis. Four deaths were recorded. Findings at mastoidectomy showed a prevalence of infective granulations (60 per cent) over cholesteatoma (40 per cent) as a cause of the extension of infection. The surgical protocol for the management of lateral sinus thrombosis was mastoidectomy, needling the sinus and removal of the thrombus, if necessary. Medical treatment consisted of Ampicillin and Metronidozol.
BACKGROUND: Dural sinus thrombosis is a relatively rare syndrome, often with a very poor prognosis. Systemic anticoagulant therapy has produced poor results; therefore rapid recanalization of the affected vessels is essential. The recent advancements in angiographic technique and catheter technology enable us to perform direct selective venography. CASE REPORT: We observed a case of acute superior sagittal sinus thrombosis in a pregnant woman. The patient's consciousness level and motor function gradually deteriorated. Direct thrombolysis was performed via venography. RESULTS: The patient was treated successfully by thrombolysis with infusion of t-PA via selective venography within 2 days of rapid clinical deterioration and sustained a dramatic improvement of her neurological deficits. CONCLUSIONS: Direct thrombolysis via selective venography is considered a safe and useful treatment for dural sinus thrombosis in the acute phase.
BACKGROUND AND PURPOSE: Cerebral sinus thrombosis (CST) needs to be considered in the differential diagnosis of all patients with acute headache. Early diagnosis is essential because early treatment may prevent morbidity and may even be life-saving. Definite exclusion, however, needs advanced neuroradiologic diagnostics, which are not readily available in many hospitals. Because measurement of D-dimers has been demonstrated to be helpful in excluding thromboembolic disease, our aim was to investigate whether D-dimers would be also sensitive enough to exclude CST. METHODS: We undertook a prospective multicenter study over a 2.5-year period including all patients who came to the emergency departments with symptoms suggestive of CST. All patients were diagnosed either by magnetic resonance venography, spiral computed tomography scan venography, or intra-arterial digital subtraction angiography. D-dimer levels were measured at admission and analyzed by the same method in all patients. RESULTS: A total of 343 patients were included. CST was diagnosed in 35 patients, of whom 34 had D-dimers above the cutoff value (>500 microg/L). From the 308 patients not having CST, D-dimers were elevated in 27. Sensitivity of D-dimers was 97.1%, with a negative predictive value of 99.6%. Specificity was 91.2%, with a positive predictive value of 55.7%. D-dimers were positively correlated with the extent of the thrombosis and negatively correlated with the duration of symptoms (Spearman rank correlation coefficients 0.76, -0.58, respectively). CONCLUSIONS: D-dimer measurement is useful in patients with suspected CST. Normal D-dimers make the presence of CST very unlikely.
Sinus thrombosis has rarely been associated with closed head injury; more often, thrombosis of the sigmoid or transverse sinus is caused by otogenic inflammations or tumours, or occurs during pregnancy. Symptoms are frequently vague, while untreated thrombus progression may be fatal due to venous congestion and infarction. We report a 32-year-old man presenting with right hearing loss, tinnitus and headache 2 days after a closed head injury. Neurological examination showed no additional abnormality. The EEG showed focal bifrontal slowing. CT revealed a fracture of the occipital bone. MRI and MRA demonstrated complete thrombosis of the right sigmoid and transverse sinuses. After 2 weeks of intravenous heparin therapy followed by warfarin, the patient's hearing improved and MRI and MRA showed complete recanalisation of the sigmoid and transverse sinuses. Venous sinus thrombosis can be an undetected sequel to head injury. Appropriate imaging studies should be carried out to enable therapy to be started as soon as possible.
PURPOSE: We report a patient with an enlarging internal carotid mycotic aneurysm secondary to septic cavernous sinus thrombosis presenting with acute visual loss. DESIGN: Single observational case report. METHODS: Retrospective review of the medical record and review of the literature. RESULTS: A 19-year-old man with residual left sixth nerve palsy and decreased vision in his left eye caused by left cavernous sinus thrombosis secondary to pansinusitis was seen 2 weeks after discharge with acute decreased visual acuity in the right eye. A workup revealed an enlarging left carotid/ophthalmic aneurysm that compressed the optic chiasm and right optic nerve. The patient was taken to the interventional angiography suite, where his left internal carotid artery was occluded endovascularly. The patient's vision improved on discharge. CONCLUSIONS: Visual loss caused by a mycotic carotid aneurysm is an infrequent sequelae after cavernous sinus thrombosis and is not well described in the literature. To our knowledge, this is the first reported case of acute visual loss associated with a mycotic ophthalmic aneurysm. The result of treatment was good in this case, with the patient's visual acuity returning to pretreatment status.
The outcome of cerebral venous sinus thrombosis (CVST) depends on rapid diagnosis and initiation of effective anticoagulation. We report seven cases of a subgroup with deep cerebral venous sinus thrombosis (DCVST) treated in our institution since 1990. Six of our seven patients presented with early neuropsychological deficits (mental obtundation, bradyphrenia or apathia). This clinical presentation, in combination with headache, and focal neurological deficits, aids the early diagnosis of DCVST. Thalamic hyperintensities on T2-weighted MRI images, previously considered infarctions, were fully reversible during treatment with heparin. This indicates that early in the course of the disease they correspond to vasogenic oedema.
OBJECTIVE: To explore the controversial issue of anticoagulant therapy and indications for surgery in association with severe sinus thrombosis. METHODS: During the last 4 years, we have treated three patients with severe sinus thrombosis of the dural sinuses. All three patients received systemic anticoagulant therapy and, after experiencing neurological deterioration, underwent open thrombectomy and local thrombolysis. After the operation, aggressive intensive care was given and included cerebral perfusion monitoring, barbiturate administration, hyperventilation, and osmotherapy. The treatment was guided by repeated neuroradiological investigations. RESULTS: All three patients returned to their normal lives. CONCLUSION: Intracranial sinus thrombosis, even in the worst neurological state, should be treated aggressively. A cornerstone in treatment is systemic anticoagulant therapy and repeated neuroradiological studies. When, despite adequate anticoagulant therapy and intensive care, neurological deterioration occurs, a combination of open thrombectomy and local thrombolytic therapy should be considered.
A case of cerebral venous sinus thrombosis after central venous cannulation is presented. This occurred after a catheter had been in place for 5 days. The patient presented with thrombosis of the left internal jugular vein 4 days after removal of the catheter. Despite anticoagulation, the patient developed symptoms of increased intracranial pressure. Subsequently, a diagnosis of superior sagittal sinus thrombosis was made. The aetiology, diagnosis and management of this uncommon complication of central venous cannulation are discussed.
Two patients with superior sagittal sinus thrombosis are reported. Papilloedema was an important diagnostic sign in both cases. Magnetic resonance imaging (MRI) provided the diagnosis in each case and proved to be the investigation of choice. Superior sagittal sinus thrombosis should be considered in the differential diagnosis of papilloedema as it is both potentially fatal and probably underdiagnosed.