Intracranial haemorrhage with a twist

Abstract

D. Magnetic resonance venogram. The diagnosis of cerebral venous sinus thrombosis (CVST) was missed preoperatively but suspected intraoperatively when, strikingly, the vein of Labbé was unusually dark, firm and rubbery. Some of the superficial cortical veins were similar in appearance and consistency, and one of these was sent for pathological examination. We traced the vein of Labbé back to the left transverse sinus and suspected it to be thrombosed as well. The brain was swollen and discoloured and the haematoma uneventfully evacuated. MRI venography confirmed the diagnosis of CVST postoperatively (Fig. 1B). A retrospective review of the CT scan on admission revealed left transverse sinus hyperdensity (Fig. 1A). Despite its recognition as a potentially life-threatening clinical entity since 1825,[1]Ameri A. Bousser M.G. Cerebral venous thrombosis.Neurol Clin. 1992; 10: 87-111PubMed Google Scholar CVST remains a diagnostic challenge owing to its protean clinical and radiological presentation.[2]Singh T. Chakera T. Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: an easily misdiagnosed cause of cerebral haemorrhage.Australas Radiol. 2002; 46: 351-365Crossref PubMed Scopus (13) Google Scholar CVST accounts for fewer than 2% of patients with non-traumatic intracranial haemorrhage but haemorrhagic transformation of a venous infarct has been reported in 20% to 40% of patients with CVST.3Gum G.K. Numaguchi Y. Foster R.W. et al.Superior sagittal sinus thrombosis with intracerebral hematoma.Comput Radiol. 1987; 11: 199-202Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 4Keiper M.D. Ng S.E. Atlas S.W. et al.Subcortical hemorrhage: marker for radiographically occult cerebral vein thrombosis on CT.J Comput Assist Tomogr. 1995; 19: 527-531Crossref PubMed Scopus (29) Google Scholar While most hemorrhages associated with CVST are small, patchy, or merely petechial foci in larger hypodense areas,1Ameri A. Bousser M.G. Cerebral venous thrombosis.Neurol Clin. 1992; 10: 87-111PubMed Google Scholar, 3Gum G.K. Numaguchi Y. Foster R.W. et al.Superior sagittal sinus thrombosis with intracerebral hematoma.Comput Radiol. 1987; 11: 199-202Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 4Keiper M.D. Ng S.E. Atlas S.W. et al.Subcortical hemorrhage: marker for radiographically occult cerebral vein thrombosis on CT.J Comput Assist Tomogr. 1995; 19: 527-531Crossref PubMed Scopus (29) Google Scholar rapid and dramatic enlargement of lobar hemorrhagic infarction has on rare occasions been observed in the setting of this condition.[5]Stefini R. Latronico N. Cornali C. et al.Emergent decompressive craniectomy in patients with fixed dilated pupils due to cerebral venous and dural sinus thrombosis: report of three cases.Neurosurgery. 1999; 45 (discussion 629-30): 626-629Crossref PubMed Scopus (133) Google Scholar Early diagnosis and expeditious treatment of CVST are essential. This particular patient’s diagnosis was missed on admission and, anecdotally, this appears to be an experience shared more broadly.[2]Singh T. Chakera T. Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: an easily misdiagnosed cause of cerebral haemorrhage.Australas Radiol. 2002; 46: 351-365Crossref PubMed Scopus (13) Google Scholar Although the need for aetiological workup and medical treatment via anticoagulation and/or thrombolytic therapy are widely accepted, surgical options also exist for this condition.6Soleau S.W. Schmidt R. Stevens S. et al.Extensive experience with dural sinus thrombosis.Neurosurgery. 2003; 52 (discussion 542-4): 534-544Crossref PubMed Scopus (117) Google Scholar, 7Bentley J.N. Figueroa R.E. Vender J.R. From presentation to follow-up: diagnosis and treatment of cerebral venous thrombosis.Neurosurg Focus. 2009; 27: E4Crossref PubMed Scopus (29) Google Scholar Our patient was found to have protein S deficiency, but other risk factors for CVST are oral contraceptive pill use, pregnancy and oestrogen replacement in females, and underlying malignancies, deficiencies of protein C and factor V Leiden, and vasculitis or anti-phospholipid antibodies.[7]Bentley J.N. Figueroa R.E. Vender J.R. From presentation to follow-up: diagnosis and treatment of cerebral venous thrombosis.Neurosurg Focus. 2009; 27: E4Crossref PubMed Scopus (29) Google Scholar The patient underwent anticoagulation therapy and made an excellent clinical recovery. Intracranial haemorrhage with a twistJournal of Clinical NeuroscienceVol. 19Issue 4PreviewA 55-year-old, previously healthy male train conductor with a history of migraines developed a gradual-onset left temporal headache while at work, followed by new-onset word-finding difficulty. During helicopter transfer from a small regional emergency department to a tertiary referral hospital, the man’s aphasia worsened, and he became densely right hemiplegic and somnolent. After emergent intubation and hyperventilation with concomitant intravenous administration of mannitol, he was taken to the operating room for a definitive procedure. Full-Text PDF