A unilateral thalamic lesion referred for biopsy: Answer

Abstract

•Venous thrombosis of the great cerebral vein can lead to thalamic infarction.•Venous infarction can have similar MR imaging appearance to a space occupying lesion.•CT venography or gadolinium-enhanced MR venography is the most frequently used technique to show venous thrombosis. Answer–Venous infarct involving the left great cerebral vein Computerised tomography of the body did not show any primary malignant disease. The patient was referred to neurosurgery for consideration of a brain biopsy in view of the presumed neoplastic aetiology. However, further neuroradiological review raised the possibility of a deep venous infarct. This was confirmed with subsequent MR venography which showed absence of the left internal cerebral veins due to thrombosis related filling defect (Fig. 1B). The patient was treated with systemic anticoagulation and recovered without sequalae. Screening for prothrombotic tendencies and underlying precipitants was negative. This image report illustrates the challenging clinic-radiological diagnosis of a deep venous infarct, and the potential risk of misdiagnosis as a space occupying lesion. It is essential to consider venous infarction in the differential diagnosis of space occupying lesions of the brain [1Bakshi R. Lindsay B.D. Bates V.E. Kinkel P.R. Mechtler L.L. Kinkel W.R. Cerebral venous infarctions presenting as enhancing space-occupying lesions: MRI findings.J Neuroimaging. 1998; 8: 210-215https://doi.org/10.1111/jon199884210Crossref PubMed Scopus (30) Google Scholar, 2Dmytriw A.A. Song J.S.A. Yu E. Poon C.S. Cerebral venous thrombosis: state of the art diagnosis and management.Neuroradiology. 2018; 60: 669-685https://doi.org/10.1007/s00234-018-2032-2Crossref PubMed Scopus (51) Google Scholar]. This ensures patients receive prompt treatment with anticoagulation or endovascular therapy, and avoids unnecessary and potentially harmful invasive investigations such as brain biopsy [[3]Renard D. Castelnovo G. Campello C. Bouly S. Le Floch A. Thouvenot E. et al.Behav Neurol. 2014; 2014: 1-17Crossref Scopus (26) Google Scholar]. The following are the Supplementary data to this article: Download .xml (.0 MB) Help with xml files Supplementary data 1 A unilateral thalamic lesion referred for biopsyJournal of Clinical NeuroscienceVol. 76PreviewA 44-year-old man presented to the emergency department suffering with a three-week history of unremitting headaches associated with evolving paraesthesia and numbness involving the whole right side of the body. There was no significant past medical or pharmacological history. Routine blood tests were normal, and a lumbar puncture for cytology and microscopy was unremarkable. FLAIR magnetic resonance (MR) brain imaging demonstrated a region of high-attenuation and oedema in the left thalamus (Fig. Full-Text PDF