We have a great case on my Stroke Unit: A young pediatric intensive care unit nurse, non-smoker, taking the pill that developed headache over a few days, then over the course of a morning (some hours) became somnolent, slow in thinking, slightly confused. CT being “normal”, we got an LP, showing 9 neutrophilic cells and a high protein of 1,7 g/l – unfortunately, no pressure was measured. Ceftriaxone, Ampicilline and Aciclovir iv were initiated and she was admitted to our Stroke Unit, since this is the nearest thing to an intermediate care neurology ward that we have.
The next day she complained about persistent headache, slightly nebulous thinking. Psychopathologically she was slow, somewhat distanced, hard to get information from. An MRI showed dramatic T2 changes bilaterally in the basal ganglia and the thalami with not so extensive DWI lesions (ADC down), yet no involvement of white matter. Additionally a single DWI lesion flared up behind the right lateral ventricle (again, ADC down). The veins were identifiable.
We discussed the differential of this image extensively, until we had to conclude it was internal vein thrombosis. In retrospect, you could discover all the relevant imaging findings in the first CT.
So before you start reading up on cerebral venous thrombosis (vide infra), remember the anatomy of the cerebral veins. The best source for this (at least for me) is this wonderful page from the neuroangio site.
Next I list a few things on imaging and deep venous thrombosis…
- Rodallec et al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics 2006
- Bousser. Cerebral venous thrombosis. An update. Lancet Neurology 2007
- Deep cerebral venous thrombosis: Imaging in eight cases. Neuroradiology 1999
- Cerebral venous sinus thrombosis. Eur Radiol 2004
- Cord sign facilitates diagnosis of deep cerebral thrombosis. Am J Emerg Med 2010